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HomeMy WebLinkAbout08-0567r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, : CIVIL COURT DIVISION Plaintiff _ V. Docket No. 0$ 5L'1 0'ivi e?Y?? Walter M. Patterson, III, Individually; Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III; and Civil Action-Law Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Defendants NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after the complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the Shippensburg Health Care Centers. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT REDUCED FEE OR NO FEE. LAWYER REFERRAL SERVICE Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 Le had demandado a usted en la corte. Si usted quiere defenderse de estas demandas expuestas en las paginas siguientes, usted tiene viente dias de plazo al particular de la fecha de la demanda la notificication. Hace falta ascentar una comparencia escrita o en persona o con abogado y entregar a la corte en forma escrita sus defenses o sus objeciones a las demandas en contra de su persona. Se adviso que si usted no tiene defiende, la corte tomara medidas y puede continuar la demanda en contra suya sin previo aviso o notificacion. Ademas, la coorte puede decidir a favor del demandante y requiere que usted cumpla con todas las provisiones de esta demanda. Usted puede perder dinero o sus propiedades y otros direchos importantes para usted. LLEVE ESTA DEMANDA A SU ABOGADO IMMEDIATAMENTE, SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. LAWYER REFERRAL SERVICE Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 Date: i // -7 0 By: 2 Respectfully submitted, CAPOZZI AND ASSOCIATES, P.C. m , Esquire Atto7N . 7441 2933 h Front Str et Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff, Shippensburg Health Care Center IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, : CIVIL COURT DIVISION Plaintiff V. : Docket No. 01- SG 7 Li 7_e,w. Walter M. Patterson, III, Individually; Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, 111; and Civil Action-Law Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, COMPLAINT NOW COMES, Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center ("Shippensburg Health Care Center"), by and through its attorneys, Capozzi & Associates, P.C., and makes the following Complaint for a money judgment against Defendants and in support thereof, respectfully avers as follows: Plaintiff, Shippensburg Health Care Center, is a Pennsylvania corporation, which operates a long-term care nursing facility located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania, 17257. 2. Shippensburg Health Care Center is licensed to participate in the Medicaid and Medicare programs. Defendant Walter M. Patterson, III ("Defendant Walter Patterson" or "Resident") is an adult individual residing at Plaintiff's nursing care facility. 4. Defendant Larry E. Patterson ("Defendant Larry Patterson") is an adult individual residing at 4284 Berkley Court, King George, VA 22485, and was the Resident's Powers of Attorney when Resident was admitted to the nursing facility. Defendant Eddie L. Collins, Jr. ("Defendant Collins") is an adult individual residing at 2234 Penn Street, P.O. Box 2105, Harrisburg, Dauphin County, PA 17105, and is the Resident's current Powers of Attorney. A true and correct copy of the Powers of Attorney is attached and incorporated herein as Exhibit "A." 6. On or about February 3, 2007, Resident and Defendants Larry Patterson and Collins requested that Shippensburg Health Care Center admit Resident so he could receive long term nursing care and services. A true and correct copy of the Admission Agreement is attached hereto and incorporated herein as Exhibit "B." 7. On or about February 3, 2007, Shippensburg Health Care Center provided Resident and Defendant Larry Patterson with a copy of the PA Department of Public Welfare ("DPW") Admissions Notice Packet as required under 42 U.S.C. § 1396(r). A copy of the MAO 1 Certification page signed by Defendant Larry Patterson acknowledging receipt of the Notice is attached hereto and incorporated herein as Exhibit "C." The DPW Admissions Notice Packet provides Resident and his Responsible Party inforination regarding Medicaid eligibility requirements and procedures. 9. By executing the Admission Agreement, Shippensburg Health Care Center represented a promise to provide nursing care and services to the Resident. Defendants Larry Patterson and Collins as Resident's Powers of Attorney, Responsible Parties, and/or Legal Representatives represented a promise to pay Shippensburg Health Care Center for the nursing care and services to Resident. 10. The nursing care and services rendered by Shippensburg Health Care Center met all 4 applicable federal, state, and local standards of care. 11. The account for Resident is currently in arrears in the amount of $52,822.42, through January 2008. A true and correct copy of the Account Invoice for services rendered and costs incurred is attached hereto and incorporated herein as Exhibit "D." 12. To date, Defendants have refused to remit payment in full each month for the nursing care and services rendered to Resident. 13. Resident will not qualify for Medical Assistance ("Medicaid") because he failed to provide the required asset information to submit a complete Medical Assistance application to the Cumberland County Assistance Office. 14. On November 15, 2007, counsel for Shippensburg Health Care Center provided written notice to Defendants that the Resident's account was in default and demanded payment to satisfy the account. A true and correct copy of the demand letter is attached hereto and incorporated herein as Exhibit "E." COUNT I - BREACH OF CONTRACT Walter M. Patterson, III, Individually, and Larry E. Patterson and Eddie L. Collins, Jr., Individually, and as Powers of Attorney, Responsible Parties and/or Fiduciaries for Walter M. Patterson, III 15. Shippensburg Health Care Center hereby incorporates paragraphs 1 through 14 of this Complaint as if set-forth at length herein. 16. Paragraph 1 of the Admission Agreement provides that, "This Agreement is between Shippensburg Health Care Center ... and Walter Patterson ...and, if you or the court have designated an individual to act on your behalf, or there is another individual to act on your behalf, or operation of law, Larry Patterson...." 17. Exhibit 2.A of the Admission Agreement provides the daily room rate of $199.00 5 per diem for a long-term care resident in a semi-private room. 18. Paragraph 2 of the Admission Agreement provides that, "If you are applying to this facility as a private-pay resident, you must provide all financial information requested by us. If we later find that the information you or your representative provided was incomplete or inaccurate; we will consider that as a breach of this Agreement which gives us the right to pursue all legal remedies against you or your representative." 19. Paragraph 4 of the Admission Agreement provides that, "If you are a beneficiary of Medicare, Medicaid or any other third-party payment plan, your representative agrees to make all necessary payments from your funds. Your representative could face a civil penalty for intentionally failing to pay required amounts from your funds and could face a criminal penalty for abusing your funds." 20. The Admission Agreement provides that payment is due no later than 45 days from the date of the invoice, and the penalty for late payments is ".5% of the amount due [per diem] . . If you or your representative do not pay the money you owe us and we hire a collection agency or attorney, you agree to be liable for their fees and court costs." 21. The Admission Agreement and DPW Admissions Packet Notice provide that Defendants Larry Patterson and Collins would responsibly use and safeguard Resident's income and assets for his care as the Resident's Responsible Parties and Powers of Attorney. 22. Resident and Defendants Larry Patterson and Collins, personally, and as Resident's Powers of Attorney, Responsible Parties and/or Fiduciaries are responsible for payment of the outstanding balance owed to Shippensburg Health Care Center for nursing care services. 6 23. Defendants' failure to remit payment to Shippensburg Health Care Center when due and upon demand, and Defendants' failure to provide complete financial information to submit an accurate Medical Assistance application constitute breach of contract. 24. Shippensburg Health Care Center has been financially damaged by the failure of Resident and Defendants Larry Patterson and Collins, personally and as Resident's Powers of Attorney, Responsible Parties and/or Fiduciaries to pay for the nursing care and services that Shippensburg Health Care Center rendered to Resident in the amount of $52,822.42, as of January 2008, plus interest, attorneys' fees, and costs of collection. WHEREFORE, Shippensburg Health Care Center demands judgment against Defendants in the amount $52,822.42, plus interest, attorneys' fees, and costs of collection, which amount exceeds the local jurisdictional limit for arbitration. COUNT II - QUANTUM MERUIT Walter M. Patterson, III, Individually, and Larry E. Patterson and Eddie L. Collins, Jr., Individually, and as Powers of Attorney, Responsible Parties and/or Fiduciaries for Walter M. Patterson, III 25. Shippensburg Health Care Center hereby incorporates paragraphs 1 through 24 of this Complaint as if set forth at length herein. 26. Shippensburg Health Care Center's expectation of payment in exchange for rendering the nursing care and services to Resident is reasonable. 27. In rendering intensive long-term nursing care and services to Resident, Shippensburg Health Care Center has conferred a substantial benefit upon him. 28. Defendants retained the benefit of the bargain with Shippensburg Health Care Center for the provision of nursing care and services, but have not conferred a similar benefit in return upon the Shippensburg Health Care Center. 7 29. Resident has been unjustly enriched at the expense of Shippensburg Health Care Center. 30. Shippensburg Health Care Center is entitled to proper compensation for the services rendered to Resident. 31. Shippensburg Health Care Center has demanded restitution from Defendants, but Defendants have refused to remit payment in full. 32. Resident's unjust enrichment at Shippensburg Health Care Center's expense has financially damaged Shippensburg Health Care Center in the amount of $52,822.42 through January 2008. WHEREFORE, Shippensburg Health Care Center demands judgment against Defendants in the amount $52,822.42, plus interest at the legal rate of 6% per annum until judgment is satisfied, which amount exceeds the local jurisdictional limit for arbitration. COUNT III - BREACH OF FIDUCIARY DUTY Larry E. Patterson and Eddie L. Collins, Jr., Individually, and as Powers of Attorney, Responsible Parties and/or Fiduciaries for Walter M. Patterson, III 33. Shippensburg Health Care Center hereby incorporates paragraphs 1 through 32 of this Complaint as if set forth at length herein. 34. Shippensburg Health Care Center, by virtue of the Admission Agreement, is an intended third party beneficiary of the agency relationship and Powers of Attorney that existed between Resident and Defendants Larry Patterson and Collins, as Resident's Powers of Attorney, Responsible Parties, and/or Legal Representatives. 35. As the Powers of Attorney, Responsible Parties, and/or Legal Representatives for Resident, Defendants Larry Patterson and Collins had a Fiduciaries duty to act in Resident's best interest pursuant to the Admission Agreement and DPW Admission Notice Packet. 36. Defendants Larry Patterson and Collins owed a Fiduciaries obligation to Shippensburg Health Care Center to use the assets of Resident to pay for his nursing care and services when invoiced, and to make information regarding Resident's income and assets available to assist Shippensburg Health Care Center in submitting an accurate application for Medical Assistance funds, or Medicaid. 37. The income and assets of Resident were, at all times relevant and material hereto, accessed, and controlled by Defendants Larry Patterson and Collins as Resident's Powers of Attorney, Responsible Parties, and/or Legal Representatives. 38. As his fiduciaries, Defendants Larry Patterson and Collins have failed to transfer Resident's income or assets to Shippensburg Health Care Center to pay for his nursing care and services as required under the Admissions Agreement and Medicaid regulations. 39. Defendants Larry Patterson and Collins have access to and control of confidential personal financial and asset information about Resident, which is required by the DPW to approve payment of public Medical Assistance funds. 40. Defendants Larry Patterson and Collins have failed to provide a complete inventory of Resident's income and assets to Shippensburg Health Care Center to submit an accurate application for Medical Assistance. 41. The Cumberland County Assistance Office denied Medical Assistance to Shippensburg Health Care Center because Resident's Medical Assistance application was not accurate, and because Resident possessed excess personal resources to be immediately eligible 9 for Medicaid. A true and correct copy of the DPW Form 162 Notice to Applicant detailing Defendants' failure to provide the required financial information is attached hereto and incorporated herein as Exhibit "F." 42. Defendants' breach of fiduciary duty is the proximate and actual cause of Resident's delinquent account with Shippensburg Health Care Center. 43. Shippensburg Health Care Center has been financially damaged by Defendants Larry Patterson's and Collins' breach of their Fiduciaries duty to Resident and Shippensburg Health Care Center in the amount of $52,822.42, plus interest and costs of collection. WHEREFORE, Shippensburg Health Care Center demands judgment against Defendants Larry Patterson and Collins in the amount of $52,822.42, plus interest, attorneys' fees, and costs of collection, which amount exceeds the local jurisdictional limit for arbitration. COUNT IV - PETITION FOR ACCOUNTING Larry E. Patterson and Eddie L. Collins, Jr., Individually, and as Powers of Attorney, Responsible Parties and/or Fiduciaries for Walter M. Patterson, III 44. Shippensburg Health Care Center hereby incorporates paragraphs 1 through 42 of this Complaint as if set forth at length. 45. Shippensburg Health Care Center is entitled to an accounting of: a. All transactions and dealings with relation to their duties as Powers of Attorney, Responsible Parties and/or Fiduciaries over the assets and property of Resident; b. All profits and losses gained or lost as a result of any investments or businesses run during their tenure as Powers of Attorney, Responsible Parties and/or Fiduciaries on behalf of Resident; c. A listing of all of Resident's assets and liabilities during the entire time they acted as Powers of Attorney, Responsible Parties and/or Fiduciaries for Resident and had control of the Resident's assets and property, and any actions taken by Defendants Larry Patterson and Collins as Powers of Attorney, Responsible Parties and/or Fiduciaries, with regard to the assets and property of the Resident; 10 d. Defendants Larry Patterson and Collins are constructive trustees of the funds and assets of Resident and should account for any and all of Resident's funds spent for their personal use; and e. Defendants Larry Patterson and Collins should account for any wrongful conversion, dissipation, and sale of Resident's property and return the items or their value to pay for Resident's obligations. 46. As a party to the Powers of Attorney between Defendants Larry Patterson and Collins and Resident, the Shippensburg Health Care Center is also entitled to a full and complete inspection of any books or records in the possession of Defendants Larry Patterson and Collins pertaining to their actions as a Powers of Attorney. WHEREFORE, Shippensburg Health Care Center petitions this Court for an Order directing Defendants Larry Patterson and Collins to produce all books and records for inspection relating to their actions as Powers of Attorney, Responsible Parties, and/or Fiduciaries, account for all of the transactions, dealings, assets and liabilities of their transactions and such other relief that the Court may deem just and proper. Date: (7 a By: Respectfully submitted, CAPOZZI AND AS$QC4TES, P.C. isel ,,On, Esquire Attorney . o. 441 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff, Shippensburg Health Care Center VERIFICATION I, Jeffrey Benevit, Business Office Manager of Shippensburg Health Care Center, do hereby verify that the facts made in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in Title 18 of the Pennsylvania Consolidated Statutes Section 4904, relating to unsworn falsification to authorities. Date: 0 Jeffrey Be vi Shippensburg Health are Center JAN 1 4 2008 CHARLES E. PETRIE ATfORMY AT LAW 5 : 3528 BRISBAN STREET HARRISBURG, PENNSYLVANIA 17111 4 717.561-1939 ra NOTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT') BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN, AFTER YOQBECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 Pa.C.S. Ch. 56. EXHIBIT A IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. WALTER M. PATTERSON III PRINCIPAL AGENT'S ACKNOWLEDGEMENT I, EDDIE L. COLLINS, have read the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. 2-4 r 2 o O AGENT DATE COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN On this, the day of , 2007, before me, A Notary Public, personally appeared EDDIE L. COLLINS, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed it for the purposes therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. ARY WBLIC COMMONWEALTH OF PENNSYLVANIA KeNy P. c :::= PamaN ty My Corraras2009 ania Association of Notaries Member, Pennsy±v DURABLE POWER OF ATTORNEY _ KNOW ALL MEN. BY THESE PRESENTS, that I, WALTER M. PATTERSON III, currently residing at 507 Muench Street, Harrisburg, County of Dauphin, Pennsylvania, hereby revoke any general power of attorney that I have heretofore given to any person and do hereby appoint EDDIE L. COLLINS of 2234 Penn Street, Harrisburg, County of Dauphin, Pennsylvania, (hereinafter "my Agent") my true and lawful Agent for me and on my behalf to perform all such acts as my Agent in my Agent's absolute discretion may deem advisable, as fully as I could do if personally present. This Power of Attorney shall not be affected by my subsequent disability or incapacity. My Agent is hereby given the fullest possible powers to act on my behalf: to transact business, make, execute and acknowledge all agreements, contracts, orders, deeds, writings, assurances, and instruments for any matter, with the same powers and for all purposes with the same validity as I could, if personally present. SPECIFIC POWERS INCLUDED IN GENERAL POWER Without limiting the general powers hereby already conferred, my Agent - shall have the following specific powers which are included in the foregoing general powers: (1) To create a trust for my benefit. (2) To make additions to an existing trust for my benefit. (3) To claim an elective share of the estate of my deceased spouse. (4) To disclaim any interest in property. (5) To renounce fiduciary positions. (6) To withdraw and receive the income or corpus of a trust. (7) To authorize my admission to a medical, nursing, residential or similar facility and to enter into agreements for my care. (8) To authorize medical and surgical procedures. (9) To engage in real property transactions. (10) To engage in tangible personal property transactions. (11) To engage in stock, bond and other securities transactions. (12) To engage in commodity and option transactions. (13) To engage in banking and financial transactions, including checking and savings account(s), certificates of deposit, and savings bonds transactions. (14) To borrow money. (15) To enter safe deposit boxes. (16) To engage in insurance transactions. (17) To engage in retirement plan transactions. (18) To handle interests in estate and trusts. (19) To pursue claims and litigation. (20) To receive government benefits. (21) To pursue tax matters. DURATION OF POWER, RELIEF FROM LIABILITY. REVOCATION 1. This Power of Attorney shall not expire by reason of lapse of time. 2. I hereby ratify and confirm all that each Agent acting hereunder shall do or cause to be done under this General Power of Attorney. I specifically direct that such Agent shall not be subject to liability for such Agent's decisions, acts or failures to act. . s acting' hereunder written notification of the revocation, which notice shall not be considered binding unless actually received. HIPPA RELEASE AUTHORITY I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1966 (aka HIPPA), 42 USC 1320d and 45 CFR 160-164. I authorize: (a) any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health care provider any insurance company and the Medical Information Bureau Inc., or other health care clearinghouse that has provided treatment or services to me or that has paid for or is seeking payment from me for such services; (b) to give, disclose and release to my agent, without restriction all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse. The authority given by agent shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclose of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. IN WITNESS WHEREOF, and intending to be legally bound, I have hereunto set my hand and seal this 4 day of , 2007. Signed, sealed, and delivered in the presence of. WALTER M. PATTERSON III COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN On this, the Cam! day of , 2007, before me, A Notary Public personally appeared WALTER M. PATTERSON III, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed it for the purposes therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and official seal, Notarial Seal KeNy P. Roberts, Notary Public Paxmg Born, Dauphin Co NdY My Commission Expires Jan. 27, 20)09 I, Member, Pen nsvivania Association otNotades Elf A " 5- - 1 5 2007 HEALTH CARE CENTER 121 Walnut Bottom Road Shippensburg, Pennsylvania FAX (71*0-8304 17257-9005 TTY 1-800-654-5984 ADMISSION AGREEMENT This Agreement iaetween Shippensburg Health Care Center (the "Facility" or "we" and) ?'k P?QK, (the "Resident" or "you") and, if you or the court have designated an individual to act on your b?, or there is another individual to act on your behalf, or operation of law, L4? W?jCJJ ("your representative"). A checklist of the rights and responsibilities applicable to your representative is listed in Exhibit 1 and is incorporated into this Agreement. Paying for Your Care If you are applying to this facility as a private-pay resident, you must provide all financial information requested by us. If we later find that the information you or your representative provided was incomplete or inaccurate; we will consider that as a breach of this Agreement which gives us the right to pursue all legal remedies against you or your representative. Who Can Be Required to Pay for Your Care Only you and your insurer can be required to pay for your care. No other person, (i.e. a family member, friend, neighbor, legal representative or guardian) can be required to pay from their own funds for your care, although he or she may knowingly and voluntarily agree to guarantee payment for the cost of your care. We require the person responsible for making payments on your behalf to pay for your care under the terms of this contract in a timely manner. If you are a beneficiary of Medicare, Medicaid or any other third-parry payment plan, your representative agrees to make all necessary payments from your funds. Your representative could face a civil penalty for intentionally failing to pay required amounts from your funds and could face a criminal