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DECEDENT'S ESTATE
COURT OF COMMON PLEAS OF
Cumberland COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF John F. Peifer, Jr.
, DECEASED
c_,
No. 21-07-0519
, :;
PETITION FOR ADJUDICATION /
STATEMENT OF PROPOSED DISTRIBUTION
PURSUANT TO Pa. O.C. Rule 6.9
This form may be used in all cases involving the Audit of the Account of a Decedent's Estate. If
space is insufficient, riders may be attached Attach the spouse's election, if any; the papers
required under items 8-19 inclusive; and any instrument pertinent to the adjudication.
INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.
Name of Counsel: Michael L. Bangs, Esquire
Supreme Court J.D. No.: 41263
Name of Law Firm:
Address: 429 South 18th Street, Camp Hill, PA 17011
Telephone: (717) 730-7310
Fax: (717)730-7374
Form OC-Of rev, fO 13.06
Page 1 of 10
GJ
Estate of John F. Peifer, Jr.
, Deceased
1. Name(s) and addressees) ofPetitioner(s):
Name:
Patricia A. Haslam
Address:
42 Wheatfield Drive
Carlisle, PA 17015
Identify any executors or administrators who have not joined in the Petition for
Adjudication and Statement of Proposed Distribution and state reason:
N/A
Is this the first accounting by this fiduciary? . . . . . . . . . . . . . . . . . . . . . IZ1 Yes 0 No
Ifnot, identify prior accountings, the accounting periods covered, and the date of
adjudication of the prior accounting.
2. Decedent died on 09/18/2003
IZ1 Letters Testamentary or 0 Letters of Administration were granted to Petitioner(s) on
Date of Will (ifapplicable): 11/18/1997
Date(s) ofCodicil(s) (if applicable): N/A
Date of probate (if different from date Letters granted): OS/29/2007
Was a bond required? DYes IZ1 No If yes, state amount:
Are proofs of advertising of the grant of Letters attached? ......... IZ1 Yes 0 No
Dates of advertising of the grant of Letters: The Sentinel: 6/6,6/13 and 6/20/2007
Cumberland Law Journal: 6/8, 6/15 and 6/22/2007
FormOC-OI rev. 10.13.06
Page 2 of 10
Estate of John F. Peifer, Jr.
, Deceased
3. Was decedent survived by a spouse? ., . . . . . . . . . .. .. .. ., ., . . . . . . .. DYes IZ] No
If yes, name of the surviving spouse:
4. Has the surviving spouse filed to take an elective share? ............. DYes D No
(See Section 2201 et gg. of the Probate, Estates and Fiduciaries Code)
If yes, date of election:
5. In the case of an intestacy, state the names of the decedent's surviving children or
surviving issue of deceased children (if none, so state):
N/A
6. Did decedent marry after execution of Will or Codicil(s)? . . . . . . . . . ., DYes IZ] No
Were any children born to decedent after execution of
Will or Codicil(s)? ........................................... DYes (Z\ No
If yes, give names and dates of birth:
Name:
Date of Birth:
7. If required by the Medical Assistance Estate Recovery Act,
62 P.S. 9 1412, was a request for a statement of claim sent to
the Department of Public Welfare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IZ]Yes D No
Form OC-()l rev.10.13.()6
Page 3 of 10
Estate of John F. Peifer, Jr.
, Deceased
8. Written notice of the Audit as required by Pa. o.c. Rules 6.3, 6.7 and 6.8 has been or will be
given to all parties in interest listed in item 9 below, all unpaid creditors and all claimants
listed in item 10 below. In addition, notice of any questions requiring Adjudication as
discussed in item 14 below has been or will be given to all persons affected thereby.
A. If Notice has been given, attach a copy of the Notice as well as a list of the names
and addresses of the parties receiving such Notice.
B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and
addresses of the parties receiving such Notice shall be submitted at the Audit
together with a statement executed by a Petitioner or counsel certifying that such
notice has been given.
C. If any person entitled to Notice is not suijuris (e.g., minors or incapacitated
persons), Notice of the Audit has been or will be given to the appropriate
representative on such party's behalf as required by Pa. O.c. Rule 5.2.
D. If any charitable interest is involved, Notice of the Audit has been or will also be
given to the Attorney General as required under Pa. O.c. Rule 5.5. In addition, the
Attorney General's clearance certificate (or proof of service of Notice and a copy
of such Notice) must be submitted herewith or at the Audit.
9. List all parties (charitable and non-charitable) of whom Petitioner(s) has/have notice or
knowledge, having or claiming any interest in the estate as beneficiaries under the Will or
Codicil(s) or as intestate heirs if there is a complete or partial intestacy:
A. State each party's relationship to the decedent and the nature of each party's
interest( s):
Name and Address of Each Partv in Interest
Relationship and Comments. if any Interest
Patricia A. Haslam
42 Wheatfield Drive
Carlisle, PA 17015
Niece One-third of residue
Scott M. Stoner
101 7 Dogwood Lane
Enola, P A 17025
Nephew One-third of residue
Form DC-OI rev. 10.13.06
Page 4 of 10
Estate of John F. Peifer, Jr.
, Deceased
Name and Address of Each Party in Interest
RelationshitJ and Comments, if any
Interest
Stephen J. Stoner
1604 Airport Drive
Mechanicsburg, P A 17055
Nephew
One-third of residue
B. Identify each party who is not sui juris (e.g., minors or incapacitated persons).
For each such party, give date of birth, the name of each Guardian and how each
Guardian was appointed. Ifno Guardian has been appointed, identify the next of
kin of such party, giving the name, address and relationship of each.
N/A
C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for
this Audit (see Pa. o.c. Rule 12.4).
N/A
D. If distribution is to be made to the personal representative of a deceased party,
state date of death, date and place of grant of Letters and type of Letters granted.
N/A
FormOC-OI rev. 10.13.06
Page 5 of 10
Estate of John F. Peifer, Jr.
, Deceased
10. Other than the claim for the family exemption, list the names of all known claimants and
the amount of their claims and state whether each claim is admitted.
Name and Address of Each Claimant Amount of Claim Claim Will Claim
Admitted:' Be Paid In
Full ?
PA Department of Public Welfare $74,603.80 lZIYes DYes
Bureau of Financial Operations DNo lZINo
Post Office Box 8486
Harrisburg, P A 17105-8486
DYes DYes
DNo DNo
DYes DYes
DNo DNo
DYes DYes
DNo DNo
If the estate is insolvent, attach a schedule setting forth the order of preference under
20 Pa.C.S. S 3392 and the proposed payments.
11.
Was family exemption claimed?
DYes
lZINo
Was family exemption allowed?
DYes
lZINo
Family exemption claimant's name and relationship:
Relationship:
Name:
Form OC-OI rev. IO.J3.06
Page 6 of 10
Estate of John F. Peifer, Jr.
, Deceased
12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate
Tax paid, the date(s) ofpayment(s), and the interest(s) upon which paid, are as follows:
Date
Payment Interest
9/4/07
0