penalty for abusing your funds. Private Pay Residents The items and services included in our daily rate is basic room, board and general nursing care as required by your medical condition. Payment for items and services that are included in the daily rate is payable one month in advance and due on the first of each month. Items and services included in your daily rate are listed in Exhibit 2.A. You will-be charged separately for additional items and services not included in our daily rates such as special nursing care, special equipment, pharmacy charges, laboratory charges, medical transportation and additional services such as telephone expense, dry cleaning, beauty and barber services and newspapers. Items and services for which you will be charged are listed in Exhibit 2.B. Payment for these additional items and services are due after you have requested them, and; you have received and have been billed for them. Within 30 days of receiving an item or service, EXHIBIT B you have the right to ask us for an itemized financial statement that briefly but clearly describes each item and the amount charged for it. You will be given an updated listing of services and related charges, including any charges for services not covered under Medicare or by the facilities basic per diem charges, annually on or about January 1 of each year. Medicare Residents We participate in the Medicare Program. Medicare may pay for some or all of your nursing home care. For information on Medicare, see Exhibit 3. If you are eligible for Medicare, you have the right to have claims for your nursing home care submitted to Medicare. Medicaid Residents We participate in the Medicaid program. For information on Medicaid, see Exhibit 3. You are not required to give up any of your rights to Medicaid benefits to be admitted or to stay here. If your private funds are used up during your stay here and you are eligible for Medicaid; we will accept Medicaid payments although Medicaid may require you to pay some amount in addition to what Medicaid pays for your care. If you are planning on applying to Medical Assistance later, you may want to find out now if your are "medically eligible" for nursing home payment by Medicaid. You are responsible for applying for and obtaining Medicaid benefits and we will assist you. We may not charge, ask for, accept or receive any gift, money, donation or consideration other than Medicaid reimbursement as a condition of your admission or continued stay here except that Medicaid may require you to pay certain amounts from your private funds. If you receive Medicaid, most of your nursing home charges such as room, board, and general nursing care are covered. For a list of services covered by Medicaid, see Exhibit 4.A. The local Board of Assistance will tell you whether you have to pay part of the charge for your care and, if so, how much. Some of the items and services that we offer are not covered by Medicaid. If you want any items or services, which are not covered by Medicaid, you or your representative will have to pay for them. A list of the items and services not covered by Medicaid and the charges for them are in Exhibit 4.B. Payment for items and services that are not covered by Medicaid is due after you have requested them, and; have received and have been billed for them. Within 30 days of receiving the item or service, you have the right to ask us for an itemized statement that briefly but clearly describes each item and the amount charged for it. Increases in Charges and Fees Any time we increase a fee or charge for item or service or add a new item or service, we will provide you and your representative with 30 days advance written notice. Penalties We may not charge you interest if you pay your bill in time. Your payment is on time if it is made within 45 days of the date the bill is post marked, or 30 days after the end of the billing period, whichever is later. The penalty we charge is .5% of the amount due, calculated on a per day basis. If you or your representative do not pay the money you owe us and we hire a collection agency or attorney, you agree to be liable for their fees and court costs. Private Duty Nurses Geriatric Aides If you want a private duty nurse or a private duty geriatric aide, you are responsible for selecting a person licensed and/or certified according to Pennsylvania laws and regulations. You are also responsible for paying him or her and for letting us know that you have hired one. The person you hire is not an employee or agent of the facility, but he or she must meet our standards and follow our policies and procedures. Employees of the Facility may not serve as private duty nurses or private duty geriatric aides. Holding Your Bed if You Leave the Facility If you are hospitalized or on leave from the Facility, we will hold your bed for you as follows: A. If you are private-pay resident, or are receiving inpatient care reimbursed under Medicare Program (and you are not covered under Medicaid), unless you notify us otherwise, we will hold your bed for as long as you pay for it at the daily rate you are currently being charged. B. If Medicaid pays for part or all of your nursing home care and you need to be hospitalized, we will hold your bed for up to the maximum number of days required by this state, currently 15 days. If you leave for any other reason, we will hold your bed for up to the maximum number of days required by this state, currently 18 days. You have a right to be readmitted to the facility to the first available appropriate bed. While we are holding your bed, you are still required to pay the Facility any amount for which you are liable as determined by the Medicaid Program. C. If you have applied for Medicaid, your bed will be reserved in accordance with Paragraph B. However, if you are found to be ineligible for Medicaid, then you are required to pay for the bed as a private pay resident as described in Paragraph A. D. Other third-party payers may or may not have a bed hold policy. We will discuss this if it applies to you. Your Right to Make Complaints and Suggest Changes in Policies and Services As a nursing home resident, you have many rights according to State and Federal law. These are described in detail in Exhibit 6, which is attached and is part of this Contract. You may make complaints about your care in the Facility and you may also suggest changes in the policies and services of the Facility. You will not be harassed or discriminated against for making a complaint or suggesting a change in a policy or service. You may present your complaints to the facility, management company or to one of the following State agencies: Lin Tierson, NHA Administrator Shippensburg Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 717-530-8300 Ombudsman Office of Aging 16 West High Street Carlisle, PA 17013 717-240-6110 717-532-7286 Ext. 6110 Mr. John Perini President Magnolia Management, Inc. 1710 Underpass Way, Suite 201 Hagerstown, MD 21740 301-745-8700 Department of Health 100 North Cameron Street 2nd Floor Harrisburg, PA 17101 717-783-3790 Your Right to Make Decisions You have the right to make your own medical decisions and to manage your personal affairs. If you become disabled, it may be necessary for someone else to make decisions for you. For this reason, we recommend that you have a living will and/or advance directive for medical decisions and a financial Power of Attorney, but you are not required to do so. See Exhibit 7 for a description of your legal rights to decide about your future medical treatment. Transfer, Relocation and Discharge You have the right to remain here, and you may not be transferred, relocated or discharged against your will, except for the following reasons: (1) A medical reason (i.e. the facility cannot provide the kind of care that you need, your condition has improved so that you no longer need the care we provide, or a medical emergency arises; (2) Your welfare or the welfare of other residents or staff; (3) Nonpayment for a stay, or (4) the Facility ceases to operate. If we decide that you should be transferred or discharged, we will notify you, and an immediate family member or legal representative, by letter 30 days in advance. If you are transferred because of an emergency situation, we will provide the required notice as soon as practicable. The letter will contain the reasons for the transfer or discharge and its effective date. The letter will also tell you how you can appeal our decision to transfer or discharge you. If you are discharged involuntarily, we will attempt to make other appropriate arrangements for your care. However, if other arrangements are not available, your representative agrees to accept you into his or her custody if it is medically appropriate. Your Right to End This Contract If you decide to end this Contract and leave the Facility, you must pay your bill before you leave. You must give us five (5) days written notice to terminate this contract. If you leave before the end of that time, you must still pay for each day of the required notice. In the event you die while a resident of the facility, your representative is responsible for making the funeral arrangements. We will notify your representative immediately. If we are unable to reach your representative, -we will. contact the funeral home of your choice to. facilitate arrangements. Additional Documents It is not possible to cover everything that is important to your'stay in our Facility in the body of this Contract. Therefore, we have included additional important documents as Fxhibits. These Exhibits are part of this Contract. Please'verify that you received the Exhibits and that the contents of the Exhibifs were explained to you by placing -your initials on-the line-next to the description of each Exhibit. Exhibit I. Rights and Obligations of Representatives. Exhibit 2. For PrNate Pay Residents: (a) Items and services covered by daily rate. (b) Items and'servicea not covered by daily rate. Exlu?bit 3. How to Apply For and Use Medicare and Medicaid Benefits. Exhibit 4. (a) Items and Services Covered by Medicaid. (c) Items and Services Not Covered by Medicaid. Exhibit 5. Physicians Who Practice at the Facility. Exhibit 6. Legal Rights of Pennsylvania to Decide Future Medical Treatment. Exhibit 7. Policies and Procedures Concerning Your Personal Funds and Your Personal Property. Exhibit 8. Services Provided by Outside Health Care Providers. Cha.nzes in Law Any provision of this Contract that is found to be invalid or unenforceable as a result of a. change in State or Federal law will not invalidate the remaining provisions of this Contract. If there are services we have agreed to provide that are later fiound to be impossible to render as-.a result of a change in State or Federal law, it is agreed that to the extent possible, the Resident and the Facility will continue to fuLfiii our respective obligations under this Contract consistent with the law. ,PQ)-?Jmn IN WITNESS WHEREOF, the parties have executed this Contract on this re?, day of CU QQJ7 . WBy: "Ilk W. Scott Murray, Administrator Shippensburg Health Care Center Witness Resident If the resident has been adjudicated disabled or the Resident's doctor determines that the Resident is incapable of understanding or exercising his or her rights and responsibilities, the Facility may require the signature of another person on this contract. The other person may be: (1) An appointed healthcare agent under and advance directive for medical care; (2) A guardian or Power of Attorney of the person; (3) A surrogate or family member. U Title: Indicate w ether you are (1), (2) or (3) JXV HEALTH CARE CENTER 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257-9005 (717) 530-8300 FAX (717) 530-8304 TTY 1-800-654-5984 POLICY REGARDING PRIVATE INSURANCE Shippensburg Health Care Center will submit claims to your private insurance for reimbursement for your stay,. All co-insurance, co-pays, and deductibles are due immediately following payment from your insurance company. If at any time your insurance company denies payment or benefits have been exhausted the resident will be considered a private pay account and will be subject to the private pay statement outlined in the Admission Agreement. I have been informed of private insurance coverage pertaining to the period of stay at _ Shippensburg Health Care Center and understand the" above policy. Resident Date 110A or Responsible Party Date . Wits ss Date. Ir?? HEALTH CARE CENTER 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257-9005 Resident Name L?C.f' m 3? Date of Admission (717) 530-8300 FAX (717) 530-8304 TTY 1-800-654-5984 By signing below it is acknowledged that the insurance coverage for the above resident has been satisfactorily explained as it pertains to the stay at Shippensburg Health Care Center. Also, the Medical Assistance application process was discussed including the qualification requirements of the program and when to begin the application. The sheet of required information for Medical Assistance has been provided at this time. The resident or resident's responsible party agrees to cooperate fully with the facility and all applicable State and Federal agencies in the attainment, maintenance, and re-certification of program payment guidelines. If the resident or responsible party fails to cooperate or obtain information necessary for the procurement of payment, the resident or responsible party will be held responsible for payment as permitted under State and Federal law and all applicable legal fees associated with the collection of monies due. Resident / Responsible Party Signature Witness Signature / Title Cj k,-J A/rn (Uri ecky' EXHIBIT 1 RIGHTS AND OBLIGATIONS OF REPRESENTATIVE The Representative shall have the right to be notified by the Facility of any event or occurrence involving the Resident, which directly affects any obligation of the Representative under this Agreement. Representative agrees to assume independently, under this Agreement, the following obligations and is entitled to the following rights, as indicated by Representative's initials accompanying any of the following provisions: Representative agrees to be responsible for ensuring that any payment from the resident to which the Facility is entitled pursuant to this Agreement shall be paid to the Facility in a. timely manner. In the event the Resident is a beneficiary of Medicare, Medicaid or any other third-party payment plan, Representative agrees to ensure that all co-payments, co-insurance or charges and fees for non-covered items and services, together with any late fees as described under this Agreement, shall be paid from the Resident's funds. Representative is subject to a civil penalty for willful violation of the agreement to distribute the Resident's funds to the facility. • (Unless the Representative voluntarily agrees to act as guarantor), Representative shall be responsible for any payments required under this Agreement only to the extent of the Resident's funds. Resident is applying for admission on private pay basis, and Representative agrees to assist the Resident in providing all financial information required by the Facility to determine the extent of the Resident's resources. If it is ever determined the Representative participated in the disclosure of incomplete or inaccurate information, the incomplete or inaccurate disclosure shall be deemed a material breach of this Agreement and the Facility reserves the right to pursue all available legal remedies against the Representative, including but not limited to an action for breach of contract. • Representative is signing this Agreement as a duly authorized agent such as an appointed healthcare agent under an advance directive or guardian appointed by a court. A copy of all supporting documentation for this representation is attached to this Agreement. • Representative is signing this Agreement on Resident's behalf, based upon a physician's certificate, a copy of which is attached to this Agreement, certifying that Resident does not possess the capability to understand his or her rights and responsibilities. • Representative agrees that in the event of the Resident's death, Representative shall take responsibility of all burial arrangements for the Resident and for removal of all personal property from the Facility. (Exhibit 1, Continued) • If it is the desire of the Resident or Representative to obtain the supplemental services of private duty nurses in accordance with the requirements described under this Agreement, Representative agrees to be responsible for arranging independently for those services, including ensuring any payment. Representative agrees that in the event the Resident's private funds are exhausted during the Resident's stay and the Resident is eligible to apply for benefits under the Medicaid Program, the Representative shall assist the Resident and the Facility with any application for Medicaid benefits. Representative further agrees to act, on behalf of the Resident, to facilitate any Medicare, Veterans Administration or other third-parry benefits which may be available to cover the cost of Resident's care at the Facility. • In the event the resident seeks to terminate this Agreement, the Representative agrees to ensure that all notices required under this Agreement are provided to the Facility. • In the event of an involuntary termination of this Agreement, if other arrangements acceptable to the Resident cannot be made, the Representative agrees to accept the Resident into the Representative's custody, if medically appropriate. • Representative has the right to copies of the following documents and any amendment to them. Representative further acknowledges receipt of the following documents, which may be amended from time-to-time. 1. A copy of this Admission Agreement. 2. A list of the Facility's rates, subject to amendment on thirty-(30) days notice, and a description of charges for services not included. 3. A list of health care providers offering services at the facility. • Representative acknowledges the Facility's right to any legal remedies available under law for Representative's breach of this Agreement. EXHIBIT 2.A Private Pay Residents DAILY ROOM RATES Total Daily Room Rates Effective January 1, 2007 Private Rooms ........................ $200.00 Semi-Private Rooms ................. $190.00 Triple/Quad Rooms .................. $185.00 A. The daily rate includes the following services: Special Care Program $204.00 $199.00 $189.00 • Room • Board • Social Services • Nursing Care, including: o The administration of prescribed medications, treatments and diets o The provision of care to prevent skin breakdown, bedsores, and deformities. o The provision of care necessary to encourage the resident from accident, injury and infection. o The provisions of care necessary to encourage, assist and train the resident in self-care and group activities. The daily rate does NOT include the following items/services: • Physician Services • Medications • Specialized and/or specially ordered medical supplies/services/equipment • Prescribed dietary supplements • Cable ($7.00 per month) • Telephone and telephone services • Beauty/Barber Shop Services • Disposable Diapers • Items listed on Ancillary Charge Sheet • Personal Laundry Payment: Payment is due in full and on the first day of each month. Bill is done on a monthly basis. Each monthly payment shall also include any additional fees and charges incurred in the proceeding month. EXHIBIT 2.B ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE The following items and services are not covered by the Facility's basic daily rate: Item or Service Physician Services Medications Prescribed Dietary Supplements Personal Dry Cleaning, Personal Linens Telephone Television Service Beauty/Barber Shop Services Clothing Sundry Pharmaceutical Ambulance Service, Medical Transportation IV Therapy X-Ray Services Medical-Nursing Supplies Dental, Podiatrist and Ophthalmology Services Physical, Speech and Occupational Therapy Services Oxygen Newspaper, Periodicals Lab Services Specialized and/or specially ordered medical services/equipment Guest meals (Exhibit 23, Continued) ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE (refer to the Ancillary Charge List for additional costs) Item Telephone Television/Cable per month Beauty/Barber Shop Services: Permanent Haircuts and Blow-dry Hair Sets Cut Only Color Personal Laundry Personal Dry Cleaning Physical Therapy Service Occupational/Speech Therapy IV Therapy Aerosol Therapy Charge Direct bill from telephone company $ 7.00 per month $35.00 $ 10.25 $ 8.25 $ 8.25 $30.00 $ 45.00 per month Same as billed by cleaner Determined by level of care required Determined by level of care required Charge list will be provided by contract pharmacy prior to delivery of services Determined by level of care required ****************************************************************************** Shippensburg Health Care Center cordially invites family members, guests and friends to join our Resident's at meal times. The prices for guest trays, effective July 1, 2001 are as follows: Breakfast A $4.00 Will be served at 7:00 AM Breakfast B $4.00 ($3.77 +.23 state tax) served at 7:30 AM Lunch A $4.00 Will be served at 12:00 PM Lunch B $4.00 ($3.77 +.23 state tax) served at 12:30 PM Dinner A $4.00 Will be served at 5:00 PM Dinner B $4.00 ($3.77 +.23 state tax) served at 5:30 PM *The Resident's will be assigned their meal times upon admission. Meals can be paid for at the Receptionists' desk. In order to prepare sufficient quantities we require a 2-hour notice to prepare guest tray. EXHIBIT 3 The following summarizes the Medicare and Medicaid programs. It also tells you who to call for more detailed information. If you have questions, our staff will also help you. What's Covered - Medicare 1. Care in a hospital 2. 100 days of skilled care in a nursing home. Medicare provides full coverage for the first 20 days. You must make a co-payment after that. The following services are examples of skilled care: a. Injections & feedings given through an IV b. Tube feedings c. Application of a dressing that involved prescription medication d. Treatment of stage 3 or 4 bedsores Medically necessary doctor's services. What's Covered -Medicaid Medicaid is a comprehensive program that will cover most of the costs of a nursing home stay. See Exhibit 4 for information about.covered and non-covered items. Your Contribution - Medicare Medicare does not pay 100% of the cost of covered services. You will be required to pay part of the charges. Your payment may be called a "co-payment", "deductible" or "premium", depending on the type of care provided. If you receive Medicaid, Medicaid will pay for any payment that you are responsible for under Medicare. Your Contribution - Medicaid Depending on your income and assets, you may be required to make a contribution toward the cost of your care. The amount of any contribution will be decided by the local Board of Assistance. Who's Eligible - Medicare People 65 years old or older who are eligible to collect old-age benefits under Social Security are eligible. Persons who receive Social Security disability benefits for at least 24 months, or have been found eligible for Medicare by the Social Security Administration because they have end stage renal disease requiring regular dialysis or kidney transplant are also eligible. Who's Eligible - Medicaid Eligibility depends on whether your income and assets are below certain levels: 1. Income: You should consult the local Board of Assistance to find out whether your income makes you eligible. That phone number is listed on the next page. If you qualify, $30 per month of your income is protected for your personal use while in the Facility. (Exhibit 3, Continued) 2. Assets: The Cumberland County Board of Assistance will also be able to evaluate your assets and tell you whether you qualify. The following are examples of things not counted as assets. a. Your house if your spouse lives there. b. Household goods. C. A certain amount of cash. d. Personal Property in your possession in the Nursing home. e. A certain amount of money for burial arrangements. How to Apply - Medicare Contact the local Social Security Office at the following address: Social Security Office 401 E. Louther Street Carlisle, PA 17013 (800) 772-1213 (717) 243-0085 How to Apply - Medicaid Contact the local County Board of Assistance at the following address: Board of Assistance 33 Westminster Drive Carlisle, PA 17013 (800) 269-0173 (717) 249-2929 Whom to Contact if you have a Question or Problem - Medicare If Medicare denies a claim, you have the right to appeal the denial. You may appeal by writing to: Aetna Medicare Claim Administration 501 Office Center Building Fort Washington, PA 19034 (215) 643-7200 Whom to Contact if you have a Ouestion or Problem - Medicaid If your application for Medicaid is denied, your coverage is terminated, or a service is not covered, you may appeal in writing to: County Board of Assistance Office 33 Westminster Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 (Exhibit 3, Continued) Whom to Contact if you have Incurred Medical Expenses prior to your MA Effective Date Medicare - Not applicable. Whom to Contact if you have Incurred Medical Expenses prior to your MA Effective Date - Medicaid Medical bills that you received in the 3 months prior to receiving Medicaid may be covered by Medicaid. Contact: County Board of Assistance Office 33 Westminster Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 EXHIBIT CA A. Items and Services Covered by the Medicaid Per Diem Rate • Regular room, dietary services, social services and other services required to meet certification standards, medical and surgical supplies, and the use of equipment and facilities. • General nursing services, including but not limited to, administration of oxygen and related medications, hand feeding, incontinency care, tray service and enemas. • Basis Beauty/Barber Services. The facility must provide shampooing and hair care which is considered necessary for hygiene. The facility must inform the resident of the types and frequency of the services provided. • Items furnished routinely and relatively uniformly to all residents, such as water pitchers, basins, and bedpans. • Items furnished, distributed, or used individually in small quantities such as alcohol, applicators, cotton balls, band-aids, antacids, aspirin (and other non- legend drugs ordinarily kept on hand), suppositories, and tongue depressors. • Items used by individual residents, but which are reusable and expected to be available such as ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment, and other durable medical equipment. • Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diets, even if written as a prescription item by a physician. • Laundry services for other than personal clothing. • Non-emergency medical transportation services. • Other special medical services of a rehabilitative, restorative, or maintenance nature, designed to restore or sustain the resident's physical and social capacities. • Personal care items including a patient gown, shampoo, skin lotion, comb, brush, toothpaste, toothbrush, and denture cream. EXHIBIT 4.B B. Items and Services Not Covered by the Medicaid Per Diem Rate Medical expenses such as, but not limited to: • Health insurance premiums. • Visits by a non-participating physician other than approved by the nursing care facility. • Emergency ambulance services, if the ambulance company does not accept MA. • Over-the-counter medications, which are a particular brand not supplied by the nursing facility. For example, the nursing facility must provide aspirin, but the patient may request and buy a specific brand of pain reliever, such as Excedrin PM, or Tylenol. • Hearing aids and batteries. • Specialized Beauty/Barber Shop services. • Diapers, if the resident wants a style or brand which is not provided by the nursing care facility. • Personal care items of the resident's choice if preferred instead of the items provided by the nursing care facility. This includes items such as brushes, combs, toothbrushes, cosmetics, etc. EXHIBIT 5 PHYSICIANS WHO PRACTICE AT THE FACILITY Dr. Yogindra S. Balhara, M.D. 761 Fifth Avenue Chambersburg, PA 17201 (717) 261-2583 Dr. Paul Orange, M.D. Dr. Baxter Drew Wellmon, II, D.O., P.C. 4225 Lincoln Way East Fayetteville, PA 17222 (717) 352-3616 127 Walnut Bottom Road Shippensburg, PA 17257 (717) 532-3211 EXHIBIT 6 LEGAL RIGHTS OF PENNSYLVANIANS TO DECIDE ABOUT HEALTH CARE You Have the Right to Decide About Your Health Care Adults generally have the right to decide if they want medical treatment, unless they are not competent. This right includes decisions about treatments that extend life, life-support machines, or feeding tubes. Sometimes, an accident or illness takes away a person's ability to make health care choices. But the decisions still must be made. If you are unable to make them, others will. They will decide based on your wishes or your best interests if your wishes are unknown. Pennsylvania law gives you the right to make many health care decisions in advance. One way to do this is by using a written advance directive to name an agent to make your health care decisions if you cannot. A written advance directive can also state your treatment preferences, especially about life sustaining procedures. Naming a Health Care Agent You can name anyone to be your health care agent. The only exception is that, in general, someone who works where you are receiving your care cannot be your agent. Your agent can be a family member or a friend. You choose when your agent can decide for you - right away, if you want, or only after two doctors agree that you are not able to decide for yourself. You also choose the kinds of decisions your agent can make for you. For example, if you want, you can give your agent very broad power to decide about life-sustaining treatment. Pick our health care agent very carefully. Make sure your agent knows what you want. Your agent will then follow your wishes, even if your friends of family disagree. Using Advance Directives There are many ways to use an advance directive. A living will is a type of written advance directive that states your wishes on life-sustaining treatments. It usually comes into affect when a person will die very soon from an incurable condition. It can also be used when a person is permanently unconscious (in a vegetative state). You can make a broader written advance directive for other health care issues too. For example, you can decide whether you want life-sustaining treatment if you are in an end-stage condition. An end-stage condition is an advanced, progressive, and incurable condition resulting in complete dependency. What Happens If You Do Not Make an Advance Directive? No one can deny you health care because you do not have an advance directive. But you should know what happens legally if you do not. (Exhibit 6, Continued) Pennsylvania law allows a surrogate to make medical decisions for you, if you have not named a health care agent and are no longer able to decide treatment issues yourself. Then, your closest relative would be asked to make health care decisions for you. Your spouse, adult children, parents, or adult brothers and sisters, in that order, are considered your closest relatives. If these relatives are not available, another relative or close friend can make decisions for you. A surrogate, though, might have less authority to decide against life-sustaining procedures than a health care agent. If there is no one to be a surrogate, a court might have to appoint a guardian to make your medical decisions. The guardian might be somebody who does not know you personally. How Do You Get More Information? This summary does not cover every issue. If you have legal questions about your rights, please speak to a lawyer. Also talk to your health care provider about the medical issues involved in your care. Tell those caring for you about your decisions and give them a copy of any advance directive. For a free copy of a Living Will or Advance Directive form contact: State Representative Jeff Coy 39 West King Street Shippensburg, PA 17257 (717) 532-1707 or Cumberland County Office of Aging Human Service Building 16 West High Street Carlisle, PA 17013 (717) 532-7286 Ext. 6110 (717) 240-6110 EXHIBIT 7 POLICIES AND PROCEDURES CONCERNING YOUR PERSONAL FUNDS AND YOUR PERSONAL PROPERTY A. Your Rights: 1. You have the right to keep and use your personal property, including some furnishings and clothing, so long as there is enough space and other residents are not inconvenienced. You also have the right to security for your personal possessions. 2. You have the right to manage your financial affairs unless a court determines that you are incapacitated or the Social Security Administration selects a representative to receive Social Security funds for your use and benefit. We cannot require you to deposit your personal funds with us. You may, however, choose any person to manage your funds, including the Facility. 4. If you decide to have us manage your personal funds, you may withdraw your money that we keep in the Facility during the Facility's business hours. If we have deposited any of your funds in a bank, you may obtain those funds within three banking days, provided the funds have cleared. If you need help to perform your banking transactions, you may give the administrator of our Facility legal authority to access your account. This authority is called "representative payee." To give the administrator this authority, you will need to complete a special form. 6. You and your personal representative have the right, during normal business hours, to inspect our written records that concern your personal funds. 7. You and your personal representative have a right to file a complaint if either of you believes that your funds, valuables or other assets have been stolen or damaged. The agencies to contact in order to make a complaint are listed below: a. The Cumberland County Office of Aging Attn: Ombudsman Human Services Building 16 West High Street Carlisle, PA 17013 (717) 532-7286 Ext. 6110 (717) 240-6110 (Exhibit 7, Continued) b. Cumberland County Board of Assistance 33 Westminster Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 C. The Department of Health Division of Nursing Care Facilities 100 North Cameron Street 2nd Floor Harrisburg, PA 17101 (717) 783-3790 B. Our Responsibilities: 1. We will provide a reasonable amount of secure space for you to keep your clothing and other personal property. We must investigate any damage to or loss of your personal property. 2. If you want us to manage $50.00 or less of your personal funds, we will deposit this money-ina non-interest bearing account or a petty cash fund. 3. If you want us to manage more than $50.00 of your personal funds, we will deposit this money in an interest bearing account that is insured by the federal government. This account will be separate from the accounts we use to operate the facility. In addition, we will credit you with all interest earned on your money. 4. We will maintain a full, complete and separate accounting of your personal funds. We will also provide you with a quarterly statement of the activity of your account. 5. If you receive Medicaid benefits, we will notify you if your account balance becomes too high. If you are to remain eligible for Medicaid, your account balance must be under a certain dollar limit that is established by the Federal government and changes periodically. 6. We may not use your personal funds to pay for an item or service that Medicare or Medicaid covers. 7. We will maintain adequate fire and theft coverage to protect your funds and personal property that are kept at the Facility. We shall also obtain a surety bond or otherwise assure the security of your personal funds that are deposited with the Facility. (Exhibit 7, Continued) 8. If you are discharged, there are several things we must do: a. We will ensure the return of your personal funds in our possession. If we have deposited your personal funds in a bank account, we will ensure that this money is made available to you or your authorized representative within 30 days. b. If we are your representative payee for Social Security benefits, we will promptly ask the Social Security Administration to name a new representative payee and we will transfer your money to that person. 9. In the event of your death, there are several things we must do: a. We will convey your personal funds and a final accounting of those funds to the person in charge of administering your estate within 30 days. We will immediately notify any government agency that paid for all or part of your care in our Facility. That agency shall have the right to assist us in determining what to do with your property. b. If a government agency did not pay for your care, we will immediately notify your representative or next of kin to determine what to do with your property. C. If we have your funds, valuables or other assets in our possession, we will hold them until the appointed personal representative of your estate presents a copy of the certified Letters of Administration to us. All conveyance of personal funds will be by check made payable "To the Estate of...". d. We will make reasonable attempts to locate your personal representative and your heirs. If no claim is made on your funds, valuables or other assets in our possession within six weeks of your death, we will write the State Office of the Comptroller for direction. 10. If we are in possession of your funds, valuables or other assets for more than one year from the date of your transfer or discharge, we will transfer your funds, any interest on your funds, and your valuables or other assets to the State Office of the Comptroller's Office of any account(s) in your name of which we have knowledge. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ADMISSIONS NOTICE PACKET IMPORTANT INFORMATION FOR NURSING FACILITY RESIDENTS AND THEIR SPOUSES ndvtsnielaN(fndgrtrt iselnitvngnrnnnsvtntsumtiimra3ncu(ftttil'tt ?vnsrveirn7 t8snnnr?n(?rmrntiBlssa:Glmarlrr?ilsejn q{intuny-lrisrntvuni(?untu r?sdnuengtu attn?vglnt?v?ltnmr gtnriaasalmitmnitviftutt?jrvnisnnn{fry dalnrgtlmrvni?v?n(?! rnismtusmmtinitniGy Important information for nursing facility residents and their spouses. If you need this information in another language or someone to interpret it, please notify the nursing facility or contact your local County Assistance Office. Language VjWi E*(x tMb4*4bA, * 1(county Assistance Office) p7lk assistance will be provided free of charge. In rns y sus importante pars los residences hogares ancoanos y sus BBBtawe cac;tcum orHOczmnHo anrreaerl AOmOB npccrapenwx H m( Th8ng tin quan trgng vi cd sa dubng 16o danh cho thvbng tnf ahan va vi esposos. Si usted ted necesita eato ts informaci6 n en C,t,pyr (cynpyr S). Bars BBw HyHBS ABHHwa AOxymeHT He Apyrom mmxe phei ngau. N6u qui vl cin thong tin nay hang mpt th9 dang ldlac hay mot ono idioms o alguien que se la traduzca, favor de notificar al Hna em ycr awri nepeBOA, 06PBUXATreCL B AOm npeCrapeD= AH60 B phcen dish vier, xin thong hao cho cd sa duang ion hay hen 14c vdi van personal de Is residencia c comunicarse con la oficina local mecraoe Stopo nomoum (County Assistance Office). nououne nepeaox mm Phong Tro Cap Qu$n H}L Trd gittp v8 ngon nga se duce cung cap mign de Asistencia del Condado (CAO). Asistencia lingll[stica npeAOCrawmeres (immarno. phisera; proveida gratis. This information packet contains important information about your rights as a resident of a nursing facility, and information about Medicaid (also known as Medical Assistance), a program which can help pay for nursing facility care for people who cannot pay all of the costs of care by themselves. Federal law, 42 U.S.C. § 1396r (c) (1) (B) and (e) (6), requires the nursing facility to give you this information. Even if you are paying for your nursing facility care yourself, or if Medicare or another insurance is paying, it is important for you to learn about Medicaid before you might need it. There are four (4) parts to this Admissions Notice Packet. PART 1 - Pages 1-8 Notice of Rights of Nursing Facility Residents Applies to Everyone PART 2 - Pages 9-12 Medicaid Payment for Nursing Facility Care Eligibility Requirements and Procedures Everyone should read this part - Even if you do not need Medicaid now. PART 3 - Pages 15-18 Protecting Resources and Income for the Spouse Living at Home Applies if you have a spouse who is living in the eummunity, i.e., is not in a nursing facility or medical institution. PART 4 - Pages 19-22 Resource Assessment Form (PA 1572) To be used by a couple when one of them is in a nursing facility or other medical institution, and the other lives in the community. I certify that the notices required by 42 U.S.C. § 1396r (c) (1) (B) and (e) (6) were provided to me at the time of my admission to: Note: A new 401 is needed for each admission. WC1 kr rr) • -PcAer, 00 Name of Resident 5, L4 0, 54?50 Resident's Social Security Number i esident or Si nature of Patient or Resident Representative ?{ fP-? 1e Relationship to Resident a/3),1-7 <S4u, Name of Facility Date EXHIBIT Affix UMR stamp here PLACE IN MA401 UNTIll C REPRESENTATIVE MA 401 (1105) • F I A SAO N E A E...°1. I-( C A 12 E C 1v N 'F E }: 121 Walnut Bottom Rd. Shippensburg, PA 17257 ph: (717) 530-8300 fax: (717) 530-8304 BILL TO: Ed Collins P.O. Box 2105 Harrisburg, PA 17105 William Patterson DATE INVOICE # 1/17/2008 200714 DESCRIPTION Unit Price Quantity AMOUNT Room & Board since April 2007 $ 199.00 295 $ 58,705.00 Cable since April 2007 $ 7.00 9 $ 63.00 Deductable from Insurance $ 554.42 1 $ 554.42 Payment on 12/ 19/2007 $ (5,000.00) Payment on 1/4/08 $ (1,500.00) PAYMENT TERMS: IDUE UPON RECEIPT TOTAL $ 52,822.42 INVOICE SUBMITTED BY: J. Benevit EXHIBIT D H:\Shared Actg Filefforms\INVOICE 1121/20083:47 PM tL • Louis J. Capozzi, Jr., Esquire* Daniel K. Natirboff. Esquire Donald R. Reavev. Esquire Bruce G. Baron, Esquire Andrew R. Eisemann, Esquire Timothy Ziegler, Reimb. Analyst Karen L. Fisher, Paralegal Jennifer Kain, Paralegal • (l--d in PA. NJ and MD) 2933 North Front Street Harrisburg, PA 17110 C_., apo Associates, P .C. Telephone: (717) 233-3101 ,ftf*J7"t2S Cr'w Fax: (717) 233-4103 www.capozziassociates.com Craig L Adler, Esq. Of Counsel November 15, 2007 Larry E. Patterson 6611 Netties Lane, Unit J Alexandria, VA 22315 Eddie L. Collins, Jr. 2234 Penn Street Harrisburg, PA 17110 RE: Account with Shippensburg Health Care Center Account Name: Walter Patterson Account Balance: $41,008.67 through November 2007 Our Matter No.: 958-07 Dear Messrs. Patterson and Collins: Please be advised that our law firm represents Shippensburg Health Care Center regarding its accounts receivable. I am writing to notify you that we have been instructed by our client to prepare a lawsuit, if necessary, against the two of you and Walter Patterson to collect upon the above-referenced account. This action is being taken because, despite previous invoices for payment, our client has not received any compensation whatsoever. The account balance continues to increase because Walter Patterson's monthly Social Security or other income has not been transferred to Shippensburg Health Care Center, and because his Medical Assistance application has not been submitted in a timely manner. When suit is filed it may give rise to the following consequences: 1. To defend this suit, it may be necessary for you to appear in court. 2. If a judgment is obtained against you, you may be required to pay court costs, attorney's fees, and interest in addition to the money you now owe. 3. If a judgment is obtained against you, a writ of execution may be issued ordering the seizure and sale of your personal or real property. 4. A judgment is a matter of public record, and it will negatively affect your credit rating. EXHIBIT E A t If you notify this office in writing within 30 days after receiving this Notice that the debt, or any portion thereof, is disputed, we will obtain verification of the debt or a copy of any judgment against you and we will mail a copy to you. Unless you dispute the validity of the debt, or any portion thereof, within 30 days after receiving this Notice, the debt will be assumed to be valid. Please make arrangements to pay this debt in one or more installment payments, or you may call me if you have any other questions regarding a settlement agreement. This letter and all other communications from us are attempts to collect a debt. Any information obtained will be used for that purpose. I trust that you will give this Notice your immediate attention. ARE/kj g cc: Jeffrey Benevit, Business Manager Walter Patterson 2 • Sy • NOTICE TO APPLICANT CUMBERLAND CAO 33 WESTMINSTER DRIVE PO BOX 599 BENEFIT rereaio CARLISLE, PA 17013-0599 e 6&E ? ASSISTANCE After the first check which may be a special amount you will receive $ CHECK ? Twice a Month ? Once a Month ? In the Mail 0 At the Bank 91 MEDICAL ? You have a patient pay liability of $ ASSISTANCE for the period beginning and ending ? Effective Date ? FOOD You will receive $ for the morhh(s) of then you will receive food stamps in the amount of $ STAMPS a month fnxn to ? In the Mail ? At the Bank n fie cxmm _ wm= rreoc ? Level of care authorized 1019/2007 you are expected to pay $ a month toward your care. NAME MI. rwu rnm ISERVICE ?cl NAME son X ssPAG?de20?.r az As a condition of eligibility for Medicaid and Long Term Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person (s) and item (s) by the date requested: Pmot of gross monthly income, date Income started, proof of any medical insurance premiums deducted from gross monthly Income; proof of where monthly retirement is being deposited or how it has been spent; copies of the checks written on 7/19107 for $625; 7/26/07 for $235; and 7/30/07 for $375 + CO RECORDMUMBEIR I CAT ICTRDIGI D Judy Peiper 12/5/2007 240-2720 21 0116611 PAN Worker's Signature Mailing Date Telephone Number Walter Patterson E LEGAL SERVICES INC. c/o Shippensburg Health Center 8 IRVINE ROW 121 Walnut Bottom Road CARLISLE, PA 17013-0000 Shippensburg PA 17257 (717) 243-9400 F L ? CLIENT ? APPEAL COPY ? CASE RECORD COPY PA/FS 182 7/07- a ? W O SHERIFF'S RETURN - NOT FOUND CASE NO: 2008-00567 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND PERINI SERVICES SOUTHAMPTON MA VS PATTERSON WALTER M III ET AL R. Thomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT -I mm T- C1 rITT T.77T T T11r) M T T T but was unable to locate Him in his bailiwick. He therefore returns the COMPLAINT & NOTICE , the within named DEFENDANT NOT FOUND , as to . PATTERSON WALTER M III SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 PER LIN TIERSON, DEFENDANT HAS BEEN DISCHARGED FROM FACILITY AND IS CURRENTLY IN CHAMBERSBURG HOSPITAL. Sheriff's Costs: Docketing 18.00 Service 19.20 Not Found 5.00 Surcharge 10.00 a/a g?0,. ? .00 52.20 So answers R. Thomas Kline Sheriff of Cumberland County CAPOZZI & ASSOCIATES 02/27/2008 Sworn and Subscribed to before me this day of A.?D. SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2008-00567 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND PERINI SERVICES SOUTHAMPTON MA VS PATTERSON WALTER M III ET AL R. Thomas Kline Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT to wit: COLLINS EDDIE L JR but was unable to locate Him deputized the sheriff of DAUPHIN serve the within COMPLAINT & NOTICE County, Pennsylvania, to On February 27th , 2008 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: So answers,' Docketing 6.00 f Out of County 9.00 Surcharge 10.00 t` Thom s in Dep Dauphin County 35.25 Sheriff of Cumberland County Postage 2.84 ?-` 6 3. 0 9 ? 2/? 9/b 8 %r 02/27/2008 CAPOZZI & ASSOCIATES Sworn and subscribe to before me this day of in his bailiwick. He therefore A. D. In The Court of Common Pleas of Cumberland County, Pennsylvania Perini Services Southampton Manor Ltd vs. Walter M. Patterson et al SERVE: Eddie L. Collins Jr. No. 08-567 civil Now, January 28, 2008 I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Dauphin' County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. Sheriff of Cumberland County, PA Now, within upon at by handing to a and made known to So answers, the contents thereof. Sheriff of copy of the original Sworn and subscribed before me this day of , 20 COSTS SERVICE MILEAGE _ AFFIDAVIT County, PA 20 , at o'clock M. served the Affidavit of Service (Mlitip- Elf the C*hcr t Mary Jane Snyder Real Estate Depu William T. Tully Solicitor Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 780-6590 fax: (717) 255-2889 Charles E. Sheaffer Chief Deputy Michael W. Rinehart Assistant Chief Deputy Jack Lotwick Sheriff Commonwealth of Pennsylvania County of Dauphin PERINI SERVICES SOUTHAMPTON MANOR LTD VS EDDIE L COLLINS, SR Sheriff s Return No. 2008-T-0193 OTHER COUNTY NO. 08-567 I, Jack Lotwick, Sheriff of the County of Dauphin, State of Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for EDDIE L COLLINS, SR the DEFENDANT named in the within NOTICE & COMPLAINT and that I am unable to find him/her in the County of Dauphin, and therefore return same NOT FOUND, FEBRUARY 19, 2008. SERVERAL ATTEMPTS WERE MADE WITH NO REPLY Sworn and subscribed to before me this 26TH day of February, 2008 NOTARIAL SEAL ARY JANE SNYDER, Notary Publi Highspire, Dauphin County IrMv Commission Ex ires Set 1 2010 So Answers, Sheriff C yeo: Rv J Deputy Sheriff Deputy: S WEVODAU Sheriffs Costs: $35.25 2/5/2008 Shippensburg Health Care Services, Plaintiff V. Walter M. Patterson, III, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III, and Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Defendants In the Court of Common Pleas of Cumberland County, Pennsylvania : Docket No.: 08-567 Civil Term Civil Action - Law PRAECIPE TO REINSTATE To the Prothonotary, Pursuant to Pa. R.C.P. 401, please reinstate the above-captioned Complaint. Capozzi & Associates, Date: By: se " ,Esquire Attorney I.D. o.: 87441 2933 N. Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff ? ?..? ' C `" = ' t: 7 _` ?? c-a -.? _ P ? ? '? ??, 'Ik ?' :^?.a ? t ?, - c? ? _ 6' 4? ? ? ?' ? z ? -- , .?=? , Cr.7 '? 0)j Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, Petitioner V. Walter M. Patterson, III, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III, and Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Respondents In the Court of Common Pleas of Cumberland County, Pennsylvania Docket No.: 08-567 Civil Term Civil Action -Law PETITION FOR PRELIMINARY INJUNCTION NOW COMES, Petitioner, Shippensburg Health Care Center ("Shippensburg Health Care Center") by and through its attorneys, Capozzi & Associates, P.C., and submits this Petition for Preliminary Injunction, and in support thereof, respectfully avers as follows: Parties 1. Shippensburg Health Care Center operates a long-term care nursing facility located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania, 17257. 2. Shippensburg Health Care Center is licensed to participate in the Medicaid and Medicare programs. 3. Respondent Walter M. Patterson, III ("Respondent Walter Patterson" or "Resident") is an adult individual residing at Shippensburg Health Care Center' facility. 4. Respondent Larry E. Patterson ("Respondent Larry Patterson") is an adult individual residing at 4284 Berkley Court, King George, Virginia 22485, and was the Resident's Power of Attorney when Resident was admitted to the nursing facility. 5. Respondent Eddie L. Collins, Jr. ("Respondent Collins") is an adult individual residing at 2234 Penn Street, P.O. Box 2105, Harrisburg, Dauphin County, Pennsylvania 17105, and is the Resident's current Power of Attorney. A true and correct copy of the Power of Attorney is attached to the Complaint as Exhibit "A." Admission Agreement 6. On or about February 3, 2007, Resident and Respondents Larry Patterson and Collins requested that Shippensburg Health Care Center Care Center admit Resident so he could receive long term nursing care and services. A true and correct copy of the Admission Agreement is attached to the Complaint as Exhibit "B." 7. On or about February 3, 2007, Shippensburg Health Care Center Care Center provided Resident and Respondent Larry Patterson with a copy of the PA Department of Public Welfare ("DPW") Admissions Notice Packet as required under 42 U.S.C. § 1396(r). A copy of the MAO 1 Certification page signed by Respondent Larry Patterson acknowledging receipt of the Notice is attached to the Complaint as Exhibit "C." 8. The DPW Admissions Notice Packet provides Resident and his Responsible Party information regarding Medicaid eligibility requirements and procedures. 9. By executing the Admission Agreement, Shippensburg Health Care Center represented a promise to provide nursing care and services to the Resident. Respondent Larry Patterson, as the Resident's former Power of Attorney, and Respondent Collins, as Resident's current Power of Attorney and Responsible Party represented a promise to pay Shippensburg Health Care Center for the nursing care and services to Resident. Default of Admission Agreement 10. The account for Resident is in arrears in the amount of $52,822.42 through January 2008. A true and correct copy of the Account Invoice for services rendered and costs incurred is attached to the Complaint as Exhibit "D." 2 11. To date, Respondents have refused to remit payment in full each month since February 3, 2007 for the nursing care and services rendered to Resident. 12. Resident will not qualify for Medical Assistance ("Medicaid") because his personal countable assets, including substantial liquid assets and real property, exceed the maximum limit allowed under federal and state law. 13. Counsel for Shippensburg Health Care Center provided written notices to Respondents that the account was in default and demanded payment to satisfy the account. A true and correct copy of the demand letters are attached to the Complaint and incorporated herein as Exhibit "E." 14. On January 25, 2008, Petitioner filed with this Court a Complaint for a money judgment against Respondents for breach of contract, quantum meruit, and breach of fiduciary duty, and for a report of accounting. Petition for Preliminary Injunction 15. Shippensburg Health Care Center hereby incorporates paragraphs 1 through 14 of this Petition as if set forth at length. 16. Pennsylvania Rule of Civil Procedure No. 1531 provides that this Court may issue Shippensburg Health Care Center injunctive relief after written notice and hearing. 17. Shippensburg Health Care Center has no adequate remedy at law as Respondents Larry Patterson and Eddie Collins continues to refuse to cooperate regarding Resident's financial matters as Resident's Power of Attorney. a. Respondents' Oblizations as Power of Attorney and Resident's Representative 3 18. Respondents represented to the staff and administration of Shippensburg Health Care Center that they were entirely justified in relying upon them to act as Resident's Representatives and Powers of Attorney. 19. Respondents represented to the staff and administration of Shippensburg Health Care Center that they would use Resident's assets to pay for his nursing care and services pursuant to the Admission Agreement and Medicaid rules and regulations. 20. Respondents Larry Patterson and Collins had, and continue to have, access to and control of Resident's assets. 21. Respondents Larry Patterson and Collins have a contractual, legal, and fiduciary obligation to assist Shippensburg Health Care Center in qualifying the Resident for Medical Assistance funds by providing information necessary to the completion of the Resident's Medical Assistance Application. b. Respondents' Breach of Contractual and Fiduciary Duties 22. Respondents Larry Patterson and Collins withheld critical information relating to the Resident's assets and finances that is required for the County Medical Assistance Office to evaluate and approve a DPW Medical Assistance Application, which further constitutes abuse of their authority as Resident's Power of Attorney. 23. Respondents Larry Patterson and Collins continue to use, or withhold, Resident's personal assets for personal gain. 24. Respondents Larry Patterson and Collins received copies of Resident's Invoices and have knowledge that Resident's account is delinquent. 4 25. Respondents Larry Patterson and Collins continue to refuse to remit payment to Shippensburg Health Care Center upon demand, which constitutes abuse of their authority as Resident's Power of Attorney. 26. Respondents Larry Patterson and Collins have refused to transfer Resident's assets to Shippensburg Health Care Center as required under Medicaid and Social Security Administration regulations. 27. Respondents Larry Patterson and Collins's conversion of Resident's assets constitutes further evidence of abuse of their authority as Resident's Power of Attorney. c. Immediate and Irreparable Financial Harm to Nursing Facility 28. Resident has no other means for paying for his nursing care other than to use his personal assets. 29. Shippensburg Health Care Center continues to be severely financially damaged as an unsecured creditor by the failure of Respondents to provide to the Cumberland County Assistance Office complete information related to Resident's finances and assets for Medicaid funding, and by their failure to pay for the nursing care and services that Shippensburg Health Care Center continues to render to Resident in the amount of $52,822.42 through January 2008, plus interest, attorneys' fees, and costs of collection. 30. To date, Shippensburg Health Care Center continues to provide nursing care to the Resident with nominal financial compensation since February 2007, and under state and federal law Shippensburg Health Care Center is not permitted to unilaterally discharge Resident unless he can receive proper long term care at home, from his family, or at another licensed nursing facility. 31. No family members or Respondents Larry Patterson and Collins are willing or able to discharge Resident and provide care in a personal home or another nursing facility. 32. Shippensburg Health Care Center will suffer immediate and irreparable harm if Respondents Larry Patterson and Collins are permitted to have unrestricted control and access of Resident's assets for purposes other than paying for Resident's nursing care and services. 33. Shippensburg Health Care Center is suffering immediate and irreparable financial harm by being legally obligated to provide nursing care and services to Resident without compensation from Medicaid or Resident's assets. 34. Respondents Larry Patterson and Collins's abuse of their authority as Power of Attorney and Resident Representative constitute cause for immediate removal as Power of Attorney regarding Resident's financial matters. d. Injunctive Relief Requested 35. Petitioner Shippensburg Health Care Center respectfully requests that this Honorable Court enter an Order for injunctive relief as follows: a. Compelling Respondents Larry Patterson and Collins to produce documentation to Shippensburg Health Care Center necessary for the submission of an accurate appeal to the denied Medical Assistance application on behalf of Resident; b. Compelling Respondents Larry Patterson and Collins to produce and file a record of accounting as to the disposition of Resident's real property and liquid assets since February 3, 2003; c. Staying any pending transactions involving the income or assets of Resident pending the resolution of this matter in an amount sufficient to satisfy the Resident's outstanding balance with Shippensburg Health Care Center; d. Requiring Respondents Larry Patterson and Collins to surrender assets sufficient to satisfy the outstanding balance to pay for Respondent Walter Patterson's ongoing care by Shippensburg Health Care Center; e. Voiding and garnishing any transfer of Resident's assets and income to Respondents Williams and/or Lathrop or any third party; and, 6 f. Removing Respondent Eddie Collins as Power of Attorney for Resident as to financial matters only and appointing Shippensburg Health Care Center as the Court-Appointed Receiver of the personal assets of Resident. WHEREFORE, Petitioner Shippensburg Health Care Center respectfully requests this Honorable Court conduct a hearing and issue injunctive relief as suggested above. Respectfully submitted, CAPOZZI AND WOCIATES, P.C. Date: I& By: 1 7 .' i , Esquire Attorne 67441 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorneys for Shippensburg Health Care Center ???cti `tea ._a "?-?' `'?? C5 ti'i t . rt ?-^ ..+ ? , ?-, ,,,.,. ;,L.a •.. Y'j w l r ? ?? ''r-? r ??, i..?% Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, Petitioner vu. In the Court of Common Pleas of Cumberland County, Pennsylvania : Docket No.: 08-567 Civil Term Walter M. Patterson, III, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III, and Civil Action - Law Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Respondents ORDER FOR INJUNCTION HEARING AND NOW, this day of , 2008, upon consideration of the foregoing Petition for Preliminary Injunction, IT IS HEREBY ORDERED THAT: (1) A Hearing on disputed issues of material fact, shall be held on J'0 at 3 ; 3C wpm in Courtroom of the Cumberland County Courthouse; and, (2) Notice of the Entry of this Order shall be provided to all Parties by the Petitioner. BY THE COURT, Distribution: -Andrew R. Eisemann, Esq., Capozzi & Associates, P.C., 2933 N. Front Street, Harrisburg, PA -'Walter M. Patterson, III, Shippensburg Health Care Center, 121 Walnut Bottom Road, Shippensburg, PA 17257 ./Larry E. Patterson, 4284 Berkley Court, King George, VA 22485 .-Eddie L. Collins, Jr., 2234 Penn Street, P. O. Box 2105, Harrisburg, PA 17105 10 17110 VIN'VAIASNN3d Z t :6 WV t- ddV 8002 mii"P 11oud' 341 ?o Jo- Penn Services Soutampton Manor, Ltd. Dba Shippensburg Petitioner Walther M. Patterson, 111, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, 111, and Eddie L. Collins Jr., Individually and as Power of Attorney for Walter M Patterson 111, Respondents : In the Court of Common Pleas : Cumberland County, Pennsylvania : Docket No.: 08-567 Civil : Civil Action Law RESPONDENTS OPPOSITION AND/OR MOTION TO OPPOSE PETITIONERS PETITION FOR PRELIMINARY INJUNCTION Respondent, Ed Collins, POA for patient Walther M. Patterson Respectfully request this Honorable Court to DENY Petitioners request for preliminary',injuction: The best interest of patient Walter M. Patterson and the quick resolution of financial matters would be served. Dated: April 8, 2008 Respectfully submitted, C? Ed Collins, POA 2234 Penn Street Harrisburg, Pa 17110 717-421-3108 Penn Services Soutampton Manor, Ltd. Dba Shippensburg Petitioner Walther M. Patterson, 111, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, 111, and Eddie L. Collins Jr., Individually and as Power of Attorney for Walter M Patterson 111, Respondents : in the Court of Common Pleas : Cumberland County, Pennsylvania Docket No.: 08-567 Civil : Civil Action Law STATEMENT OF THE FACTS 1. On/around February 2007 patient Walter Patient was admitted to Shippensburg Health Care Center (SHCC). 2. Patient's benefits and/or insurance coverage is Blue Cross and P.E.B.T.F. 3. At some time after admission SHCC made an assessment On patient and "removed" patient from "Skilled Nusing Care" to "Custodial Care and/or Resoration". 4. The above-referenced actions are related to the financial Matters before the court. 5. Patient and POA forwarded ongoing complaints of Improprieties (medical records), mis-management and/or non- Communitation (accurate information) with SHCC. 6. Some time after admission patients doctor (Balhara) Recommended "aggressive" therapy for patient. 7. At some point after admission, patient and POA began toreceive invoices for private pay (not covered by insurance) wth no explanation. 8. At some point after admission patient began to complaint About mis-treatment neglect and faulty record keeping. 9. At some point after admission POA was approached by Jeffrey Benevoit about Medcial Assistance Application for Patient. Business Manager Benevoit explained Medical As "only" a supplemental benefit for patient in case of need and That patient was presently fully covered by Commonwealth Insurance coverage. 10. Subsequent to said conversation with Benevoit, POA Began to receive invoices with no explanation. 11. At some point after admission POA contacted social work Joy Severs, and brought complains and concern to her attention. 12. At some point after admission POA, Ed Collins, requested Social Worker's assistance for the "smooth transfer" of patient toanother facility. 13 At all times POA, exercised due diligence trying to resolve financial matters and other matters with SHCC. 13.On/around December 2007 POA reached an agreement with SHCC on a payment schedule to protect patients interest until such time as pending issues were resolved. 14. On/around January 2008 POA made private payment of $5000.00 as part of mutual agreement concerning financial matters. 15.On/around March 25, 2008 a hearing was held on Patient's/POA Medical Assistance Application. The Courts by order gave respondent (POA, Ed Collins) to comply with Request from SHCC/County Assistance within ten (10) business Days (April 8, 2008). 16. Respondent (POA) hand-delivered requesed documents to County Assistance office on April 8, 2008 to comply with courts order .... with final determination by April 15, 2008. Further stated: 1. Respondent has commenced the process of selling Patients residence at 31 North 18th Street Harrisburg. 2. Respondent (POA) has submitted timely payments to SHCC since January 2008 as per our agreement. 3. Respondent has commenced the process of relocating Patient to Harrisburg Pennsylvania area. 4. Patient thru POA has requested a transfer to a new facility Near Harrisburg, Pennsylvania due to conflicts with Staff and irreconcilable differences. 5. POA on behalf of patient agrees to satisfy "all" Outstanding balances to SHCC (if required) within A reasonable time established by the courts after The sale of patients residence (Note: POA position Is that most if not all of the financial matters will be Resolved thru patients present Blue Cross/PEBTF Coverage. 6. SHCC Business Manager (Beniot) has stated the submitted invoice Amount (41,000.00) is in dispute and requires re- calculation due the the insurance issue. 7. The best interest of both parties would be served by the expedited transfer of patient Walter Patterson to the Harrisburg (Pa) area. 8. Patient Walter Patterson is the only African American Male on his floor. (4a? h+ s?+we ??vss+??iw tow?'4??w? ?JFo• ?y?e?? ?? QeMd?? w•?+1? ?IwL Cr?s? it ?' ,, + Sar?t ry 9. POA Ed Collins believes the financial matters between petitioner and respondent can be resolved amicably without court intervention. CONCLUSION WHEREFORE, respondent, Ed Collins, POA for patient Walter M Patterson respectfully request this Honorable Court to'DENY Petitioner's request for Preliminary Injunction. Respectfully submitted, Ed Collins, POA for patient Walter M. Patterson Harrisburg, Pa 17110 Dated: April 8, 2008 0 c C .7 ? Y. J7 r? 1 00 lh7 a SHERIFF'S RETURN - REGULAR CASE NO: 2008-00567 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND PERINI SERVICES SOUTHAMPTON MA VS PATTERSON WALTER M III ET AL STEPHEN BENDER , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon -I -----r NT 7.771 T 17=0 A/f T T T the DEFENDANT at 1815:00 HOURS, on the 28th day of March , 2008 at SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 by handing to WALTER M PATTERSON III a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 19.20 Postage .58 Surcharge 10.00 .00 41?o3/1) Y4?-, ? 47.78 Sworn and Subscibed to before me this day of So Answers: R. Thomas Kline 04/01/2008 CAPOZZI & ASSOCIATES By: puty Sheriff A. D. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Perini Services Southampton : Civil Court Division Manor, Ltd. Dba Shippensburg Health Care Center, : Docket No. 08-567 Civil Petitioner V. . Judge M.L. Ebert, Jr. Walter M. Patterson, 111 Individually, and Ed Collins, Individually and as Power of Attorney for Walter M. Patterson Defendants Respondents Motion for Extention Of Time to List for Sale Property Located at 31 N. 18th Street, Harrisburg, Pennsylvania Defendant, Ed Collins, Power of Attorney (POA) for individual Walter M. Patterson, respectfully request the Honorable Court for an EXTENTION OF TIME for a period of twenty (20) days until on/around May 25, 2008 to list property for sale and in support states the following: 1. Respondent met with realtors on the following dates, April 24, 2008, April 28, 2008 and May 3, 2008 to inspect property. 2. Realtors request "more" preparation before listing property for sale. 3. Respondent needs additional time to prepare property for sale. Respectfully submitted, Ed Collins, POA 2234 Penn Street Harrisburg, Pa 17110 717-421-3108 Dated: May 5, 2008 Perini Services Southampton Ltd. Dba Shippensburg Health Petitioner v. Walter M. Patterson, III Individually and Eddie L Collins., Individually and as Power of Attorney for Walter M Patterson, 111 Respondents : In the Court of Common Pleas : %;umDenana uounzy, : Pennsylvania : Docket No.: 08-567 Civil : Civil Action - Law : Honorable Judge M.L. Ebert Jr F RESPONDENTS REPLY TO COURT ORDER 1. Complied 2. Complied 3. Complied 4. Complied in part ..... A check for $200.00 (for appraisal of property at 31 North I S* Street ) cleared the account after final order. 5. Complied 6. Complied 7. A motion is pending before the court for "Extention of Time" of twenty (20) days to list for sale the property of Walter M. Patterson III located at 31 North 181 Street, Harrisburg, Pennsylvania, due to realtors request Ito better prepare property before listing for sale. Respectfully submitted, Zd Cam., Ed Collins, POA 717-421-3108 Dated: May 9, 2008 DISPOSITION OF INCOME RECEIVED FROM SERB (INCLUDING LUMP SUM) (October 2007 to May 2008) • Gifts (per request from Walter Patterson)...... $57,487,67.00 ......family, friends and relatives. • Taxes (Walter M. Patterson) ........................... $ 39712933.00 (est). • Shippensburg Health Center .......................... $ 101000,00.00 (est). • Other dispersments (credit card, vehicle transfer, registration, citations/tickets, loans, PEBTF, utilities, house appraisal ....... Note: vehicle transferred was gifted and was not sold or given away. ...........................................................................5 51920,63.00 (est). Respectfully submitted, ?---d C.j9,.r,, Ed Collins, POA 2234 Penn Street Harrisburg, Pa 17110 717-421-3108 I A&L COMMONWEALTH OF PENNSYLVANIA STATE EMPLOYEES' RETIREMENT SYSTEM 30 NORTH THIRD STREET, SUITE 150 HARRISBURG. PENNSYLVANIA 17101-1716 TOLLFREE: 1-800-633-5461 www.sers.state.pa.us E s % D ? DIRECT DEPOSIT OF ANNUITY PAYMENTS ? YOUR SS# INSTRUCTIONS: Complete Part I. Have your Financial Institution complete Part 11. This form must be filed with SERS at the address listed above. The Financial Institution may make a photocopy for their records. A copy will be returned to the payee Indicating the effective date of the new direct deposit. Your monthly annuity payment will be credited to your account and be available for use on the last working day each month. NOTE. After this form is processed, roar first monthly check will be mailed to your home address The second and subsequent checks will be electronically deposited in your new direct deposit account. ::; KEEP SEAS INFORMED OF YOUR CORRECT HOME ADDRESS PART I - PAYEE AGREEMENT NAME: FIRST MIDDLE LAST MEMBER'S SS# VV s VI - - 5 'S STREET ADDRESS TELEPHONE NUMBER f.o. emX 210 M-A ( ZI O CITY STATE P CODE TYPE PAYEE MEMBER y } <l r r s b? P f ?" o (Check One) SURVIVOR 1 O ALTERNATE PAYEE ACTION TO BE TAKEN (CHECK ALL THAT APPLY) ••` DO NOT WRITE - SERS USE ONLY ••• ? START DIRECT DEPOSIT ? STOP DIRECT DEPOSIT CHANGE FINANCIAL INSTITUTION CHANGE ACCOUNT NUMBER This change will be effective I hereby authorize and request the Pennsylvania State Employees' Retirement System (SERS) to direct the net amount of my monthly benefit checks for crediting to my account indicated at the PAYEE'S SIGNATURE Financial institution designated below,, and I further authorize the Financial Institution to credit the same to such account without responsibility for correctness of such amount. 1 hereby A L ILA, if) o, revoke all prior payment arrangements with SERS. This authorization will remain in effect until I give written notice of its termination to SERS in DATE such time and in such manner as to allow SERS a reasonable opportunity to act upon it. I agree % / j T / ,> C to notify SERS if I wish to change the designated Financial Institution or account to which my net U pay is to bedeposited sixty 60 d rior to the effective date of such.chan e. I PAYEE - s TOP HERE. (Have your financial institution complete the remainder of this form.) PART II - FINANCIAL INSTITUTION AGREEMENT ACH ROUTING NUMBER c? ACCOUNT NUMBER 121EULI f ACCOUNT TYPE (CHECK ONE): CHECKING ? SAVINGS FINANCIAL INSTITUTION ? CHECK HERE IF PAPER CHECK IS REQUIRED NAME: C C DATE: •, vl 14 JA STREET AD RESS TELEPHONE NUMBER 73 7 CITY t?? ti f I STATE ZIP CODE r TITLE: In consideration of SERS making payments in accordance with this authorization without requiring other proof that the payee is alive on the date which such payment tails due, we hereby agree to repay, refund and/or reimburse to SERS, on demand, the amount of payments made to and received by us, the due date of which shall be after the date of death of the payee, to the extent that funds representing such payments remain on deposit with the financial institution at the time of certification of Payee's death by SERS, to the financial institution. t-I TJA?TH SIGNATURE 4 ?A SERS-123 (Rev. 312005) Voe 2 _ SERS mmHg II i fI11im all Commerce flea,* 015402INYIN00003594 WALTER M PATTERSON III PO BOX 2105 HARRISBURG PA 17105 Commerce BanklHarrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING 0537727299 Statement Balance as of 07/25107 $185.01 Plus 5 Deposits and Other Credits $760.03 Less 7 Checks and Other Debits $855.00 Statement Balance as of 08/27/07 590.04 Transactions By Date Date Description Debit Credit Balance 07126107 DEPOSIT $235.00 $420.01 07127107 WTHDRL DDA 7030 07127 13:44 $220.00 $200.01 101 N. SECOND ST. HARRISBUR PA 07/30107 DEPOSIT $375.00 $575.01 07131107 COUNTER WITHDRAWAL $15.00 $560.01 07131/07 WHORL DDA 8827 07/31 07:48 $120.00 $440.01 101 N. SECOND ST. HARRISBUR PA 08101107 DEPOSIT $75.00 $515.01 08/06/07 WTHDRL DOA 1228 08/04 > 12:44 $400.00 $115.01 101 N. SECOND ST. HARRISBUR PA 08114/07 CHECK # 1001 $15.00 $100.01 08117107 DEPOSIT $75.00- $175.01 08121107 WTHDRL DDA 7375 08121 18:21 $40.00 $135.01 3951 UNION UEPOSIT RD HARRI PA 08121/07 CHECK. # 1002 $45.00 $90.01 08127/07 INTEREST PAYMENT $0.03 $90.04 lCheck Transactions Number Date Amount Number Date Amount Number Date Amount 1001 08114 $15.00 1002 08121 $45.00 421842' 07131 $16.00 Items demoted with an "E" are electronic entries anofmAll not have a check image. Interest Sunmiaiy Beginning Interest Rate 0.15% Number of Days in this Statement Period 33 hderest Earned this Statement Period $0.03 Annual Percentage Yield Earned this Staternent Period (APY) 0.15% Interest Paid Year to Date $0.04 007 Cycle e..e Page 1 of 3 NOTE: SEE REVERSE SIDE F:OR IMPORTAN r INFORMATION Member FDIC Page 3 of 3 Date 08!27!2007 Account 537727299 0194021NY1N00003594 WALTER M PATTERSON 111 or-of 1001 ED COLLINS (POA) TV Box 2103 DatC g' (!•O iFIRa16 HARRISBURG. PA 17105 Paytothe orderof '?"?'?•? :? Dollars a Can ..lerrW _ e ... ??.. ??. ro- T alt t # ZZi?T_leL L? __ 1:03430ML.61: 53 772729 91' 1001 ,-nnnnnnLSnn,r WALTER M PATTERSON 111 mar 1002 ED CO"S (POA) PO Box 4105 IWiRR91NG. PA nres DaIP _`1.LY{ IF 1R.?N Paytotho Orderof ea+?_l2s]Z_ __J $ y5•JC7 &AL A ?1:? ?UollarA s C caw* Pcr?1L41ti.. ?oA?,-eas>,d r1?"ma ?/-.A_ ?l y _ ._ 1:0313018461: 53 772729 9N 1002 ,r000000450D.' Check 1001, $15.00 Date Presented 08/14/2007 -------- ------------------ - --------- ------------ 5&ffviBrce CHECKING ACCOUNT 00421642 '1 ems, WITHURAT/AL TICKET HARRISBURG g NAME __)NA kA. tpd` tLlJ 't I"?--? T .ccrr 5 3? 2 2 1.5?I =?? 115:o U 000421642+ 1:5029?01RW: Check 421642, $15.00 Date Presented 07/31/2007 Check 1002, $45.00 Date Presented 08/21/2UU/ .a• Lk 4111110 w? o? ?n W A Z ? O O F o a o a w w 0c) w ? a v a ? 0 M x A d w Ld y ? M O F F"' ? U °°? QF° F" Y z° uw,4,? eao a , Lu a oz< -'pia 94.4 > za > 3 ?o o?,pz W 0 H p 0 zaZ ° z? w r? ti CL u ?+ ca Vi ¢xu 61 zo E 0 . z-m yF oM?, ?yaz - ?o Q Q ? o mzda?ou 0 LL bhm a S Ov w wa > xo S UQ < w'N Cfcga o z?C ? Sao COr-?aodzd `MCI ? t? p A. ?, A a u w r a O ?D z ?w • azx QO?i ??? < 4Q z ° w a e gu1j0V ZwC)" uw ov ,r " ? Wo h > NON d z o4 & Ln ?n z o o 0 u x O a [ re O U) 0w aw VV O H ?x 10. ;m x O F w u o O > a 1 g ur ? 0 Lf) > x 00 o ow 0 Qz? x N 0U, o W W R O t o N pa z z N v]i O D4 N w 3 w? N F w a ? Q O Z \ O N ? O 0 F > 0 A N H a O o O a CD O Ul Cj o m L n 0 P, W N i O "? AU ?'rMr H ?-I u O 3 7a0 H[1 a aU ?O FI C7 z w H OU p f.{ w H U a 040 1 wwW L ? W H W r Y 2 m Q? am s do u; ti Q w w i N A-V co to ?o 0 ZN? ? O O ? • ? Q Commerce Ban/c 019402INYIN00003299 WALTER M PATTERSON III P0BOX2105 HARRISBURG PA 17105 Commerce Bank/Harrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING 0537727299 Statement Balance as of 07/18107 $0.00 Plus 2 Deposits and Other Credits $625.01 Less 1 Checks and Other Debits $440.00 Statement Balance as of 07/25107 $185.01 Transactions By Date Date Description Debit Credit Balance 07119/07 DEPOSIT $625.00 $625.00 07123107 COUNTER WITHDRAWAL $440.00 $185.00 07125/07 INTEREST PAYMENT $0.01 $185.01 (Check Transactions Number Date Amount Number Date Amount Number Date Amount 1872318 07/23 $440.00 Interest Summary Beginning Interest Rate 0:16% Number of Days in this Statement Period 7 Interest Earned this Statement Period $0.01 Annual Percentage Yield Earned this Statement Period (APY) 0.12% Interest Paid Year to Date $0.01 ea>. 007 Cycle Page 1 of 2 Page 2 of 2 Date 07125/2007 Account 537727299 0184021NYlN00003299 Commerce CHECKING ACCOUNT ank WITNGRRWALTICKET 01872318 CB1 HARRISBURG NAME.___ W cg_LL 1-I-' J" 11'a ??. 53 ?lZn??9 $ yl,O.bCU MO1072318M 1:5029M0184r: Check 1872318, $440.00 Date Presented 07/23/2007 _ I im Commerce Bank 018402INYIN00003620 WALTER M PATTERSON III P O BOX 2105 HARRISBURG PA 17105 Commerce Bank/Harrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING Statement Balance as of 08/27/07 Plus 4 Deposits and Other Credits Less 4 Checks and Other Debits Statement Balance as of 09/25/07 Transactions By Date Date Description 08/31107 DEPOSIT 08131107 WTHDRL DDA 4828 08131 12:21 4250 DERRY STREET HARRI3BUR PA 09/04107 WTHDRL DDA 5926 09104 11:56 101 N. SECOND ST. HARRISBUR PA 09112107 AC-PA TREASURY DEPT-PA REFUND 09/12107, DEPOSIT 09118107 CHECK # 1004 09/24107 CHECK # 1003 09125107 INTEREST PAYMENT $15.00 $82.02 Credit $100.00 0537727299 $90.04 $197.01 $257.02 $30.03 Balance $190.04 $110.04 $30.04 $17.00 $47.04 580:00 5127.04 $112.04 $30.02 $0.01 $30.03 ----- -------- -------- ---------------------- /Check Transactions Number Date Amount Number Date Amount Number Date Amount 1003 09/24 $82.02 1004 09118 $15.00 Items denr3ted with an "E" are electronic entries and will not have a check image. Interest Summary Beginning. Interest Rate Number of Days in this Statement. Per il-d Interest Earned this Staterent Pei i, d Annual Percentage Yield Eaiswd thug Statement Period, SPY) y Interest Paid Year to Date Debit $80.00 $80:00 0.16% 29 $0.01 0.15% $0.06 Va qWW Page 1 of 2 007 CyeL1 E: SEE REVERSE SIDE FOR IMPr TINT INFORMAIIUN Member FDIC Page 2 of 2 Date 09!2512007 Account 537727299 0184021NY1N00003820 WALTER M PATTERSON 111 or-or 1003 ED COWNS (POA) ?,unu H, PO RO%N05 Date 1r j; RWtSIIUM PA 17105 pp Pay toIlie I GZ . OZ OrderaL $ --??-RT FF11,, T ro ?l•?a nn .7 0 ?IIgS ---Dollars 8 :? Bank 1^ 1:03130iB461: 53 772729 90' &003 ...'g0000D820.2. Check 1003, $82.02 Date Presented 09/24/2007 WALTER M PATTERSON 111 mm 1004 ED COLLINS (?OA) Po SM 2105 Dake 9-(y'O? ??u"ie fNRWSRU 6&1Ra. PA ln03 , Pay to the P ? Order a1 Nk-lll af( f-m..7rel? 1 $ CdNnkmkce••-??• .D t'9?1e. nallare o ?BMk •..r<..? a.?.wrra.r• Fo? 23t3?93 __ IL _ r:03i3048461: 53 772729 90 i004 ,r000000i500.' ------ .?r?.-a++.w+x-rAwMww- ....---- ............ 1004, $15.00 Date Presented 09/18/2007 .am 1? so a ?C A 7 z O P ? Qo a A N U W ?r QI al W pq U ? Fa A ? U ? O a z oa ¢0 E.z Uw pg y¢u .4UU zv?a o> a8 ?a; ?Uya ado °? w o, oWO?T5o1 F- H G7w u p fa m D 3 w? uj m _ L1r f t v OF ? a ? < a u i vaa,ao F = °F? H I? ?+1?eo Fa j FAG d y ao ??[=p ua? eaaz oF} Q °yyrr? Q F Z 5 a a Fv? F CtJ y?a0 F z03 z ?,?, Ov¢igZ C7Z ? GyaZw ? O F_vi q i] C?[ a ? U 7 H ? e z?x O d Fy Z ?a ?Qi icr`j v O , Aee U dFNO ap? ?yma xoU 04 W wx ¢ x°] ICI O F O °z? W Q?x F Ho- En q au V o W O Ueaw z of F oFW 00 o 3?5i x W WU> w a¢ QF E N O H I? A d+ ° `r z In o w Ol a O w r- U O W ri O O ° F 0 r-I W w ? M ? > oH °C4 Hz W4 M A ° 2 rn O z ° N O N N w r q O Z '-- 0 w o O 00 > O 1^ M Ln rI ?O ? W Ix N w W O ~W H F~+a'Oapa HE'+a Ucwa?" U HU] M ~r?i?o?g ul W P4 zwU^"' W H OU ? r x ° H A O z H a U H W U) t' (-J ©} «.r. f SP Cis Q O O L( r-I W WO OG 0 O w a 0 W ?O ?U O . %O .o Commerce CBank M4021NYIN00003439 WALTER M PATTERSON III P0BOX2105 HARRISBURG PA 17105 Commerce Bank/Harrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING 0537727299 Statement Balance as of 09/25/07 $30.03 Plus 3 Deposits and Other Credits 5679196.96 Less 27 Checks and Other Debits $14,490.80 Statement Balance as of 10/25107 $52,735.19 Transactions By Date Date Description Debit Credit Balance 10/01/07 DEPOSIT $67,039.74 $67,069.77 10/02107 WTHDRL DOA 8915 10102 08:57 $500.00 $66,569.77 101 N. SECOND ST. HARRISBUR PA 10/02107 CHECK #1005 $15.00 $66,564.77 > 10103/07 WTHDRL DDA 3426 10103 $500.00 $66,054.77 09:5820 NOBLE BLVD CARLISLE PA 10/04/07 WTHDRL DDA 7186 10/04 10:37 $500.00 $65,554.77 3951 UNION DEPOSIT RD HARM PA 10105107 WTHDRL DDA 0272 10105 08:10 $500.00 $65,054.77 101 N. SECOND ST. HARRISBUR PA 10105/07 CHECK# 1006 $14.00 $66;040.77 10109107 WTHDRL DDA 1662 10107 14:21 $500.00 $64,540.77 101 N. SECOND ST. HARRISBUR PA 10/09107 WTHDRL DOA 9669 10/08 12:00 $500.00 $64,040.77 4250 DERRY STREET HARRISBUR PA 10/09107 WTHDRL DDA 2048 10/06 13:20 $500.00 $63,540.77 2030 NORTH PROGRESS AVE HAR PA 10/09/07 WTHDRL DDA 7364 10/09 11:49 $500.00 $63,04017 4700 JONESTOWN RD HARRISBUR PA 10110107 COUNTER.WITHDRAWAL $700.00 $62,340.77 10110/07 WTHDRL DDA 2661 10110 11:55 $600.00 $61,840.77 101 N. SECOND ST. HARRISBUR PA 10115107 WTHDRL DDA 5018 10115 07:59 $500.00 $61,340.77 101 N. SECOND ST. HARRISBUR PA 10115107 WTHDRL DDA 4954 10114 20:45 $500.00 $60,840.77 101 N. SECOND ST. HARRISBUR PA 10116107 WTHDRL DDA 536410/16 07:49 $500.00 $60,340.77 101 N. SECOND ST. HARRISBUR PA 007 NOTE: Cycle _ 1% 10 PORTANT INFORMATION Page 1 of 3 s...r..,. entr Commerce Bank Transactions By Date Date Description 10/17107 COUNTER WITHDRAWAL 10118107 WTHDRL DDA 6492 10118 19:49 101 N. SECOND ST. HARRISBUR PA 10119107 WTHDRL DDA 6667 10119 07:47 101 N. SECOND ST. HARRISBUR PA 10119107 CHECK # 1008 Debit $3;500.00 $500.00 $500.00 $45.00 $148.50 $500.00 Credit Balance $56,840.77 $56,340.77 $55,840.77 $55,795.77 $55;647.27 $55,147.27 10119/07 CHECK # 1009 10122/07 WTHDRL DDA 7415 10120 12:45 101 N. SECOND ST. HARRISBUR PA 10/22107 WTHDRL DDA 808310121 19:35 101 N. SECOND ST. HARRISBUR PA 10122107 WTHDRL DDA 8188 10122 07:58 101 N. SECOND ST. HARRISBUR PA 10123107 WTHDRL DDA 8567 10123 06:51 101 N. SECOND ST. HARRISBUR PA 10124107 DEPOSIT 10124/07 ` WTHDRL DDA 899210/24 11:12 101 N. SECOND ST. HARRISBUR PA 10124107 CHECK # 1007 10125107 INTEREST PAYMENT 10/25107 WTHDRL DDA 6222 10!25 11:20 2030 NORTH PROGRESS AVE HAR PA $500.00 $54,647.27 $500.00 $54,147.27 $500:00 $53,647.27 $150.00 $53,797.27 $500.00 $53,297.27 $68.30 $53,228.97 $6.22 $53,235:19, $500.00 $52,735.19 (Check Tr ansactions Number Date Amount Number Date Amount Number Date Amount 1005 10102 $15.00 1008 10119 $45.00 1761596* 10110 $700:00 1006 10105 $14.00 1009 10/19 $148.60 1007 10124 368.30 490366* 10117 $3,500.00 Items denoted with an "E" are electronic entries and will not have a check image. Interest Summary Beginning Interest Rate 0.15', ;r. Number of Days in this Statement Period 30 Interest Earned this Statement Period $6.22 Annual Percentage Yield Earned this Statement Period (APY) 0.15% Interest Paid Year to Date $8.27 537727299 M4021NVrN00003432 Page 2 of 3 1TC• CCC OCUCUCC CHIC CAD IMDn0TAIJT IIJPnOUATIM Member FDIC Page 3 of 3 Date 1112512007 Account 537727299 018402INYINOON3439 WALTER M PATTERSON 111 Or." 1005 ED COLLINS (POA) PO BM 14041FOUSSURG. PA 17109 Pay tithe Orderof ?tR>•UfL I $ Q C .. .. Dollala For I, ie 1:0313018461: 3 772729 91• L005 .rnnnnnn 5 cnn_,- Check 1005, $15.00 Date Presented 10/02/2007 WALTER M PATTERSON 111 aia> 1007 ED COLLINS (POAI PO Box zips l HARRISSUaa• PA I rips Da1C l?I -1q -off °1"'?.n? Paybtbe e Ordersf Fie _ R? 1$ W3'b C °..v 1b/l1 Dollars A 1:0313D18461: 53 7727ell' 411 1007 Check 1007, $68.30 Date Presented 10/2412007 WALTER M PATTERSON 01 o74r 1009 S (PGA) COLLIN po 2105 INFmwr4a. PA 1710S C724' -I IND =')XIi-i! ?~mK "I lathe t Ordero P4 as D.^.T I $ 14T. $ (] (( ?? !. i•1.L _ 1_. [ 1, ?:_ ,.1,1118- dr t?..,. .?56?:,?ara ? iw FLr tt??l ?1 MItRnin'Zt?Aj+ I??.S?.2rr!_•,1,_._._._------ 1:03L3018461: 53 742729 90 1009 fnnnnoLLAS13.o Check 1009, $148.50 Date Presented 10/19/2007 4 ? WITHGSAIMIAAL WC EfT 01761586 HARRISBURG dd 1` NAM,E ?`?O;S1lrLS r? 139 Q? , Qc, Zt ic0 -W1 53??1.-17-_ $ ?oo.oc7 VOL76t5860 1:5029»03841: Check 1761586, $700.00 Date Presented 10/10/2007 WALTER M PATTERSON 111 or-ay 1006 ED COLLINS (POA) PO 8022105 111]13 Date N4WISBUR0. PA Mos pff OrdelrolIr _J $ t`I-oo Do llars 6 c ep „?„? ?•.w.MS...• Fl r X234.124 C -- 1:0 3 130181.61: S3 77272q 921 1006 .1.--- -- .. r,r, . Check 1006, $14.00 Date Presented 10/05/2007 WALTER M PATTERSON IN orm 1008 EDCOWNSIPOA) C7?9€7-'x'22;._- PO 80X Zia 'Mom b' J e?aana Da OURQPA Ii105 Pa7b01c p Orderof [av?l ?oT I $ 5.0 L7 a;:iz '1w- ar (t .. Dollars e w Cm)P?YY//"111?,,IC?e ?a..?11 ,....,a,......,e.. Fl. "%,,.'k 1:0 3 1 30 184 61: 53 772729 9r L008 OQ00004500.+ Check 1008, $45.00 Date Presented 10/19/2007 5? CNECIIINO'CUNT 004903E C? W L?IARNSOYRO? NAME Er, C0111JS an I1:)-11- O-[ cL Arc You ! l' 2, etl ?•I S 3 5 0 neer.: 5 3 1117 rOOL90366r 1:50 Z9»0184,: Check 490366, $3,500.00 Date Presented j -13- No. 2243351, A. PA TrrLE NUMBER (AS SHOWN ON ATTACHED TITLE) MAKE OF VEHICLE MODEL YEAR PURCHASE c C r PRICE (Sgenote onreverse) VEHICLE IDENTIFICATION NUMBER CONDITION LESS / 1 ?? ! J) ' i 7 l." '? ? GOOD ? FAIR ? POOR TRADE-IN r ¦ B T NAME ( FULL BUSINESS NAME) FIRST NAME MIDDLE INITIAL TAXABLE w AMOUNT r ¦ W CO-SELLER 1. Sales Tax Due x 8% 08 or : 07 x 7% See note an reverse) ¦ ¦ C LAST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDDLE INITIAL DATE ACQUIRED/ 1A ?pq? ? i . PURCHASED Reeeat CodYlmuet bf rluinbertn t.? d ?. o CO -PURCHASER 1B FwaAe¦y»¦N IB,&ecord Assignment x _ a STREET -- COUNTY CODE -"7 ) 2. Title Fee CITY STATE ZIP CODE REFER TO COUNTY CODES ! LISTING ON REVERSE SIDE 3. Lien Fee OF PINK COPY ¦ ¦ D LAST NAME (OR FULL BUSINESS WIME) FIRST NAME MIDDLE INITIAL DATE ACQUIRED/ . PURCHASED 4. Registration or , Processing Fee 5 CO-PURCHASER Fas Ex8r,0 Nuroo*tx ? - Z m u? 9 ueau!l! k TA7 5 S2 STREET COUNTY CODE = 5. Duplicate Reg. v Fee L No. of Cards ¦ r N °z CITY STATE ZIP CODE REFER TO COUNTY CODES N LISTING ON REVERSE SIDE 6. Transfer Fee, OF PINK COPY ¦ • E. MAKE OF VEHICLE VEHICLE IDENTIFICATION NUMBER 7. Increase Fee W • "Ir ¦ MODEL YEAR BODY TYPE (CP, TK, ETC.) CONDITION 8 R l t i .p T ? ? ? . acemen ep Fee ; FAIR POOR GOOD • ¦ F. ORI INAL PLATE ? Check One ? TRANSFER OF PREVIOUSLY ISSUED PLATE TOTAL PAID 9.1 10. PLATE TO BE ISSUED BY ? TRANSFER & RENEWAL OF PLATE (Add 1 thru 8) ¦ BUREAU (PROOF OF IN- SURANCE MUST BE AT- ? TRANSFER & REPLACEMENT OF PLATE t I GRAND TOTAL Send One ? TACHED.) ? TRANSFER OF PLATE & REPLACEMENT OF STICKER . (Add 9 & 10) Check In This ARlount y (r / V EXCHANGE PLATE TO BE ISSUED BY BUREAU PLATE NO, REASON FOR REPLACEMENT - ?LOST ? DEFACED N g ? TEMPORARY PLATE EXPIRES NEVER RECEIVED (LOST W MAIL) tC ISSUED BY FULL AGENT C Month Year N01 E: H "NEVER RECEIVED" bock is ctlecked a k ate must c TRANSFERRED FROM TITLE NO VIN . 'SIGNATURE OF PERSON FROM SIGN HERE RELATIONSHIP TO APPLICANT gy{ ri WHOM PLATE IS BEING TRANS- ? 7? p PLATE NO FERRED IF OTHER THAN APPLICANT) VEHICLE PURCHASED GVWR UNLADEN WEIGHT REQ. REG. GROSS WT. REQ. REG. GROSS COMB. WEIGHT INFO. INCLUDING LOAD I WT. (F APPLICABLE) IF APPLICABLE) INSURANCE COMPANY NAME POLICY NO. OR _ ATTACHBIty&R) POLICY EFFECTIVE DATE POLICY EXPIRATION DATE -I A., I ,, ?,', el- ISSUING I CERTIFY THAT ON MONTH DAY ' YEAR ISSUING AGENT (PRINT NAME] AGENT NO. AGENT I HAVE CHECKED TO DETERMINE THAT THE VEHICLE IS INSURED AND INFOR- ISSUED TEMPORARY REGISTRATION TO THE ABOVE APPLICANT, IN ISSUING AGENT SIGNATURE TELEPHONE NO. MATION COMPLIANCE WITH ALL APPLICABLE PROVISIONS OF THE VEHICLE CODE AND DEPARTMENT REGULATIONS. ( ) G I/WE CERTIFY THAT VWE HAVE EXAMINED AND SIGNED THIS FORM AFTER ITS COMPLETION AND THAT THE INFORMATION GIVEN IS TRUE AND CORRECT. IF AN EXEMPTION IS CLAIMED, THE PURCHASER FURTHER CERTIFIES THAT HE/SHE IS AUTHORIZED TO CLAIM THIS EXEMPTION. I/WE ACKNOWLEDGE THAT 1/WE MAY LOSE MY/OUR OPERATING PRIVILEGE(S? OR VEHICLE REGISTRATION(S) FOR FAILURE TO MAINTAIN FINANCIAL RESPONSIBILITY ON THE CURRENTLY :REGISTERED VEHICLE FOR THE PERIOD OF REGISTRATION. I/WE ACKNOWLEDGE THAT I/WE MAY BE SUBJECT TO A FINE NOT EXCEEDING $5,000 AND IMPRISONMENT OF NOT MORE THAN TWO YEARS FOR ANY FALSE STATEMENT THAT MWE MAKE ON THIS FORM. g re of First Purchaser or Authorized Signer TELEPHONE NUMBER Signature of Seller 1ST 1 ) ASSIGN- re of rchaser/Title of A zed Signer MEN7 Signature of Co-Seller ?.. Signature of Second Purchaser or Authorized Signer TELEPHONE NUMBER Slgnatul6 of Seller ' ^ rr 2ND ASSIGN- ( ) MENT Signature of Co-Purchaser/Title of Authorized Signer Signature of Co-Seller H. NOTE: If a co-purchaser other than your spouse is listed and you want the title to be listed as "Joint Tenants With l Right of Survivorship" (On death of one owner, title goes to surviving owner.) CHECK HERE ?. Otherwise, the title Jil will be issued as "Tenants in Common" (On death of one owner, interest of deceased owner goes to his/her heirs or U. estate). NOTE: IF THE VEHICLE IS TO BE USED AS A DAILY RENTAL OR LEASED VEHICLE, CHECK THIS BLOCK ?. IF BLOCK IS CHECKED, COMPLETE AND ATTACH FORM MV-IL. If your registration docwtents are not received within 90 days, please contact PennDOT t_ 3. APPLICANTS COPY/TEMPORARY REGISTRATION (VALID FOR 90 DAYS) _ au_ MESSENGER NUMBER: 'I 2of t. PA TITLE NUMBER (AS SHOWN ON ATTACHED TITLE) MAKE OF VEHICLE MODEL YEAR PURCHASE o i i 'y 7? ;Y" •'- / -) I", I -? L- [ r - ( J 1 r ci ` PRICE (See rate on reverse) ¦ ¦ z VEHICLE IDENTIFICATION NUMBER CONDITION LESS ? GOOD [I FAIR ? POOR TRADE-IN • ¦ B. LAST NAME ( FULL BUSINESS NAME) IRST NA E IDLE INITIAL TAXABLE W AMOUNT ¦ • ?i CO-SELLER 1. Sales Tax Due x 6% (.O6) a x 7% .07 See "on reverse). • m C LAST NAME (OR FULL BUSINESS NAME) FIRST NAME MIDDLE INITIAL DATE ACQUIRED/ PURCHASED A "llon r 23aD 40 m CO-PURCHASER 18 Fret Adobrto¦o ,-4 Igal rp &'A"pant STREET COUNTY CODE C 1 2 Title Fee 1 G J,j . ' ) CITY STATE ZIP CODE .y . REFER TO COUNTY CODES I ! ?I USTING ON REVERSE SIDE 3. Lien Fee ! . OF PINK COPY ¦ ¦ D LAST NAME (OR FULL BUSINESS ME) FIRST NAME MIDDLE INITIAL DATE ACQUIRED/ . PURCHASED 4. Registration or P ?`- rocessing Fee CO PURCHASER Fee Exempt Nw*ar as assigned by,tho W Bureau 54 `Z STREET COUNTY CODE x 5. Duplicate Reg. is Fee $ d No. of Cards ¦ • N N CITY STATE ZIP CODE REFER TO COUNTY CODES LISTING ON REVERSE SIDE 6. Transfer Fee OF PINK COPY E. MAKE OF VEHICLE VEHICLE IDENTIFICATION NUMBER 7. Increase Fee MODEL YEAR BODY TYPE (CP, TK, ETC.) CONDITION S" ? ? 8. Replacement Fee GOOD FAIR POOR ¦ ¦ F. OR NAL PLATE Check One ? TRANSFER OF PREVIOUSLY ISSUED PLATE TOTAL PAID g. 10. PLATE TO BE ISSUED BY ? TRANSFER & RENEWAL OF PLATE (Add 1 thru 8) • BUREAU (PROOF OF IN- F1 TRANSFER & REPLACEMENT OF PLATE Send One SURANCE MUST BE AT- TACHED.) ? TRANSFER OF PLATE & REPLACEMENT OF STICKER I I.GRAND TOTAL A s Check In ?? D EXCHANGE PLATE TO BE ( & 10) dd This Am«,r>< . ? ISSUED BY BUREAU PLATE NO. REASON FOR REPLACEMENT N [:)LOST I.LEI DEFACED El a TEMPORARY PLATE EXPIRES i ,. , -.. El I NEVER RECEIVED (LOST IN O isSUED BY FULL AGENT Month Year NOTE: If "NEVER RECEIVED" block is checked applicant moat c v TRANSFERRED FROM TITLE NO. VIN i J , - s ANS SIGN HERE { t WHOM NOWT UR PLATE IS REIN TRFROM RELATIONSHIP TO APPLICANT " FERRED (IF OTHER THAN APPLICANT) l fi" VEHICLE PURCHASED GVWR WEIGHT INFO. UNLADEN WEIGHT REQ. REG. GROSS WT REQ. REG. GROSS COMB INCLUDING LOAD -. WT (IF APPLICABLE) (IF i r . INS COMPANY NAME POLICY NO. IOR POLICY EFFECTIVE POLICY EXPIRATION f l?TTA i IN EHi h . ? 7 DATE C?- ( fe DATE ISSUING 1 CE Y THAT ON MONTH DAY YEAR I UING ENT (PRINT NAME) AGENT NO.. AGENT I HAVE CHECKED TO DETERMINE ThIATJ HICLE IS INSURED AND INFOR- ISSUED TEMPORARY REGISTRATION TO THE ABOVE APPLICANT, IN MATION COMPLIANCE WITH ALL A ISSUING AGENT SIGNATURE TELEPHONE NO. BLE PROVISIONS OF TFlE VEHICLE CODE AND DEPARTMENT REGULATIONS G 1/WE CERTIFY THAT I/WE HAVE EXAMINED AND SIGNED THIS FORM AFTER ITS COMPLETION AND THAT THE INFORMATION GIVEN IS TRUE AND CORRECT. IF AN EXEMPTION IS CLAIMED, THE PURCHASER FURTHER CERTIFIES THAT HE/SHE IS AUTHORIZED TO CLAIM THIS EXEMPTION.1/WE ACKNOWLEDGE THAT I/WE MAY LOSE MY/OUR OPERATING PRIVILEGE(S) OR VEHICLE REGISTRATION(S) FOR FAILURE TO MAINTAIN FINANCIAL RESPONSIBILITY ON THE CURRENTLY REGISTERED VEHICLE FOR THE PERIOD OF REGISTRATION. 1/WE ACKNOWLEDGE THAT I/WE MAY BE SUBJECT TO A FINE NOT EXCEEDING $5,000 AND IMPRISONMENT OF NOT MORE THAN TWO YEARS FOR ANY „ FALSE STATEMENT THAT I/wE MAKE ON THIS FORM. z Signature of First Purchaser or Authorized Signer TELEPHONE NUMBER Signature of Seller 1ST fi t. A SsIGN ( ) t ?W . re of Purchaser/Title of Authorized Signal Signature of Co-Seller solat¦6P f Purchaser or Authorized Signer 2ND TELEPHONE NUMBER Signature of Seller ASSIGN- ( ) MENT Signature of Co-P% Title of Authorized Signer Signature of Co-Seller H. z NOTE: If a co-purchaser oth r than your spouse is listed and you want the title to be listed as 'Joint Tenants With Right of Survivorship" (On death of one owner, title goes to surviving owner.) CHECK HERE ?. Otherwise the title , will be issued as "Tenants in Common" (On death of one owner, interest of deceased owner goes to his/her heirs or S c estate). NOTE: IF THE VEHICLE IS TO BE USED AS A DAILY RENTAL OR LEASED VEHICLE, CHECK THIS BLOCK ?. IF BLOCK IS CHECKED, COMPLETE AND ATTACH FORM MV-IL. n your r ation documents are not received within days, please contact PennDOT 3. APPLICANT'S COPY/TEMPORARY REGISTRATION (VALID FOR 90 DAYS) MESSENGER NUMBER: ?;. CERTIFIC 1918 .I77290122100D11?-0b2 CCU147B118516 y VEHICLE IDENTIFICATION NUMBER T.K BODY TYPE I OUP 13 ( SEAT CAP :11113/77 DATE PA TITLED DATE OF ISSUE ATE 0-F TITLE;jFOR A 1977 .CHEVROLET. YEAFC' MAKE OF VEHICLE 1I7r!17/07 PRIOR TITLE STATE ODOR. PROCD DATE 5,013 UNLADEN WEIGHT ' GVWR VEHICLE 884.78176006,.CO TITLE NUMBER EXEMPT) 4. ODOFA. MILES ODOM STATUS GCWR TITLE BRANDS ODOMETER STATUS 0 = ACTUAL MILEAGE I Q MILEAGE EYCEEDS THE MECHANICAL ?. _40 LIMITS 2 . NOT THE ACTUAL MILEAt9E 61? $- NOT THE ACTUAL MILEAGE-000METEE q ?r TA MPfiRYNVERIFIEI'1 ODOMETERDISCLOSURE` 4 ERAL LAW E EMPTMIOM ODOMETER DISCLOSURE uY ISTERED OWNERSTITLE BRANDS REGISTERED A ...VITQUEVEHICLE OOLLECTI? VEHICLE EDDIE L COLL+? OLLECVEHaE t4 N D F . OUT OF CroepiraY G + ORIGINALLY MFOD. FOR NMU S 22.34' PENN ST' r ?€ D ?, HARRISBURG PA 1711D ?`' H_AORICWL IRAI.VEMI CLE L . Lott VEHICLE P . 1'SWAS A POLICE VEHICLE R . RECONSTRUCTED S + STREET ROD T .. REIXNERER.THEFT VEHICLE V = VEHIGLECONTANt9 REISSUED VIN W r FLOOD VEHICLE FIRST LIEN FAVOR OF: SECOND LIEN FAVOR Of. X . ISIWAS A TAXI It a seCOnd fienholder Is listed upon ntisfaCilm A : i Whhldst must forward ft TAIA to lf? BLKe of IMO II' ;sh ? IWIiI he FIRST UffN RELEASE0 appropriate form end foe. _. ?. Illy„PI DATE Il,pr gY SECOND.LIEN RELEASED AUTHORIZED REPRESENTATIVE >f DATE ' MAILING ADDRESS BY AUTHORIZED REPRESENTATIVE a EDDIE L COLLINS 2234 PENN ST HARRISBURG PA 17110 5 `. _ -- --_- _1 aerall(._m of the date of Iwue, the emclel records. of the PennsyMenls Depanrrr6rlt ALLEN D BIEHLER of Transportation Mfbot that the person(s) or company named herein Is the kvMLd wmer of the "M vehlcla. 1 SecrMry of Trausportatfoa AND SWORN . ME? X17 DAY It a oofpurcnaaer Oa1w wmn w tlsm as "JDInt T*wo ovRTGt„ title gDas to su In be aetled ore *Tenants dace owner gm to hl 1ST LIEN DA IST LIENHOLDER CITY W IF THIS)S AN EL NOTE; !t ReQU11 Cn 2ND LIEkI DATE: .p the uIAw?Wree MA6r b aoplLACaP br Ur@aceb d Tft Io th. -NO; d rrt*d AN wn "w- end w w IevN d w" fw lam r- 2ND LIENHOLDER IV STFIVI L n MMUTURE OF APPLICANT OR AUTHORIZED SIGNER CITY i T IF THIS IS AN ELT V ' 1URNATIMP OF MAPPLlrJwimnE OF AUTHORIZED SKWR NOTE: MN REQUII your spouse IS MW and you waM ft Ufa to T fIyM of SrA yOrohlp'? of One fVlWlg, } CHECK =E a. Uta we - 1n Common' (QA dearth of one MVnOr, intetalf 61 ttRnet rlsir6 or estate). 1FNOLIEN CHECIK STATE ZIP tE ( 1 FINANGAL f_ .j INSTITIIfKR} NO. y ..., IF NO LIEN. CHE(1K LI?)? I!Illitli.,.".I?Ihllll III' ill. STATE ZIP tE. ? FINANCIAL. INR'rIT1.1T1?N NO .. -' I CERTIFICATE OF TITLE FORA VEHICLE 9 1919 O?z9o1??1ooa11?-ao1 1691=625H3B7102032 198+1 CHEVROLET' 1 33423016107 :C4 VEHICLE IDENTIFICATION NUMBER YEAR MAKE OF VEHICLE. TITLE NUMBER MTRH I tl ( I 10/171071 EXEMPT J4 BODY TYPE D U P SEAT CAP PRIOR TITLE STATE ODOM. PROCO. DATE ODOM. MILES ODOM. STAT US aa llII 1 E 5 1A '- 11 YO I {1 J. - .. TI E T D DA OF ISSUE TE I UNLADEN WEIGHT I GVilfi GCWR BRAN TITLE DS CYYJQMETER STATUS ODOMETER DISCLOSURE I®,bERAL LAW REGISTERED OWNER{S), t i INS;7E„TINAviti}/fltAa ? r.,,- S csr "j IE L COLL E'DD 22,54 PENN ST- 47? :? 1 ; HARRISBURG PA `17110 '`` * W LO N s Illi,.,., pon eattdocllon d the tlr? Lett; tro Mee n a secohd Berxwlder is MW u u. N1Mlalder must (onward this Tt1e to the BdresY. of MD" Vbhldaa 0h. the FIRST LIEN RELEASED ' approprlati form and fee. - I DATE BY SECOND'PEN RELEASED AUT"ORtZED REPRESENTATIVE DATE MARRM ADDRESS - BY AUTHORIZED REPRESENTATIVE EDDIE L COLLINS 2234 PENN ST HARRISBURG PA 17110 u 996. 4 ALLEN D BIEHLER' MA-cerilly as of it* date of Issue, tie official. tecords.of the Pennsylvania Deperunint of Trarreportetion r*f1W that the person(a) or company named herein Is the lawful owter d ft taN sehNte. Secretary of Trsoaportatloa FIRST LIEN FAVOR OF. SECOND LIEN FAVOR OF: ILSCRISED AND SWORN ,eEF'OF?E. ME. " le ha DAY 41iIIG $10NATVpE OF PEFIBDN AoMRne*eaa?a ?MTH naco be ts0 owner, will be iA ?irJkcr}wl Iwneq MBItM lppk tjOa 1a C Mk*. d TO ti V* velar ]t Ad Ahw+. uA?jx1 n no srohwt ft seal 04W nptl dwm"bo Here. S" ATUFE OF APPLICANT ON AUTHORIZED SIGNER SKWTURE OF 1ST 1ST CITY Kdlaser cow Mtan your spouse is IbMd and you want Um We to full 'Jdrit Twwb Wtdt MOM of 8 hip' (On death,%," le goes tO sumM g'bwmt.) CHECf ME O. O therwNa, 'ON aced 6A *Tenants ki Common' (On death of one owner; intatest of owner goes to Wier heirs or estate). Ate. ? IF NO LIEN, CHECK a' H STATE ZIP ECK HERE 11pED^ D NANGA NSTITUTION NO. IP Illlllll 2ND Liq DATE: -of- IF NO LIEN, CHECK 2ND UE11HOLDE STREET, Cm STATE' AN ELT, CHECK. HERE O REQUIRED -- ¦ 0 o H N U m m N \ • • L7 o N a1 x * ? H CA A Ei ?'? z W a P4 ' I W N H ti?_?' a 1 d4 VQ o O O ri m t:) \ C'4040 _ C) W UL;: ` H H Ln ` 0 U H C) r4 r-I Afl- P4 04 P4 r4 (- F? W .. --?d W E.., AP4 E-4 P4 11 W W z H >4 O?SHct 5 ON E-4 w a,-4 o yZEl4zoow aon?WWW E-4 E-1 E-4 0 UrCE-4 4u? azz W o ET4 H cr1 a o a 0 0 r4 ... it ?- rpUr? a r7~ a? Fw Z? a Q a d y o4 ??!3? Aao pZp w U z U? 0> Rw ?Uy?1 00 oooQ C7w ?U? 3 w? 41 >4 t- z O ? al o N a AN U c 94 w ? GT+ F 00 W W z 3 a A F a A Q- < qFs 7 V< Q S Q y F N?o c!f W GF-?ij of a ?? ?Q g F UW? Y Q?0.Q o ;uQ L, Q:. 04 ? ? ? 3 u c z? ? a 0 Or i, ? e'U7 ?6NW Z , ? ?ya , , o" z vQ0 -uI P4GX.Y ?voimo xov W wx a? x0 U °zo '? d y N?a W QWx F zoo o v uOj ?, w 1?1 ti a p H OaW a w" o 3ox W Wr,> a dH H fn O H a A ? oZ Ln ? ? o w 0) rA a O z r d O W H a a ? O O U W O F W N O > E Ho ? z a rn O N Z a% F 01 ri H w d ? q O z \ o O N O O > O U1 M W U) ? w ?? W o E-1 H ?Q w=° H v)o?aa??e 3 P .04 za HHW uMW S Hcq ?;)y,z ? Q O °z V2 P4 ODU•? W H H? ao ?o F w A 0 U z H a U h GW H Q 0 N to SP 1 to O O U) r1 a? ® O O > ? O ? U W ti UO O I4_? Commerce 9 Bank 0184021NY1N00003351 WALTER M PATTERSON III P0BOX2105 HARRISBURG PA 17105 Commerce Bank/Harrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING 0537727299 Statement Balance as of 10/26107 $52,735.19 Plus 3 Deposits and Other Credits $2,405.54 Less 13 Checks and Other Debits $13,543.76 Statement Balance as of 11/27/07 $41,596.97 Transactions By Date Date Description Debit Credit Balance 10126/07 COUNTER WITHDRAWAL $2,500.00 $50,236.19 10129107 WTHDRL DDA 121410129 17:04 $500.00 $49,735.19 101 N. SECOND ST. HARRISBUR PA 10130/07 WTHDRL DDA 1348 10/30 07:53 $500.00 $49,235.19 101 N. SECOND ST. HARRISBUR PA 10131/07 WTHDRL DDA 7626 10131 11:44 $500.00 $48,735.19 2030 NORTH PROGRESS AVE HAR PA 10/31107 CHECK # 1011 $107.27 $48,627.92 11101107 CKCD DEBIT 10131 PPL ELECTRIC $119.95 $48,507.97 UTIU800-342-5775 PA 11101107 CHECK # 1010 $316.54 $48,191.43 11102107 DEPOSIT $1,952.12 $50,143.55 11102107 WTHDRL DDA 2795 11102 08:00 $500.00 $49,643.55 101 N. SECOND ST. HARRISBUR PA 11105107 COUNTER WITHDRAWAL $3,500.00 $46,143.55 11/09/07 AC-US TREASURY 220 -TAX REFUND $447.19 $46,590.74 11113107 WTHDRL DDA 6659 11110 15:37 $500.00 $46,090.74 101 N. SECOND ST. HARRISBUR PA 11113107 WTHDRL DDA 7456 11/13 11:01 $500.00 $45,590.74 101 N. SECOND ST. HARRISBUR PA 11119107 COUNTER WITHDRAWAL $3,500.00 $42,090.74 11/21/07 WTHDRL DDA 8487 11/21 16:00 $500.00 $41,590.74 3951 UNION DEPOSIT RD HARRI PA 11/27107 INTEREST PAYMENT $6.23 $41,596.97 Check Transactions Number Date Amount Number Date Amount Number Date Amount 1010 11/01 $316.54 1011 10131 $107.27 440569' ' 11/05 Items denoted with an "E" are electronic entries and will not have a check image. $3,500.00 007 Cycle Page 1 of 3 ?.-_ ___ __..__,._ ....... ?,.., u?1??nT•uT 1uCAS\sATIAwI _ M do Member FDIC Commerce V Bank Check Transactions Number Date Amount Number Date Amount Number Date Amount 556463• 10126 $2,500.00 561181' 11119 $3,500.00 Items denoted with an "E" are electronic entries and will not have a check image. Interest Summary Beginning Interest Rate Number of Days in this Statement Period Interest Earned this Statement Period Annual Percentage Yield Earned this Statement Period (APY) Interest Paid Year to Date EFFECTIVE JANUARY 1, 2008 RESULTS OF AN ELECTRONIC TRANSFER INVESTIGATION WILL BE PROVIDED WITHIN THREE BUSINESS DAYS. f'. 0.15% 33 $6.23 0.15% $12.50 537727299 018402INYIN00003351 Page 2 of 3 NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION . Member FDIC Page 3 of 3 Date 11/27!2007 Account 537727299 0184021NT1N00003351 1 WALTER M PATTERSON 111 e1a1 1010 t ED COLLINS IPOA) I F10Rex 2101 m ulnn fURR15RURG, YA 11101 "; PRT lnthe A --1-`? ?IV.s`I yyI _ _ptf 6r,1 Sy l+>--_nnllnrc 0 ' Commerce Bank ";? ' ;?°`° """ "'• 1:0 3 1 30 1134 61: 53 772729 91I' L010 1 .?.,_... exz. ?. , K....>.•._..., ?.r>....,...,>«._.._,r?.....•?.,e!:L1QAR934x6.4?.:r,-< Check 1010, $316.54 Date Presented 11/01/2007 Commerce CHECKING CBank WITHDRAW; r \` HARRIS NAME >?1 r 5 3 -? l Z 7?? t) CCOUNT 00.140569 . TICiKEr `? ry7 I?L1VL ? e» ?R o.p, 1 +0041.0569.1 I; 50 29••0 LA1.1: Check 440569, $3,500.00 Date Presented 11/05/2007 °auMn mmu CHECKING ACCOUNT 00561181 3 Bank WITHORAWALTICKET yyy 9 1, HARR16RURG (. -7 9x NAME .-Ea._C_>i_____ nnL'? L._ 5 0S3 1-12-7 99 s M0056i181xC5029.0 LA?1: Check 561181, $3,500.00 Date Presented 11/19/2007 WALTER M PATTERSON NI W-o 1011 ED COLLINS (POA) PO Box 2105 Q Z J fA•mnn Uale_? y_? N IOY MDURG. PA 11105 I'1fy to the _ _??"v. ? _ T....??..•,1Tdi.r<.. s°lh T nGuRrA 6 ?- Coam"Orce For r:03i30i8461: 53 772729 9e i01i .100000 30 7 2 ?,F....x•........+..?..r...+?5-Wis....,-?.°x..,.: G.4-:?..«, _•a?.n.K?...:,v...a Check 1011, $107.27 Date Presented 10/31/2007 O/T1merCe ,1 ? CHECKING A Bank WITHDRAWAL (' ?\ HARRISB NAME I? u r r. r S' 3 -1 -1 2-7 1 Ll CCOUNT 00556463 y ROCKET S Z S O (? p ?L IPOCISSG463r .5029-•0i84, Check 556463, $2,500.00 Date Presented 10/26/2007 wZZ? - - - _ . ---? T H E C I T Y O F H A R R I S B U R G MONTHLY UTILITY BILLING ACCOUNT NUMBER BILL DATE DUE DATE AMOUNT DUE 09030013-0000(9) 09/26/2007 10/15/2007 107.27 PROPERTY ADDRESS PROPERTY OWNER 31 N 18TH ST W M PATTERSON III PREVIOUS AMOUNT BILLED ON 08/26/2007 ........................... 95.87 NEW PENALTIES INCURRED ......................................... 1.35 ,REFUSE PICK-UP .00 REFUSE DISPOSAL 4.83 READY-TO-SERVE-WATER 5.22 TOTAL NEW CURRENT CHARGES ...................................... 10.05 TOTAL AMOUNT DUE ............................................... 107.27 RES ** PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION ** YOUR COPY ____________ ---------------------- ------------ T H E C I T Y O F H A R R I S B U R. G MONTHLY UTILITY BILLING ACCOUNT NUMBER BILL DATE DUE DATE AMOUNT DUE 09030013-0000(9) 10/26/2007 11/15/2007 118.82 PROPERTY ADDRESS PROPERTY OWNER 31 N 18TH ST W M PATTERSON III PREVIOUS AMOUNT BILLED ON 09/26/2007 . . . . . . . . . . . . . . ............. 107.27 NEW PENALTIES INCURRED ........................................ 1.50 REFUSE PICK-UP .00 REFUSE DISPOSAL 4.83 READY-TO-SERVE-WATER 5.22 TOTAL NEW CURRENT CHARGES ........ 10.05 ............................ . . 118.82 TOTAL AMOUNT DUE. .............................................. RES * * ** PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION YOUR COPY qmw IS 40 Past Due Loan Amount $ 2,239.04 Due Date Current Balance* Loan Payment $ 316.54 Prior Balance Total Payment Due $ 2,555.58 DESCRIPTION AS OF AMOUNT 11/26/07 Payment-THANK Y 10/29107 316. . 1 RMIS 4f EFERENCE YOW MBER ? r 67200 387814 Credit Bureau Disputes; ea; CiYFirlarlciel, Credit Bureau Correc Ic PP.0 er Box 499. Hanover, Mtaryland 21076; Eratatrt. nclnl r " ` ' Bank Dept, C 140089, I TX Bureau Corrections Dept., rup Y wing, Banlgup y gprwl C*in?, 8&*iuptcy Dept i 760144419, 4 In Maryland: CiUFnencial, Inc. u t , " ' E 1+ -1 F I F iJ d f K? • I S J CITIFINANCIAL P O BOX 70918 CHARLOTTE, NC 28272-0918 Address Service Requested Please mail this coupon with your payment. II11111111111111111111111II'111111illlllllllllllllllllllllllll Mail Payment To: CitiFirlancial P.O. Box 6931 The Lakes, NV 88901-6931 Ilnlllnlllllnllnnnlllllnlllnnllnnllnllnnllnllll Account Number 67200908-0303878 c ti financials"" 12/15/07 *Not a payoff balance; FOR STATEMENT INQUIRIES: $ 8,253.30 call us for details. CitiFinancial $ 8,569.84 PO BOX 70918 P O BOX 70918 CHARLOTTE, NC 28272-0918 (800) 346-3051 APPLIED TO APPLIED TO CHARLATE EES BALANCE -316.54 j? Total Payment Due $2 555 58 Payment Due Date 12/15107 2 Total Payment $ Amount Enclosed Please check here to indicate mailing address / phone number changes and enter them on back of coupon. 01 01 19281 1 WALTER M PATTERSON 0 PO BOX 2105 Rs02 HARRISBURG, PA 17105-2105 I IIL I IIII JJ I I IIIL 1 1 1L Li ll l III II III tII rII I III 111 1 1 III r?l ? 067200908030387802555580031654000000088901693109 .2ty_ Commerce Bank 0184021NYIN00003213 WALTER M PATTERSON III P0BOX2105 HARRISBURG PA 17105 Commerce Bank/Harrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. Statement Balance as of 11/27107 Plus 2 Deposits and Other Credits Less 10 Checks and Other Debits Statement Balance as of 12126/07 Transactions By Date Date Description 11128/07 COUNTER WITHDRAWAL 11/28107 CHECK # 1012 11/30/07 AC-PA TREASURY DEPT-ANNUITANT 12104107 CHECK # 1014 12104/07 CHECK # 1013 12/10/07 CHECK # 1015 12/12/07 CKCD DEBIT 12/11 DIRECT FINANCIAL S8004604306 UT 12/14107 CHECK # 1016 12118/07 CHECK # 1016 12120107 CHECK # 1017 12124107 CHECK # 1022 12126107 INTEREST PAYMENT 50 PLUS CHECKING 0537727299 ;41,586.97 51,956.55 $23,071.55 $20,480.97 Debit Credit Balance 53,500.00 $38,096.97 94,284.92 $33,812.05 $1,952.12 $35,764.17 $3,500.00 $32,264.17 $64:91 $32,199.26 $3,500.00 $28,699.26 $635.00 $28,064,26 $364.30 $27,699.96 $3,500.00 $24,199.96 $222.42 923,977.54 53,500.00 $20,477.54 $3.43 $20,480.97 [Check Transac tions Number Date Amount Number Date Amount Number Date Amount 1012 11128 $4,284.92 1015 12110 $3,500.00 1019 12118 93,600.00 1013 12/04 964.91 1016 12114 $364.30 1022" 12124 93,500.00 1014 12104 _ $3,500600 1017 12120 $222.42 1841966" 11128 53;500:00 Items denoted with an "E" are electronic entries and Mill not have a check Image. Interest Summary Beginning Interest Rate Number of Days in this Statement Period Interest Earned this Statement Period Annual Percentage Yield Earned this Statement Period (APY) Interest Paid Year to Date 0.15% 29 $3.43 0.15% $15.93 007 Cycle ?, Z Page 1 of 3 Page 3 of 3 Date 1212612007 Account 537727299 01S4021NY1N00003213 1: . 1E, w-'ERS"•1 Uele +V:?rzIW% C1:1 n+nN(:'IL -MrkX 1111: K7 MIX: Ts / C':1R '!+(7usnN). Iw9 •+:nal,l+eu aa;> F+,M I r =wu nr.C„n1eC CA+SNF4CF."NKr WISFn IR(?Nr.1 - - _` ,r,c 011 111(L>IZF.G 51?_N:n I C 1V F+X: HE2065-H11 wnurR"`AtleRSON I`¢ f 1:03110L8461: 537727299p• 160162 0000428492,' kkkk - - .................... - - Check 1012, $4,284.92 Date Presented 11/28/2007 ALTER M PATTERSON 111 01.1 1014 ED COLLINS (POA) F10 POX 210 Dot, -h-no? wIrWI„ IW%FoSMURa, PA STIR ` 1 Paytothe 'I ?? ?'O L Order of . O „n,ti 1'. ??yy,yw_11 .t 1y rt.)? L r' 1W Dollars 0 T ?P . ^ J 7 1?iM?07 13 53772'239 sh of r, Check sA Of tC hetk I f3150U.00 ]B4 c6L0N1AL PARK For 1:031630184661: 53 772?29 4f' jolt. Check 1014, $3,500.00 Date Presented 12/04/2007 WALTER M PATTERSON 111 etor 1016 ED COLLINS (PDA) Pon=2103 Date Z' 1,0 1aiNR1? PMn8MJRa, PA ITIo3 1laytothe Orderaf C.?. I $ 310?1,3?J 1?_t- ?? ?,P? \3./I,) Dolhra ? r Fory•ae Aj,+ v- 1:0 3 16 30 184 61: 53 _772729 41" LOj6 r,'0000036t.301ti' l?= Check 1016, $364.30 I)ate Presented 1211412007 WALTER M PATTERSON 0r nr 1018 ED COWNS (POA) ' 1p sox 1163 c 1: _) Fanviu IfAnRlsaum,PAg1n J Date. ?- 0 1 Orilerhe ( x,511 1 $'3;Soo, 06 or- •,d" ==-- cdow wev A.,....tnwrcw,..r,1 P• M• C rwrp.wN li ?+7 •,f'i 12, if, n: 17 Cash ca Vs 1rr;1: For 1A1 OCRIIPt'Il 11.%?ir15f1SG-- tt1 - (.. ,?1 ????_. -_ .. 1:03 L30 LB 1. 61: 53 7:12729 90 LU LB ;heck 1018, $3,6110.00 Date Presented 12/113!: 007 CodNncrce ? CH WV ACCOUNT d ?g9plc ?l ?-t w1T ORAWAL TICKET 01841966 i !1 1 HARRISBURG _ T NAME-... Ea_La. 11 T 53112-1 -2 9 ? 3 3So o.,0 "OL8t.?9661„ 1:S029•gUL n'...! MecPc I0 S-13-5M. ss•.rsalw rn ,?-. + - , ? . ra -x+..rr? WALTER M PATTERSON 111 or-or .ll.?:+va.:?: A+.rs<l+sew.s?. ar?n+:+r.s 1013 ED COLONS (POA) PO am 2103 F"RI59URG, PA 17103 011N17 Dete_11: _?' ti Pny lOtl,e Orderof? ??4E J J S?II ! 1t• ,. -j $ ly` m I p' ?'3?'?-^?4 " ' q1 ?1? Dollars A L l C. ` ?1f-_l_ 4nw4YYnr4•wKw•IIW O?r1R ,?nrmW 1•Lr 5.1?.y 0 ??_a?._ . ?.- 1:03i30L8461: 772729 9x' 16013 0f10000649i?' u --,.ors..a,.r7mu.Gw.-_t.,,nr-.•-?+a+rx.,..irev..,..1r-.re:.t?(._2t?....?-rv..ees,.. Check 1013, $64.91 Date Presented 12/04/2007 nw- rre.+•er- 1w14w,-. rw.;>,mwranrrC.s-rt•--1 WALTER M PA S 111 07-07 1015 EO COLONS (PO 1.0 ROx 2105 1w 17,-10-0 Ie INnIs HARNSOURO. PA M03, Pay to the Order of $ -5, 0 _-:?'lv??-4._,?cn•• - !- D011aro 0 -. COAYJIe/Ce ?? CBHfI/( ,.»..1.? ?n a Ft? IwctV/10,137 9 137 71 h C. O.[A 163 CCUTAOUIi 161F.81. For I'mlaoL$t.61: 53 772129 91' 10165 Check 1015, $3,500.00 Date Presented 1211012007 WALTER M PATTERSON III mw 1017 ED COLLINS (PDA) PO SM 2106 Date 11-%1-01 ?' q NIRA SSURa. PA I?N6 r*r of e O PE I $ zzz.yL rder e ` , "?r? -VitL?an1,.,Um U. 1 ?T?l•) Dollars ?1 For #?Z 3?4 0-84 X15 brae I:D3130181.64 53 772729 91' i0i7 onnnnn7a7L2.0 Check 1017, $222.42 Date Presented 12120/2007 raworol.reelNOw... aqr rALl%R M PATTERSON NI 07ar 10'12 ONS (POA ) ro 0002103 pate tZ? 1'Z'p7 1. 1MRRISMM PA 17105 I'nq to the ' (tS? 1 $ SC'S 7 ' •ot I Urderol - ` ` ?? --._.. •-1?.?.n•..__ 1 ..?iwL.A? o?./?`-.. ?A?l? Dollars ®= COnMrMrr9s A-k.10 a r.., ?? PII 12?22r07 6 537Tt7:99 rea.?r< ,..a ` r Cash oa Us Clock tt S3•AlO.RI A 187 L!I16110fPOSIT G` ?Il s - For 1:03, 30168461: 53 772729 91' L022 Check 1022, $3,500.00 Date Presented 12/2412007 • its, CASH CENTRAL ONLINE LENDING MADE SIMPLE 84 EAST 2400 NORTH, N. LOGAN, UT 84341 WWW.CASHCENTRAL.COM 0000046 01 MB 0.326 **AUTO T2 0 3853 17103 lu?lll?uln?llllm??llu?l?l?l?l?ll?nnll?ulln??ll?lnll Walter Patterson 31 N 18th Street Harrisburg, Pennsylvania 17103-2503 Demand Statement FI=B 06, 2007 Past Due Amount: $635.00 Dear Walter Patterson, As of the date of this letter, you are in default of your personal loan. We are writing to inform you that your account had insufficient funds and therefore, your scheduled. loan payment was dishonored by your bank. In order to cure this default we must receive the past due amount within 15 days from the date listed above. Our payment options include automatic debit, Western Union, and VISA. Please call us immediately at 1-800-460-4352 to make payment arrangements. If you are unwilling to respond or take care of this problem within 15 days from the date listed above, Cash Central will begin commencement of final collection procedures including but not limited to: National Collection Agency, Negative Credit Reporting, and a judicial suit. The binding contract, letters, and documented phone conversations will be used as evidence in the curing of this account. The defaulted amount may remain on your permanent Credit Report until we have received payment in full. Cash Central reserves the right to collect the funds or electronically draft the amount at any time. Please contact us as soon as possible to avoid any further actions. We urge you to handle this matter now. Sincerely, Collections Manager 1-8004604352 .. Z7 . II 2IT 210 17 11 : 23 FAX 716-1114212.3 ?i 1) FINANCT kL NCO FINANCIAL SYSTEMS INC I- 1-,20. 5H_ ?IPA71-PERSON F}F20615-1427-0 }1')060 ;,ALTER M PATTERSON _ 1 V 18T'I -I1,11 HAIR"' i :TRCJRC: , PA -1 ; 1 () 0 ot12 0112 PO BOX 15630 WILMINGTON LE 19650 y00-2Zj- 9 8 8 2 :?FFI(--'E HOURS 'A A- 9 P M MON TH =,T; T'I-TRSDA Y 8AM-5FM FRIDAY SAM- 12 PM SATLJRT)' Y Nn-j 27, 2007 Cr_d,tC, r Account # Principat Intere=.t Int Rate Other Amt Owed CITIFINANCIAL 7009080303878 8559.84 0.00 0.00 8569.84 PURStJ}ANT Tu IuiJR A FEME-J T, THIS LETTER. IS TO CONFIRM THAT 'THE ABOAIE CREDITOR ,GILL, ACCEPT TH E AMOUNT OF $ 4284.92 AS SETTLEMENT r)F' TI:P ABOVE AC(-'OL?NT IF PAYMENT TS RECET,VED BY 11/27,107. I-IOPE T1LkI,7 $u00 OF YOUR DEBT IS CANC-:LED BY THIS SE'T'TLEMENT, PLEA:=E E A-T)VI SED T1-'AT CT'T`TBANK IQ kE(;?LI:I'_EI) BY FEDER.?L, LFiT.•J l' IN! ER?NT,?L REVEIi ]c SFt';'=OLJ 6050F? TO REPORT TH-S IjM0-UNT. . L.F'A--"P iv.Tk"F_. Fr ?'nIFNT I-)AY TO- !,ITIEANK. ;-'H 'SIC.ATI A.UTdRES's . 1\T ,0 F'INP-d 'T?>L Y,"Trrl_, T1\C 5.0"; PRUDENTIAL ROILD HOR-SI-AM PA 194 J4 MSKIP 08/01/07 PLEASE ?-4.IL ?AI-MEIvT TO; NCO F:II`iANCIAII '"17 P- TEM?, , TNC' . PO BOX -75889 tTI .M Nc? T OIV DE 19850 TELEPHONE: 800-213-9852 -ALLS T(' , (JR FT<<?f?1 T1"iT CCT?IPANY }1l;:i' BE NJJNiTORFD OF }2.?",C0> IJEL) F'rR ??? :LIT'r: T -'Tc IS Ati ATTEMP'T' TO COLLECT A DEBT_ ANY T_NFO_RMATION OBT!-? INED WILL RR USED FOR TILT PTIPPOSE_ THIS :CS A COMMUNICATION FROM A DE-±T COLLECTOR. WALTER M PATTERSON 111 07-07 ED COLLINS (POA) 1 12 PO BOX 2105 HARRISBURG, PA 17105 i' • Z, _ V "? Date 80-184/313 T'aY to the _ 16 Orderof NiCi3 America's Most Convenient 8ank8 1-888-937-0004 Dollars EALANCE MAY FE CEF,TS'I' OI? OTI ER tF'li TOP, OI' 7. For `? L`? ?y???,?. I ?ZZ 1:D3 L-in int r.• r M' 'T V1 AT ION Past Due Loan Amount $ 0.00 Due Date 01 / 15 / 08 *Not a payoff balance; FOR STATEMENT INQUIRIES: Current Balance* $ 3,968.38 call us for details. CitiFinancial Loan Payment $ 316.54 Prior Balance $ 8,253.30 PO BOX 70918 P 0 BOX 70918 Total Payment Due $ 316.54 CHARLOTTE, NC 28272-0918 (800) 346-3051 DESCRIPTION AS OF AMOUNT APPLIED TO LATE APPLIED TO 12/26/07 CHARD FEES BALANCE Payment- HANK YOU 11130107 -4,284.921 1 -4,284.92 l t? assets REFERENCE YOUR ACCOUNT NUMBER: 672009080303878 Credit Bureau Disputes: CiliFirianciel, Credit Bureau Corrections Dept, P.O. Box.499, Harwver, Maryland 21076; ` 86lil Wicy Real Ealate: CitiFinancial, Bankruptcy Dept.. P.O. Box 140069, Irving, TX 75014-0089: Bankruptcy Personal: CiitiiFwwwial, Bankruptcy Dept, P.O. Box 140469, kvi%, TX 75014-0489 ' In Maryland: CiBFinancial, Inc. CITIFINANCIAL P 0 BOX 70918 . CHARLOTTE, NC 28272-0918 sMAccount Number 67200908-0303878 Total Payment Due $316.54 sg d0financial Payment Due Date 01 / 15108 Address Service Requested F ?• , 8? Total Payment $ Please mail this coupon Amount Enclosed with your payment. E Please check here to indicate mailing address / phone number changes and enter them on back of coupon. ??IIIIII?II??II?IIII?'?? + ++ 11??1?1?1'I?I"111'?II?III?II??III?I1? Mail Payment To: CitiFinancial 01 WALTER M PATTERSON 01 22130 1 0 P.O. Box 6931 PO BOX 2105 RS02 The Lakes, NV 88901-6931 HARRISBURG, PA 17105-2105 ??n?l?n?l?l?nl?uurr ??r??n?r?nn??nu??rr??nn??nll?? ?nrll?nllul??llnnll?nrll?nr???lnn?r?l?? nu?l?nl??l? 067200908G3O387800316540031654000000088901693107 on, Aft The City of Harrisburg, Pennsylvania, Incorporated March ty, 184M City Government Center - Harrisburg, Pennsylvania 17101 ***REMINDER NOTICE*** ***REMINDER NOTICE*** ***REMINDER NOTICE*** CITY REAL ESTATE TAX REMINDER NOTICE FOR 2007 TAX YEAR MILLAGE RATE APPRAISAL LAND............ 0.0286700 7,400 DATE OF BILL IMPROVEMENTS.... 0.0047800 24,900 01/17/2007 +10%- PENALTY PAYMENT OF 364.30 IF PAID BY 12/31/2007 O -PROPERTY INFORMATIG - 'ro W M PATTERSON III C8 31 N 18TH ST T W PO BOX 2105 PATTERSON III,W M HARRISBURG PA 17105-2105 'J CA CJO OE Co 024357 09030013-9 w IMPORTANT INSTRUCTIONS ' 1. PLEASE RETURN THE CITY COPY ALONG WITH A 1. FAUOR DE DEU CITY COPY CON UN CHEQUE 0 CHECK OR MONEY ORDER MADE PAYABLE TO: "CITY GIRO POSTAL PAGADERO A: "CITY TREASURER" NO TREASURER- DO NOT SEND CRSH!!!! MANDE DINERO EN EFECTIUGH ! 2. IF YOU DESIRE A RETURN RECEIPT, ENCLOSE BOTH COPIES AND A SELF-ADDRESSED STAMPED ENUELOPE. DELINOUENT REAL ESTATE TAXES ARE SENT TO THE TAX CLAIM BUREAU AFTER FINAL DATE. 2. SI USTED DESEA UN RECIBO, FAUOR, DE INCLUIkAMBAS COMAS ESTAMPADO UN SOBRE CON SU NOMBRE, Y DIRECCIOH. DESPUES DE LA FECHA FINAL, LAS FACTURAS UENCIDAS SERAN DEUUELTAS AL TAX CLAIM BUREAU. CUSTOMER COPY 3?0 - COMMONWEALTH OF PENNSYLVANIA COUNTY OF: DAUPHIN Mag. Dist. No.: 12-1-04 MDJ Name: Hon. MARSHA C. STZKART Address: 1520 WJLTJN DT ST HARRISBURG, PA Telephone: (717 ) 233-1220 17103 RECEIPT OF PAYMENT COMMONWEALTH OF PENNSYLVANIA VS. DEFENDANT: NAME and ADDRESS rPATTERSON III, WALTER N P.O.BOZ 2105 HARRISBURG, PA 17105 WALTER N. PATTERSON III L J P.O.BOZ 2105 Docket No.: TR-0003387-07 HARRISBURG, PA 17105 Date Filed: 11/13/07 O 83-131 513D STREET CLEANING 2284058 (rharnp) RECEIPT NO: 225929 DATE: 11/28/07 PAGE: 1 SOURCE: PAID AT WINDOW AMOUNT RECEIVED: $ 64.91 METHOD: PAID BY CHECK AMOUNT APPLIED: $ 64.91 CHECK#: 01013 COLLATERAL APPLIED: $ .00 CHANGE: $ .00 MANUAL RECEIPT#: CITATION#: 01141194 NEXT PAYMENT AMOUNT: COSTS INCLUDED ON: NEXT PAYMENT DATE: NEXT PMT TYPE: ESCROW DESCRIPTION BALANCE FWD AKT APPLIED C URRENT BAL COLLATERAL .00 64.91- 64.91- TOTAL .00 64.91- 64.91- CURRENT BALANCE DUE .00 RECVD FROM PATTERSON III, WALTER M THANK YOU! BL DATE PRINTED: 11/28/07 12:37:54 PM AOPC 450-99 _ ?, - Commerce Commerce Bank/Harrisburg N.A. P.O BOX 4999 Ban/? Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 018402INYIN00003198 WALTER M PATTERSON III P0BOX2105 HARRISBURG PA 17105 We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING 0537727299 Statement Balance as of 12/26/07 $20,480.97 Plus 2 Deposits and Other Credits , - $1,953.65 Less 5 Checks and Other Debits $12,794.10 Statement Balance as of 01/25108 $9,640.52 Transactions By Date Date Description Debit Credit Balance 12/27/07 CHECK # 1020 $794.10 $19,686.87 12131107 AC-PA TREASURY DEPT-ANNUITANT $1,952.12 $21,638.99 12/31107 CHECK # 1021 - $3,500.00 $18,138.99 12131107 CHECK # 1019 $5,000.00 $13,138.99 01/09108 CHECK # 1023 $1;500.00 $11,638.99 01115108 COUNTER WITHDRAWAL $2,000.00 $9,638.99 01125108 INTEREST PAYMENT $1.53 $9,640.52 (Check Transactions Number Date Amount Number Date Amount Number Date Amount 1019 12/31 $5,000.00 1621 1201 $3,500:00 619520* 01115 $2,000.00 1020 12127 $794.10 1023* 01109 $1,500.00 Items denoted with an "E" are electronic entries and will not have a check image. Interest Summary Beginning Interest Rate Number of Days in this Statement Period Interest Earned this Statement Period Annual Percentage Yield Earned this Statement Period (APY) Interest Paid Year to Date 0.15% 30 S1.53 0.15% 51.53 EFFECTIVE: JANUARY 1, 2008 - IF YOUR BANK CHECK CARD OR ATM CARD IS INACTIVE FOR ONE YEAR THE CARD WILL BE CLOSED. 007 Cycle Page 1 of 2 Page 2 of 2 Date 01/2512008 Account 537727299 018402INYIN00003196 ,,;... s.?.. rr.--ee•r .......n --n WALTER M PATTERSON 111 •.;;rn::,:axr::.•-..... n. 0707 :ran: a:rr ?.. -,.a:.... ,,>.r.r....?:.u,....:;n;.wn, 1019 ED COLLINS (POA) FoBOll zlos 0 Date IZ-It111-11t] to-Rlrn6 /URRi50UAG. PA 11105 ' o dt°or S tiJS ??•. a?aF1, CA1 l Ct:?1?o. 1 $ 5? ooo•oa Coin en a ?Y. a: CBank '°"" For?elk M•Qa4kl, s,'. l? --- 1:03L3018461: 53 772729 9a' LO19 Check 1019, $5,000.00 Date Presented 12131/2007 PATTERSON IN oral 1021 S (PDA) PA 11/D3 Date 12_2 ,0 rslalnu N oraeror 1C1l J $ ?, 500.0 CorrurTerce b.. ut O nwA rMM- ?BarTk u r. 1157 fli 12.23%07 I2 ssrzn93 cash Oa It; Ulsd. S3.SOh .00 104 DMMi(M.I F:C21S', 6 For =?._Cq?__ r L1'.O343OL8461: 53 772729 9a. L021 Check 1021, $3,500.00 Date Presented 12/31/2007 Commerce CNECKINC Bank WITHORM 1 (1 HARRI NAME V OAk-1?1' 1\ YCI'1'W-100 _ . ct.: 111 7 x414 s,D06L9510r 1:5D29.DL8Ie: 00619520 C?K URO € Check 619520, $2,000.00 Date Presented 01/15/2008 WALTER M PATTERSON fit 07-07 1020 ED COLLINS (PDA) Po Box 2105 YlaOala "ARRRMRO, FA Mob DxtC 11.2 1 . J?. R Orlaule C.?'. -T r rl S? rtiy, 1 '? 9 Io Order o $ f y . -?•.^• M M - *' ?-? -11- 3 ?It -Do11arB ? ?_ C°Mr?ferceAM.v..ra.e.,,.. "o 2:1 3L30L81.61: 53 772729 90' 4020 O?L1 a? :?. Check 1020. $794.10 Date Presented 12/27/2007 { 1 WALTER M PATTERSON 111 mm 1023 ED.COLLINS (PDA) ?j Fo eo1 21*1 Date L Z - a S ae RI"1 1 10 HARnwum, PA 17105 1'1y totho orderDr???1??.a. C $ 11seo.oo Dollars 8 =- Commerce .r„xr.swro.^..w.rw r CBank , „...., For P1+1<..E Mtk tA. VIAL -0 - ?'? --- '._ ?° -" ----= 1.03L30LBL.61: 53 772729 90' L023 .. Check 1023, $1,500.00 Date Presented 01/09/2UUU y Harrisburg School District 2101 N Front St, Building #2, Harrisburg, PA 17110 4565 ***REMINDER NOTICE*** ***REMINDER NOTICE*** ***REMINDER NOTICE*** HARRISBURG SCHOOL DISTRICT REAL ESTATE TAX REMINDER NOTICE FOR 2007 TAX YEAR ` MILLAGE RATE APPRAISAL LAND............ 0.0223500 7,400 DATE OF BILL IMPROVEMENTS.... 0.0223500 24,900 07/16/2007 +10% PENALTY PAYMENT OF 794.10 IF PAID BY 12/31/2007 W M PATTERSON III PO BOX 2105 HARRISBURG PA 17105-2105 024357 09030013-9 -PROPERTY INFORMATION- C11 31 N 18TH ST TD PATTERSON III,W M C:) -p W O D t C7 n ,0E C7 {01, Please read the important instructions on the back of this notice. CUSTOMER COPY 31l- Commerce Bank 0184021HYIN00003162 WALTER M PATTERSON III P0BOX2105 HARRISBURG PA 17105 Commerce Bank/Harrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING 0537727299 Statement Balance as of 01/25/08 ;900:52 Plus 3 Deposits and Other Credits $2,328.68 Less 4 Checks and Other Debits $7,375.00 Statement Balance as of 02/26/08 $4,594.20 Transactions By Date Date Description 01/28/08 COUNTER WITHDRAWAL 01131/08 AC-PA TREASURY DEPT-ANNUITANT 02108108 CHECK #1026 02111108 CHECK # 1027 02/15108 DEPOSIT 02120108 BANK DEBIT 02/26/08 INTEREST PAYMENT Debit Credit Balance $3,500.00 56,140.52 $1,952.87 $8,093.39 $1,500.00 $0,593.39 $2,000.00 $4,593.39 $375.00 $4,968.39 $375.00 $4,593.39 $0.81 $4,594.20 (Check Transactions Number Date Amount Number Date Amount Number Date Amount 1026 02/08 $1,500.00 1027 02111 $2,000.00 695670' 01128 $3,500:00 Items denoted with an "E" are electronic entries and will not have a check Image. Interest Summary Beginning Interest Rate Number, of.Days in this Statement Period Interest Earned this Statement Period Annual. Percentage Yield Earned this Statement Period (APY) Interest Paid Year to Date t 007 Cycle NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION ft 3 r! 0A6% 32 $0.81 0.15% $2.34 Page 1 of 2 Member FDIC Page 2 of 2 Date 0 212 612 00 8 Account 537727299 M4021NY11400003162 CMECAMa C001E 5E? ANIf, N.A. p/ ProoS error, eretli*cd iD wrong aceuun?' ?i,?altier• rn. PafLe.r-?o,? ?-?? : SO 2 7.0 Wt.,: Check 0, $375.00 Date Presented 02/20/2008 WAL ER M PATTERSON 111 07a7 1027 ED COLLINS (POA) PC) O 1 Dam eo-n'013 1 -p > 1 RRG. PA 17109 wMMM 'ay Wthc r RSh o Order 2000. d0 I $ - { ?y.?t•, ? ae.,.r? AsS?. . ?. ~ I1 rte. iMlLvs B CDIN/nBl CYl , ,. .Aw• BarTk ';,, 9'2x"1;( e?•t!?!e ? 5??arzss ? ..s e0 LIE 0-0, 2,OMI.O1 Ill 1t7'IfCt7i. cT lccy.t. I For ?- 1:03L30181.61: 53 772729 99' L027 Check 1027, $2,000.00 Date Presented 02/11/2008 WALTER M PATTERSON NI srar 1026 ED COLLINS (POA) W Box 210 SURG. PA 17103 Date 2- 5-OE' Paymthe S r.•e lluslil, date Ceu?en.__I $ j OTdarof-?Lr?? 1500. oj) Dollars f3 r-onsinerce r ` . For l k-,. Whjkr 403L3018461: 53 772729 9M 1026 Check 1026, $1,500.00 Date Presented 02/0812008 Coaunerce CNECKINaACCOUNT 00695570 C? WITHOARRARIISSUH0 NAME ? \ k,1(n - tficc?. I-L wyA Flue I (?f?rcc?- i 4 ACCC•: 53?? 21 299 $ .. 35c,.o_.-Q'o! A`0069SS70" •:5029-O1a I.,: Check 695570, $3,500.00 Date Presented 01/2812008 e. "Im. Mtm4? Commerce Commerce Bank/Harrisburg N.A. P.O BOX 4999 Bane Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 018402INYIN00003064 WALTER M PATTERSON III PO BOX 2105 HARRISBURG PA 17105 We're here 7 days a week, 24 hours a day at 1-888-937-0004. Statement Balance as of 02/26/08 Plus 2 Deposits and Other Credits Less 4 Checks and Other Debits Statement Balance as of 03/26/08 Transactions By Date Date Description 02127108 CHECK # 1028 02129106 AC-PA TREASURY DEPT-ANNUITANT 03103108 ; WTHDRL DDA 9589 03103 12:14 4250 DERRY STREET HARRISBUR PA 03111108 CHECK # 1031 03/13108 CHECK # 1030 03/26108 INTEREST PAYMENT 50 PLUS CHECKING 0537727299 54,59410 ;1,963.46 ?.? $2,625.94 $3,921.72 Debit Credit $25.94 $1,952.87 $100.00 $1,500.00 $1,000.00 $0.59 Balance 94,568.26 ' $6,521.13 $0,421.13 $4,921.13 $3,921.13 $3,921.72 (Check Transactions Number Date Amount Number Date Amount Number Date Amount 1028 02/27 $26.94 1030' 03f13 $1,000.00 1031 03111 $1;600.00 Items denoted with an "E" are electronic entries and will not have a check image. Interest Summary Beginning Interest Rate 0.16% Number of Days in this Statement Period 29 Interest Earned this Statement Period $0.59 Annual Percentage Yield Earned this Statement Period (APY) 0.16% Interest Paid Year to Date $2.93 007 Cycle 2 asp 4111 'F_ CGF DFVFDCC CIr1C CnD IRADnOTAWT IWCn ORMAT1nm Page 1 of 2 Page 2 of 2 Date 03126/2008 Account 537727299 018402INYIN00003064 WALTER M PATTERSON NI 07107 1028 ED COLLINS (PDA) PO aux 2103 s ?•- zs srvlsusl PUUM aRO, PA irt0 5 R Dafr pn Paytnthe 1 ' " OrderoL b.. - 1 $ Z s. 9 y ?yI 1 s Dollars 9 M CdtNr7er+Ce 1 ` ?r.? ?J_ M.by? l'enw.Ww 4.N ? - For_?3`jqu-?4ci S 1:03130181.61: 53 772729 90' 1028 ..,.,...,.,,,??. , Check 1028, $25.94 Date Presented 02/2712008 1 11 M PATTERSONJII, 0710. 1031 ED COL COLONS (FDA) PAnRM 1pS Date ?7 '11 -o ti' eralon IN111LLRCURO, PA In03 Peytoth6 11 ()fdCr Ol ?Sn l $ ?, SOD.oO CmIffoPCe a w. co...r ...+ C B McR OVIV0211 537;2?23? task c1 2i ctec11 51 mo tit For 104 Dr,A410LC1 H:+?GI:RRG ?,? 1:0 3 9 30 184 81: 53 772729 9rr 1031 Check 1031, $1,500.00 Date Presented 03/11/2008 r?-?.f?%%"?T.ti:!:R1-::!:M?':?YS°..l?IC"_tY:?':it'XCXC`-`!.'m_.i'--.r5.-a?yn-.: JiT-!:Aa?.?./ :__sTe•JT'L-..cr i WALTER M PATTERSON 111 or-0r 1030 Hgp INB (POA) Po 1 m jOS??Pq tr103 se•nwu Dale 3-1-D? K F F Urderoi 1 Cc $ 1omO Do ?° i-dA/L,u•„p?, ???I? Dollars 6 `weavlk NM Ut?wNwt .r..nla?n.? Forte • '- --• c 1:03130X8.61: 53 772729 a.:,alettxnnaoa.o.s?avn,,:,.>+roec>r.c.- xwYn 91' 3030 ...u.r ..eo.oY...vu mc«-,e._ . . . .- Check 1030, $1,000.00 Date Presented 03/13/2008 -'! IV.... P'PL Electric Utilities Electric Service For: WALTER M PATTERSON 31 N 18TH ST HARRISBURG PA 17103 Questions about this bill? Please contact us by Feb 15 at 1-800-342-5775 (1,800-DIAI,PPL) or write to: Customer Service 827 Hausman Rd_ Allentown, PA 18104-9392 www-pplelectric.com Electric pp, Page I Summary Page Balance as of Jan 25, 2008 Yiwr B9ti?ccwtm;I<Hsm6er 73790-84015 fTsewtieei-cat Qe:?riii $13.51 Char FPes: TotaPL ELECTRIC UTILITIES Charges $12.43 Total Charges $25.94 . This. Atnoat 1' L4(ir #httt Y eb 15,E[8 .. . Account Balance $25.94 KWH - Average Per Day Use 12 This part of your bill 10 helps you understand 8 your electric use- If? PCs of 1% ter Readings: 6 4 Actual - Estimated 2 t:ustomer 0 N D J 2007 Months 2008 Meter Reading Information Meter #23104964 Jan 25 Actual 15074 Dec 26 Actual 15036 30 Da_vs KW-H Bi11ed 38 The graph shows the average number of KW'H you used each day- You used 38 KWH in 30 days, or an average of I KWH a day- The average daily temperature for your area last month was 34F. Other important information on back 4 --- --------------------------------------------------------------------------------------- . Bond Company LLC acid which Ff1at c0ih di1? tlsL? ?- incurred to recover a portion of PPL Elecric'Utilitles' stranded costs. The gross receipts tax, which is collected for the Coini-nonwealth of Pennsylvania, is equal to 5.9% of the ITC. For your convenience, you can now pav your bill using your Visa, MasterCard, wl Discover, your rediCard. tall t and ATM cad a serv service fee fr n Icing this payment. Before diggin#? around your home or property, you should always call the state's One Call notification system to locate any underground utility lines. You can do this by simpl dialing 811, which will connect you to the One Call system. Be safe andycall 811 before you dig. 3?I- Commerce L ffBank 0164021NY1N00003056 WALTER M PATTERSON III P0BOX2105 HARRISBURG PA 17105 Commerce Bank/Harrisburg N.A. P.O BOX 4999 Harrisburg, Pennsylvania 17111-0999 1-888-937-0004 We're here 7 days a week, 24 hours a day at 1-888-937-0004. 50 PLUS CHECKING Statement Balance as of 03126/06 Plus 2 Deposits and Other Credits Less 5 Checks and Other Debits Statement Balance as of 04/24/08 Transactions By Date Date Description 03/27/08 WTHDRL DDA 7505 03127 14:11 101 N. SECOND ST. HARRISSUR PA 03128108 WTHDRL DDA 7934 03128 12:29 101 N. SECOND ST. HARRISBUR PA 03/28108 CHECK # 1033 03131/08 AC-PA TREASURY DEPT-ANNUITANT 04108108 COUNTER WITHDRAWAL 04117108 CHECK # 1034 04124/08 > INTEREST PAYMENT Debit Credit $500.00 $300.00 0537727299 $3,921.72 $1,953.10 $5,200.00 $674.82 Balance $3,421.72 $3,121.72 $1,000.00 $2,121.72 $1,952.87 $4,074.59 $3,200.00 $874.59 $200.00 $674.59 $013 $674.82 (Check Transactions j Number Date Amount Number Date Amount Number Date Amount 1033 03/28 51,000.00 1034 04117 $200.00 742909" 04/08 $3,200.00 Items denoted with an "E" are electronic entries and will not have a check image Interest Summary Beginning Interest Rate Number of Days in this Statement Period Interest Earned this Statement Period Annual Percentage Yield Earned this Statement Period (APY) Interest Paid Year to Date 7". 007 Cycle 1"- 111% Im 0.16% 29 $0.23 0.15% $3.16 Paste 1 of 2 Page 2 of 2 1 c Date 0412412008 Account 537727299 0114021NY1HOD003056 . /..?r.!n :..:xr.?:f-i?-:ts::::ii:;:.ry1.:..AGF P.{`:r:?t!`C.crs:r.?c?Fr:=:wr??..•.-+.n'_?.r. ?ef?'c?- . WALTER M PATTERSON 111 07-07 1033 1 ED COLLINS (PDA) PO Box 2105 Date ?22'? WIp3m HARRISBURG, PA 07105 of ` ca i Ca k? I $ 1, DO,V. 00 r Orde ( ? a. Dollar, 8 Com a .. •, .?? 1.. ,- D F ?l'• ?Rt k rA u ] rrWN .. • P\ For -----"'^-a- -= 1.'031630&8L.&1: 53 772729 40 1033 wm.AaveOes•?v -•-. a? .> xw ;» . e. . . , .. ...uces.:- .. ..aw,aleu.r. e• . Check 1033, $1,000.00 Date Presented 03/28/2008 -'r-Cormnerce CHECKING ACCOUNT 0 0 7 4 2 9 0 9 C w'TMHARRISOUR0KV NAME E11 ? A Aar.: 0007429090- . IC 50 29-0 LB 417 Check 742909, $3,200.00 Date Presented 04/08/2008 WALTER M PATTERSON 111 07-07 1034 ED COLLINS (PDA) PO BOX 2105 1i-12.87 0.110313 NARRBBURG, PA 1710 Data Pay W the 1? .P7S013 ?? O H'A Orderof I $ zoo.C 0 ` ` , ? ` Dollars e Cwm? r-. • r...?r,... For_!vt-mo+ &Y: l\t ti. 1:03130184612 53 772729 Sur 1034 Check 1034, $200.00 Date Presented 04/17/2008 4 -y1 The City of Harrisburg, Pennsylvania, Incorporated March 19, City Government Center - Harrisburg, Pennsylvania 17101 CITY REAL ESTATE TAX FOR 2008 TAX YEAR MILLAGE RATE APPRAISAL LAND............ 0.0286700 7,400 DATE OF BILL IMPROVEMENTS.... 0.0047800 24,900 01/15/2008 -2% DISCOUNT PAYMENT OF 324.56 IF PAID BY 03/15/2008 FLAT PAYMENT OF 331.18 IF PAID BY 05/15/2008 +10%- PENALTY PAYMENT OF 364.30 IF PAID BY-12/31/2008 - -PROPERTY INFORM@ION- W M PATTERSON III C31 31 N 18TH ST ,D PO BOX 2105 PATTERSON III,W M ? D HARRISBURG PA 17105-2105 %D 0 U7 t 0 024357 09030013-9 A 'NR C7 t tp8 1860 12943 Please read the important instructions on the back of this notice. CUSTOMER COPY HARRISBURG SCHOOL DIS rRic-r 2007 OCCUPATION ASSESSMLYT-IAX Not valid unless ieceipted by machine. To receive a validated receipt by mail, return It both taxpayer's and cashier's receipts along with a stamped, self addressed,envelope 159.00 03/28/2000 168 For information call: 717-234-3217 See back for Discover/Novus Credit Card Payment ?' 1710 0016 8330 'G SCHOOL DISTRICT 6606, ION ASSESSM? '+ f y ? &8 ot:?G U•'s Ct 22 iC i. #'N tJENt °NtT #CE I I_TC0 cAsH RECEIPT CTS CA111H, RECEIPT, . ` SOCIAL SECURITY NUMBER , (3lJE` $143.00, TOTAL DUB iL4 .00 ;jr 4 f4AT ; BE F OASL'I SHED, , 175 40 5450 4. ( '60ROENEO TA,lipkYERS MAIL TO: TAX YEAR ? )e ?E > 0l? 0 1 AI :S I BUREAU 7, TO /NFORMA716hf SiIOWN SEA Q 7 nN E ackb enve[6po to detrrrtin? w!lla4 PM fl£ YOU, mwpe fa operated4rotopayment of this 1-M schb6l bilf<` v,.. i ####+?#?1' **#? 3?b T I ? `? Js 01788310 17540545b 'us 11 N PI NS TO INFORMATION SHOWN BE1 0 PATTERSON WALTER M .`' OELiNQUENT N11TIC£ 01/18/08 AT3377fl2725020fl7 PATTERSCI'I WALTER PC 8Cx 2105 17105 ??,a,.s?lf's •??-, •, ;r..yrfll.? I:JF,•;? UT?ct:;::,` I,:S -SH f?V UPT r:_1 '1J '?.1J 71 7027250 f Ir. r` - HARR. ) ?m i.f?'l; -10 1 i 1I, Ear TTi•N •.rO rt ?, ? Ddeeh end rdum bottom portion with your payment ? 0 0 7 7 5 6 2008 REAL ESTATE TAX NOTICE FOR PAYMENT COUPON TAXES TAXES NUMBER AX ARE DUE AND PAYABLE. DO NOT ALTER DAUPHIN COUNTY D O NOT FOLD TAX AMOUNT, DISCOUNT AND PENALTY HAVE BEEN COMPUTED FOR YOUR CONVENIENCE, H You a ErlriaaaW DATE: February 1, 2008 ? TINB pER10D PAY REMIT TO: Dauphin County Treasurer PHONE: (717) 780-6555 Courthouse Room 105 HOURS: Monday - Friday P ?- in FEB - MARCH Front & Market Sts 8:00 AM - 4:30 PM APRIL - MAY 2 33.4 0 Harrisburg, PA 17101 Closed Holidays JUNE - JULY 245.07 ' AUG THRU DEC 2 5 6.7 4 Count Re Count Lib 6.87600 ML 0.35000 ML OF $222.09 $11.31 niklipw (;0UNTY PROPERTY 4MYrA CA STH ST PROPERTY ID NO.: 09 030 013 PATTERSON W M III ASSESSMENT LAND: $ PO BOX 2105 IMPROVEMENT: $ HARRISBURG PA, 11105-2105 TOTAL: $ Note: Tax notice is directed to first name shown on deed. There may be other co-owners. Recipient of notice is responsible to notify co-owners. The annual assessment appeal filing deadline with the Board of Assessment Appeals for tax year 2009 is August 1, 2008. 7,400 24,900 32,300 Sys.. Dauphin County Tax Claim Bureau P.O. Box 1295 Harrisburg, PA 17108-1295 Telephone: (717) 780-611 Fax: (717) 780-64=35 OFFICIAL RECEIPT: PARCEL: 09 030 013 000 00 00 2005 LOCATION: 192459 OWNER: PATTERSON W M III 31 N 18TH ST CO-OWNER: YEAR 2005 TAX COUNTY: FLAT PENALTY INTEREST LIBRARY: 222.09 22.21 34 77 TOTAL F.S.T. C.: 11.31 1.13 . 1 71 279.07 SCHOOL: 685 73 .00 . 00 . 14.15 MUNICIPAL: BUREAU COSTS . 277'62 68.57 •00 107.54 •00 861.84 : 39'52 317.14 DATE PAID: 9 /06/2007 182.00 PAID BY: WALTER M PATTERSON III PAY TYPE: CASH; AMOUNT PAID: ORIGINAL BALANCE: 1,654,20 NON-CASH: 1,654:20 TOT PD TO DATE: 1,654.20 CREDIT CARD: .00 BAL DUE; 1,654.20 .00 .00 Received 71 NOTICE: ALL NON-CASH PAYMENTS ARE by: F12 ACCEPTED SUBJECT TO BEING HONORED BY DRAWER'S BANK. is hereby given by the TAX CLAIM bUKr ,u if known as "Real Estate Tax Sale Law," as amended that the said BUREAU will expose at public sale in the t.rowne ri"a Harrisburg, Mat o6: oo PM on SEPTEMBER 17, 2007 or any day to which the sale may be adjourned, re-adjourned or continued, for the purpose of collecting unpaid taxes, municipal claims and all costs incident thereto, the above described real estate for at least the upset price in the amount herein above set forth. The sale of this property may at the option of the Bureau, be stayed if the owner thereof or any lien creditors of the owner, on or before the actual sale date, enters into an agreement with the BUREAU to pay the taxes and costs owing on said property in installments in the manner provided by said law. 856 I dauphsa.qxd 6/07 -oft VA qW COMMONWEALTH OF PENNSYLVANIA STATE EMPLOYEES' RETIREMENT SYSTEM 30 NORTH THIRD ST STE 150 HARRISBURG, PA 17101-1716 1-800-633-5461 www.sers.state.pa.us SD December 5, 2007 PENSION VERIFICATION WALTER M PATTERSON PO BOX 2105 HARRISBURG PA 17105 Dear Annuitant: SSN : XXX-XX-5450 This is in response to your request for a monthly pension verification. These figures reflect your current annuity as of the above date. The information you requested is as follows: Gross Pension: $2,255.96 Less Deductions: Federal Withholding Tax: $274.14 Health Insurance: $29.70 Other: $0.00 Net Pension: $1,952.12 The effective date of your annuity is 06-30-2007. Your regular retirement benefit will be made to you for life. If we can be of further assistance, please contact the Disbursements Section at 1-800-633-5461, Ext. 8205. Remember to also notify SERS promptly when there is any change to your home address. Sincerely, Disbursements Section Benefit Determination Division -??? AIN44 _ co 0 . - 4 t4 ._ s PERINI SERVICES SOUTHAMPTON MANOR, LTD., DBA SHIPPENSBURG HEALTH CARE CENTER, PETITIONER V. WALTER M. PATTERSON, III, Individually, and ED COLLINS, Individually and as Power of Attorney for WALTER M. PATTERSON, DEFENDANTS IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-0567 CIVIL ORDER OF COURT AND NOW, this 12th day of May, 2008, upon consideration of Defendants' Pro Se Motion for Extension of Time to List Property, unopposed by Petitioner, IT IS HEREBY ORDERED AND DIRECTED that the Defendants' Request for Extension of Time is GRANTED. Defendants will list the property in question with a reputable realtor on or before May 26, 2008. By the Court, Andrew R. Eisemann, Esquire Attorney for Petitioner Ed Collins, Defendant, Pro Se bas 0--n O c t s m t LecL 3/08 VI VVAIr,.f'if qd p i Nno1-. r n r-,.imonno ? ! •E Wd Z I AN OR E • Perini Services Southamton In the Court of Common Pleas Ltd. Dba Shippensburg Health Cumberland County, Pennsylvania Petitioner v. Walter M. Patterson, III Individually and Eddie L Collins, Individually and as Power of Attorney for Walter M Patterson, III : Docket No: 08-567 Civil : Civil Action -Law : Honorable Judge M.L. Ebert Jr. Respondents RESPONDENTS REPLY TO COURT ORDER 7. Respondent Walter M. Patterson 111 property located at 31 North 1 Sth Street, Harrisburg, Pennsylvania was listed for sale on/around May 15, 2008 by real estate broker "Chester Crone Real Estate, Carol Nguyen, agent for a list price of $49,900.00 U.S. dollars (see exhibit "A". Respectfully submitted, Ed Collins, POA 717-421-3108 Dated: May 23, 2008 10163959 Status Active Type Attached Address 31 N 18th Street Not City Harrisburg State PA Zip 17103 Area 2 Class Residential/Farm List Price $49,900 Sale/Rent For Sale 1` A List Date 5/15/2008 Expiration Date 11/13/2008 Listing Type Exclusive Right County Code Dauphin Subdivision School District Harrisburg Municipality Harrisburg Map Page Map Coordinate Parcel # 090300130000000 Possession Lock Box Description combo Sub Agent Comm 3 Buyer Agent Comm 3 Original Price $49,900 Other Agent Comm TLC Trans Lic Fee Listing Agent CAROL NGUYEN - (717) 957-3634 List Office CHESTER CRONE REAL ESTATE - Office (717) 238-8171 Listing Agent 2 Listing Agent 3 Showing Instructions Call List Office Photo Yes List Team Owner Name (I.f:L) .. ?:?? ?: Acres Owner Phone Directions From Arsenal Blvd. right onto N. 17th to left onto Regina St. right onto N. 18th St. home sits on left. # Bedrooms 5 # of Fireplaces # of Full Baths # of Half Baths Total Baths 0 Full Baths Basement 0 Full Baths Main 0 Full Baths 2nd Floor 1 Associated Document Count 1 Full Baths 3rd Floor 0 Half Baths Basement 0 Half Baths Main 0 Half Baths 2nd Floor 0 Half Baths 3rd Floor 0 Bedroom 5 Yes/No Yes Bedroom 4 Yes/No Yes Bedroom 3 Yes/No Yes Bedroom 2 Yes/No Yes Master Bedroom Yes/No Yes Kitchen Yes/No Yes Den Yes/No No Family Room Yes/No No Dining Room Yes/No Yes Living Room Yes/No Yes Living Room Dim Living Room Level Level 1 Living Room Desc X Dining Room Dim Dining Room Level Level 1 Dining Room Desc X Family Room Dim Family Room Level Family Room Desc X Den Dim 1% z0+2. .yam r C. ~7 r- i x. 47 ? 3 cn . CY4 --< ar SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2008-00567 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND PERINI SERVICES SOUTHAMPTON MA VS PATTERSON WALTER M III ET AL R. Thomas Kline Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT ....r T T2Tf? TTT1T Tl T TT) to wit: but was unable to locate Him deputized the sheriff of DAUPHIN serve the within COMPLAINT & NOTICE On May 21st , 2008 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: So answers: Docketing 18.00 Out of County 9.00 Surcharge 10.00 R. Thomas Kline Dep Dauphin County 29.25 Sheriff of Cumberland County Postage 3.77 70.02 ?/,2q/Cam L 05/21/2008 CAPOZZI & ASSOCIATES Sworn and subscribe to before me this day of County, Pennsylvania, to in his bailiwick. He therefore A. D. + In The Court of Common ]Pleas of Cumberland County, Pennsylvania Perini Services Southampton Manor etc vs. Walter M. Patterson III et al 08-567 civil SERVE: Eddie L. Collins Jr. No. Now, April 110, 2008 , I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Dauphin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. Sheriff of Cumberland County, PA Affidavit of Service Now, within upon at by handing to a 20 , at o'clock copy of the original M. served the and made known to Sheriff of COSTS Sworn and subscribed before me this day of , 20 the contents thereof. So answers, SERVICE $ MILEAGE AFFIDAVIT County, PA ixthe Mary Jane Snyder Charles E. Sheaffer Real Estate Depu Chief Deputy William T. Tully Michael W. Rinehart Solicitor Assistant Chief Deputy Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 780-6590 fax: (717) 255-2889 Jack Lotwick Sheriff PERINI SERVICES SOUTHAMPTON Commonwealth of Pennsylvania MANOR LTD. DB/A SHIPPENSBURG HEALTH CARE CENTER VS County of Dauphin EDDIE L. COLLINS, JR Sheriffs Return No. 2008-T-0812 OTHER COUNTY NO. 08-567 And now: APRIL 15, 2008 at 10:20:00 AM served the within NOTICE & COMPLAINT upon EDDIE L. COLLINS, JR by personally handing to EDDIE L. COLLINS, JR true attested copies of the original NOTICE & COMPLAINT and making known to him/her the contents thereof at DAUPHIN COUTNY SHERIFFS OFFICE FRONT AND MARKET STREETS HARRISBURG PA 17101 Sworn and subscribed to before me this 15TH day of April, 2008 NOTARIAL SEAL ARY JANE SNYDER, Notary Publi Highspire, Dauphin County [My Commission Expires Sept 1 2010 So Answers, ? k?41c-- Sheriff of Dauphin County, Pa. By I ?.._. Deputy Sheriff Deputy: KIMBERLY BARTO Sheriffs Costs: $29.25 4/14/2008 SHERIFF'S RETURN - REGULAR CASE NO: 2008-00567 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND PERINI SERVICES SOUTHAMPTON MA VS PATTERSON WALTER M III ET AL SHAWN HARRISON Cumberland County,Pennsylvai says, the within PETITION PATTERSON WALTER M III RESPONDANT , at 1317:00 at SHIPPENSBURG HEALTH CARE Sheriff or Deputy Sheriff of iia, who being duly sworn according to law, was served upon the HOURS, on the 8th day of April 2008 CTR 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 by handing to WALTER PATTERSON a true and attested copy of PETITION FnR PRELIMINARY INJUNCTION together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 20.00 Postage .58 Surcharge 10.00 .00 48.58 Sworn and Subscibed to before me this of day So Answers: R. Thomas Kline 04/10/2008 CAPOZZI & AZepzy By: Sheriff A. D. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Perini Services Southampton Manor, Ltd. Dba Shippensburg Health Care Center : Civil Court Division : Docket No. 08-567 Civil Petitioner V. : Honorable Judge M.L. Ebert Jr. Walter M. Patterson, III Individually, and Ed Collins Individually and as Power of Attorney for Walter Patterson Defendants DEFENDANTS MOTION TO STAY CIVIL ACTION TO SEEK RESOLUTION Petitioner, Ed Collins, pro se, respectfully request this Honorable Court to grant petitioner's request to STAY civil action and/or LEAVE OF COURT for a period of sixty (60) days to on/around August 2, 2008 to resolve the above-referenced civil action and in support states the following: The interest of JUSTICE and FAIRNESS would be served. Respectfully submitted, EA CAS Ed Collins, Pro Se 2234 Penn Street Harrisburg, Pa 17110 717-421-3108 Dated: June 2, 2008 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Perini Services Southampton Manor, Ltd. Dba Shippensburg Health Care Center : Civil Court Division : Docket No. 08-567 Civil Petitioner V. : Honorable Judge M.L. Ebert Jr. Walter M. Patterson, 111 Individually, and Ed Collins Individually and as Power of Attorney for Walter Patterson Defendants DEFENDANTS'S BRIEF IN SUPPORT OF MOTION TO STAY CIVIL ACTION AND/OR LEAVE OF COURT TO SEEK FINAL RESOLUTION STATEMENT OF FACTS 1. On/around March 28, 2008 defendant Ed Collins was in receipt of the above-referenced civil action seeking $41,008.67 for services rendered. 2. On/around April 9, 2008 a hearing (transcript recorded) was held in Cumberland County Courthouse and a final order was granted on/around April 11, 2008. 3. Defendant Ed Collins, POA has complied with all of the courts orders to date. 4. Defendants disputes petitioner's invoiced amount of $41,008.67 through November 2007. 5. Blue Cross has launched an investigative complaint on behalf of defendant on the above-disputed amounts. 6. Blue Cross has signaled to defendant a "completion date" of investigative complaint on/around August 2, 2008.. (Note: Blue Cross investigative team contacted defendant Ed Collins,POA on/around May 30, 2008 and stated completion date). STATEMENT OF THE ISSUE WHETHER THE COURT SHOULD GRANT DEFENDANTS MOTION TO STAY CIVIL ACTION AND/OR LEAVE OF COURT TO SEEK FINAL RESOLUTION ARGUMENT In the name of JUSTICE and FAIRNESS, petitioner, pro se, wish to resolve the above-civil action amicably for both parties. Petitioner, pro se, therefore respectfully ask this Honorable Court to grant defendants's motion for STAY of civil action and/or LEAVE OF COURT for a period of sixty (60) days to seek final resolution of disputed amounts. Local Rules (LR) provides for the "leave of court" and/or "extention of time".. In pertinent part, it provides: (a) Leave and/or extention of time shall be freely granted when justice requires. The interest of JUSTICE and FAIRNESS would be be best served by granting petitioner, who has exercised due diligence, STAY to civil action and/or LEAVE OF COURT to seek final resolution. Defendants further offers the following avernments in support of the within Motion: 1. It is defendants belief than plaintiff has filed a frivolous claim. CONCLUSION WHEREFORE, petitioner/defendant respectfully request this Honorable Court to grant petitioner's/defendants request for STAY on civil action and/or LEAVE OF COURT for a period of sixty (60) days to on/round August 2, 2008 to seek FINAL RESOLUTION of the above-referenced civil action. Respectfully submitted, Ed Collins, Pro Se 2234 Penn Street Harrisburg, Pa 17110 Dated: June 2, 2008 PERINI SERVICES SOUTHAMPTON MANOR, LTD., DBA SHIPPENSBURG HEALTH CARE CENTER, PETITIONER V. WALTER M. PATTERSON, III, Individually, and ED COLLINS, Individually and as Power of Attorney for WALTER M. PATTERSON, DEFENDANTS IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-0567 CIVIL ORDER OF COURT AND NOW, this 9t' day of June, 2008, upon consideration of Defendants' Pro Se Motion to Stay Civil Action to Seek Resolution, IT IS HEREBY ORDERED AND DIRECTED that: 1. A Rule is issued upon the Plaintiff to show cause why the relief requested should not be granted; 2. The Plaintiff will file an answer on or before June 30, 2008; 3. The Prothonotary is directed to forward said Answer to this Court 4. If no answer to the Rule to Show cause is filed by the required date, the relief requested by Defendant shall be granted upon the Court's receipt of a Motion requesting Rule be made Absolute. If the Plaintiff files an answer to this Rule to Show Cause, the Court will determine if a hearing, status conference or further Order of Court is required. By the Court, Nv? M. L. Ebert, Jr., J. i j ?nVNVA-VS?W:3d n, CS z9 Wd 6- N 1 $ 041 MVION aHiOdd 3HI Andrew R. Eisemann, Esquire Attorney for Petitioner BEd Collins, Defendant, Pro Se bas I.IeT L i4lDe ,kd. r 4 ? ? Perini Services Southampton Manor, Ltd d/b/a Shippensburg Health Care Center, Plaintiff In the Court of Common Pleas of Cumberland County, Pennsylvania V. Walter M. Patterson, III, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III, and Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Defendants : Docket No.: 08-567 Civil Term Civil Action - Law JOINT PRAECIPE TO ENTER MONEY JUDGMENT AGAINST DEFENDANT WALTER M. PATTERSON, III ONLY ON THE BASIS OF A JOINT STIPULATION TO: THE PROTHONOTARY OF CUMBERLAND COUNTY, PENNSYLVANIA 1. Pursuant to Pa.R.C.P. No. 1037(c), enter judgment in favor of Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, Plaintiff and only against Defendant Walter M. Patterson, III on the basis of the Joint Stipulation executed by both parties. Assess damages in favor of Plaintiff and against Defendant Walter M. Patterson, III only in the total sum of $52,822.42, including principal, attorneys' fees, and court costs. A copy of the Joint Stipulation is attached hereto as Exhibit "A." 2. Defendant Walter M. Patterson, III is a resident of the Plaintiff's nursing facility, and is not medically competent to handle his personal finances. A true and correct copy of his agent's Power of Attorney is attached hereto as Exhibit "B." I hereby certify that a copy of this Praecipe has been mailed to the Defendant. 4. I hereby certify that the last known address of the Defendant is: Walter M. Patterson, III, c/o Shippensburg Health Care Center, 121 Walnut Bottom Road, Shippensburg, PA 17257. .LAAm. I- Q-Ou't-? Eddie L. Collins, Jr., Power of Attorney 2234 Penn Street Harrisburg, PA 17110 Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff Date: Date: 3 v rt e. ,ZOO q Capozzi & Associates, P.C. 2933 North Front Street Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, Plaintiff V. Walter M. Patterson, III, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III, and Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Defendants In the Court of Common Pleas of Cumberland County, Pennsylvania Docket No.: 08-567 Civil Term : Civil Action -Law JOINT STIPULATION FOR ENTRY OF MONEY JUDGMENT NOW COMES Plaintiff, Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, by its attorneys, Capozzi & Associates, P.C., and Defendant Walter M. Patterson, III hereby agree to entry of judgment in favor of Plaintiff and against Defendant Walter M. Patterson, III only in the amount of $52,822.42, including principal, attorneys' fees, and court costs, which represents the full settlement amount. Plaintiff will release its claim, satisfy judgment, and discontinue this action upon payment in full. AND NOW, intending to be legally bound thereby, the parties, by themselves, or through their legal representative, hereby execute this Stipulation. Eddie L. Collins, Jr., Power of A orney 2234 Penn Street Harrisburg, PA 17110 Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff Date: duve- l1 C0 Date: -3'\5.0 t q Exhibit A Capozzi & Associates, P.C. 2933 North Front Street CHARLES E. PETRIE ATMRM AT LAW 3528 BRISBAN STREET 1 HARRISBURG, PENNSYLVANIA 17111 r a 717-561-1939 NOTICE ' i ? y l. THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN. AFTER YW.BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 Pa.C.S. Ch. 56. Exhibit B IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. WALTER M. PATTERSON III PRINCIPAL AGENT'S ACKNOWLEDGEMENT I, EDDIE L. COLLINS, have read the attached power of attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. I shall exercise reasonable caution and prudence. I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal. AGENT DATE Exhibit B COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN On this, the Ag-?ay of , 2007, before me, A Notary Public, personally appeared EDDIE L. COLLINS, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed it for the purposes therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. ARY EKJBLIC COMMONWEALTH OF PENNSYLVANIA Notarial Seal Kelly P. Roberts, Notary Public Patang Boro, Dauphin County My Commission Expires Jan. 27, 2009 Member, Pennsylvania Association of Notaries Exhibit B DURABLE POWER OF ATTORNEY KNOW ALL MEN. BY THESE PRESENTS, that I, WALTER M. PATTERSON III, currently residing at 507 Muench Street, Harrisburg, County of Dauphin, Pennsylvania, hereby revoke any general power of attorney that I have heretofore given to any person and do hereby appoint EDDIE L. COLLINS of 2234 Penn Street, Harrisburg, County of Dauphin, Pennsylvania, (hereinafter "my Agent") my true and lawful Agent for me and on my behalf to perform all such acts as my Agent in my Agent's absolute discretion may deem advisable, as fully as I could do if personally present. This Power of Attorney shall not be affected by my subsequent disability or incapacity. My Agent is hereby given the fullest possible powers to act on my behalf: to transact business, make, execute and acknowledge all agreements, contracts, orders, deeds, writings, assurances, and instruments for any matter, with the same powers and for all purposes with the same validity as I could, if personally present. Exhibit B SPECIFIC POWERS INCLUDED IN GENERAL POWER Without limiting the general powers hereby already conferred, my Agent shall have the following specific powers which are included in the foregoing general powers: (1) To create a trust for my benefit. (2) To make additions to an existing trust for my benefit. (3) To claim an elective share of the estate of my deceased spouse. (4) To disclaim any interest in property. (5) To renounce fiduciary positions. (6) To withdraw and receive the income or corpus of a trust. (7) To authorize my admission to a medical, nursing, residential or similar facility and to enter into agreements for my care. (8) To authorize medical and surgical procedures. (9) To engage in real property transactions. (10) To engage in tangible personal property transactions. (11) To engage in stock, bond and other securities transactions. Exhibit B (12) To engage in commodity and option transactions. (13) To engage in banking and financial transactions, including checking and savings account(s), certificates of deposit, and savings bonds transactions. (14) To borrow money. (15) To enter safe deposit boxes. (16) To engage in insurance transactions. (17) To engage in retirement plan transactions. (18) To handle interests in estate and trusts. (19) To pursue claims and litigation. (20) To receive government benefits. (21) To pursue tax matters. DURATION OF POWER. RELIEF FROM LIABILITY, REVOCATION 1. This Power of Attorney shall not expire by reason of lapse of time. 2. I hereby ratify and confirm all that each Agent acting hereunder shall do or cause to be done under this General Power of Attorney. I specifically direct that such Agent shall not be subject to liability for such Agent's decisions, acts or failures to act. Exhibit B R 21 777177t acting hereunder written notification of the revocation, which notice shall not - - be considered binding unless actually received. HIPPA RELEASE AUTHORITY I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1966 (aka HIPPA), 42 USC 1320d and 45 CFR 160-164. I authorize: (a) any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health care provider any insurance company and the Medical Information Bureau Inc., or other health care clearinghouse that has provided treatment or services to me or that has paid for or is seeking payment from me for such services; (b) to give, disclose and release to my agent, without restriction all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse. Exhibit B The authority given by agent shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclose of my individually identifiable health information. The authority given my agent has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider. IN WITNESS WHEREOF, and intending to be legally bound, I have hereunto set my hand and seal this J9 VId-ay of , 2007. ' Signed, sealed, and delivered in the presence of: WALTER M. PATTERSON III COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN On this, the A'-4dLay of el-111, jj- , 2007, before me, A Notary Public, personally appeared WALTER M. PATTERSON III, known to me (or satisfactorily proven) to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed it for the purposes therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. COMtvIONWVtALTI4 OF PENNSYLVANIA Notarial Seal Kelly p. Roberts, Notary Public paxWV Boro, Dauphin County My Commission Expires Jan. 27,2009 Exhibit B Member, °ennsviva.nia Asscciation of Notaries IZN i y rI> O I Q> ? d A mot' 0 4 C? Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, Plaintiff V. Walter M. Patterson, III, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III, and Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Defendants In the Court of Common Pleas of Cumberland County, Pennsylvania Docket No.: 08-567 Civil Term : Civil Action -Law AFFIDAVIT OF NON-MILITARY SERVICE The undersigned, being duly sworn, according to law, deposes and says that to the best of his knowledge, the Defendant is not in the Military or Naval Service of the United States or its Allies, or otherwise within the provisions of the Service Members' Civil Relief Act of 2003, having amended the Solders' and Sailors' Civil Relief Act of Congress of 1940. I hereby certify that Walter M. Patterson, III, is over 18 years of age and resides at c/o Shippensburg Health Care Center, 121 Walnut Bottom Road, Shippensburg, PA 17257. Date: By: CAPOZZI & ASSOCIALES, P.C. mew R ise n, Esquire Attorney I 874-41 2933 North Front Street Harrisburg, PA 17110 Attorney for Plaintiff Sworn to and sbbscriibed before me t is 10th day of June, 2008. Not ry ubli COMMONWEALTH OF PENNSYLVANIA Notarial Seal Nota Susquehanna Twp., Dauphn Public County My Commission Expires ov. 2, 2008 Member, Pennsylvania Association of Notaries C? 33 V 1 Perini Services Southampton Manor, Ltd. d/b/a Shippensburg Health Care Center, Plaintiff In the Court of Common Pleas of Cumberland County, Pennsylvania V. Walter M. Patterson, III, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III, and Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Defendants : Docket No.: 08-567 Civil Term : Civil Action -Law NOTICE OF ENTRY OF JUDGMENT PURSUANT TO RULE 236 NOTICE OF DEBTOR'S RIGHTS TO: Walter M. Patterson, III, Defendant interest at 6% per annum. P of onotary You are hereby notified that on L/ 2008, the following Judgment has been entered against you in the above-caption case in the sum of $52,822.42, plus post judgment Esquire YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 32 S. Bedford Street Carlisle, PA 17013 800-990-9108 I hereby certify that the following is the address of the Defendant stated in the certificate of residence: Walter M. Patterson, III, c/o Shippensburg Health Care Center, 121 Walnut Bottom Road, Shippensburg, PA 17257. Date: ? ?© e CAPOZZI & AS%DC-14TES, P.C. Attorney Iff#€ 87441 2933 North Front Street Harrisburg, PA 17110 Attorney for Plaintiff A Walter M. Patterson, III, Defendido/a Por este medio se la esta notificando que el de del 2008, el siguiente Orden ha sido anotado en contra suya en el caso mencionado en el epigrafe. FECHA: Protonotario Certificio que la siguiente direccion es la del defendido/a segun indicia en el certificado de residencia: Walter M. Patterson, III, c/o Shippensburg Health Care Center, 121 Walnut Bottom Road, Shippensburg, PA 17257. USTED DEBE LLEVAR INMEDIATAMENTE ESTE DOCUMENTO A SU ABOGADO. SI USTED NO TIENE UN ABOGADO O NO PUEDE PAGARLE A UNO, LLAME A VAYA A LA SIGUIENTE OFICINA PARA AVERIGUAR DONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. CUMBERLAND COUNTY BAR ASSOCIATION 32 S. Bedford Street Carlisle, PA 17013 800-990-9108 CAPOZZI & ASSOCIATES, P.C. Date: C /? c By: Harrisburg, PA 17110 Attorney for Plaintiff 2933 North Front Street IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Perini Services Southampton : Civil Court Division Manaor, Ltd. Dba Shippensburg Health Care Center : Docket No. 08-567 Civil Petitioner V. : Honorable Judge M.L. Ebert Jr. Waiter M. Patterson, 111 Individually, and Ed Collins Individually and as Power of Attorney for Walter Patterson Defendants DEFENDANTS PRAECIPE TO WITHDRAW MOTION TO STAY CIVIL ACTION TO SEEK RESOLUTION Petitioner, Ed Collins, pro se, respectfully request this Honorable Court to grant petitioner's request to WITHDRAW Motion to Stay Civil Action to Seek Resolution to the above- referenced civil action and in support states the following: Petitioner/Defendant and Plaintiff has entered Into a JOINT PRAECIPE TO ENTER JUDGMENT ON THE BASIS OF A JOINT STIPULATION. Respectfully submitted, Z.A Ed Collins, Pro Se 2234 Penn Streeet Harrisburg, Pa 17110 717-421-3108 Dated: June 26, 2008 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Perini Services Southampton : Civil Court Division Manaor, Ltd. Dba Shippensburg Health Car* Center : Docket No. 08-567 Civil Petitioner v. : Honorable Judge M.L. Ebert Jr. Walter M. Patterson, 111 Individually, and Ed Collins Individually and as Power of Attorney for Walter Patterson Defendants DEFENDANTS BRIEF IN SUPPORT OF PRAECO(E TO WITHDRAW MOTION TO STAY CIVIL ACTION TO SEEK RESOLUTION STATEMENT OF THE FACTS 1. On/around March 28, 2008 defendant Ed Collins was in receipt of the above-referenced civil action seeking $41,008.67 for services rendered to patient Walter Patterson. 2. Oniaround June 29, 2008 Defendant and Plaintiff entered a "Joint Praecipe to Enter Money Judgment on the Basis of a Joint Stipulation Pursuant to Rule 286 and Affidavit of Now Military Service." STATEMENT OF THE ISSUE WHETHER THE COURT SHOULD GRANT DEFENDANTS PRAECIPE TO WITHDRAW MOTION TO STAY CIVIL ACTION TO SEEK RESOLUTION ARGUMENT Defendants "Motion to Stay Civil Action" was filed for the sole purpose of seeking resolution with Plaintiff on the matters before the court. On/around June 29, 2008 on the basis of a Joint Stipulation with Plaintiff, a resolution was obtained. The interest of resolving the above-referenced matter before the court would be best served by granting petitioner/defendants PRAECIPE TO WITHDRAW MOTION TO STAY CIVIL ACTION TO SEEK RESOLUTION. CONCLUSION WHEREFORE, petitioner/defendant respectfully request this Honorable Court to grant petitioneesidefendants PRAECIPE TO WITHDRAW MOTION TO STAY CIVIL ACTION FOR A PERIOD OF SIXTY (60) DAYS TO ON/AROUND AUGUST 29 2008 TO SEEK FINAL RESOLUTION. Respectfully submitted, A Q,1" Ed Collins, Pro Se 2234 Penn Street Harrisburg, Pa 17110 Dated: June 26, 2008 N C.? . C:.:1 DTI 1 5 - -71 A ?ry Wry/y' 4 SHIPPENSBURG HEALTH CARE SERVICES, V. Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : Docket No.: 08-567 Civil Term WLATER M. PATTERSON, III, Individually, LARRY E. PATTERSON, Individually and as Legal Representative for Walter M. Patterson, III, and EDDIE L. COLLINS, JR., Individually and as Power of Attorney for Walter M. Patterson, III, : Civil Action - Law Defendants PRAECIPE TO ENTER DEFAULT JUDGMENT AGAINST DEFENDANT EDDIE L. COLLINS. JR., INDIVIDUALLY AND AS POWER OF ATTORNEY FOR WALTER M. PATTERSON, III To the Prothonotary: Kindly enter judgment for Plaintiff and against Defendant Eddie L. Collins, Jr., only, and assess damages certified to be calculable as a sum certain from the Complaint. Current amount due: Prejudgment Interest: Attorney Fees: Cost of Court $52,822.42 $2,905.21 $9,088:50 $549.35 TOTAL: * $65,365.48 * Plus post-judgment interest at the legal rate of 6% per annum, plus costs of collection. I understand that any false statements therein are subject to the penalties contained in Title 18 of the Pennsylvania Consolidated Statutes §4904, relating to unsworn falsification to authorities. I verify that: 1. The last known address for Defendant Eddie L. Collins, Jr. is 2234 Penn Street, Harrisburg, PA 17110. 2. It is certified that a written Notice of Intention to Enter Judgment by Default was mailed to Eddie L. Collins, Jr., against whom this judgment is to be entered, after the default occurred and at least 10 days prior to the date of the filing of this Praecipe. A copy of the Notice of Intent to Enter Default Judgment is attached as Exhibit "A." Capozzi & Assocj,?tes, P.C. Date: d? By: i Aa3diew is ann, Esquire Attorney . 87441 Capozzi & Associates, P.C. 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 2 Shippensburg Health Care Services, Plaintiff V. Walter M. Patterson, III, Individually, Larry E. Patterson, Individually and as Legal Representative for Walter M. Patterson, III, and Eddie L. Collins, Jr., Individually and as Power of Attorney for Walter M. Patterson, III, Defendants In the Court of Common Pleas of Cumberland County, Pennsylvania : Docket No.: 08-567 Civil Term : Civil Action -Law NOTICE OF INTENTION TO ENTER JUDGMENT BY DEFAULT TO: Eddie L. Collins, Jr. 2234 Penn Street Harrisburg, PA .17110 DATED: November 20, 2008 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP: LAWYER REFERRAL SERVICE Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 Exhibit A A, NOTICIA IMPORTANTE TO: Eddie L. Collins, Jr. 2234 Penn Street Harrisburg, PA 17110 DATED: November 20, 2008 USTED HA NO COMPLIDO CON EL AVISO ANTERIOR PORQUE HA FALTADO EN TOMAR MEDIDAS REQUERIDAS RESPECTO A ESTE CASO. SI USTED NO ACTUA DENTRO DE DIEZ (10) DIAS DESDE LA FECHA DE ESTA NOTICIA, ES POSIBLE QUE UN FALLO SERIA REGISTRADO CONTRA USTED SIN UNA AUDIENCIA Y USTED PODRIA PERDER SU PROPIEDAD O OSTROS DERECHOS IMPORTANTES. USTED DEBE LLEVAR ESTA NOTICIA A SU ABOGADO EN SEGUIDA. SI USTED NO TIENE ABOGADO O NO TIENE CON QUE PAGAR LOS SERVICIOS DE UN ABOGADO, VAYA O LLAME A LA OFICINA ESCRITA ABAJO PARA AVERIGUAR A DONDE USTED PUEDE OBTENER LA AYUDA LEGAL. LAWYER REFERRAL SERVICE Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 CArozzi AND AAsdciATEs. P.C. By: I.D. No. Esquire 2933 N. Front Street Harrisburg, PA 17110 (717) 233-4101 2 Exhibit A C? -43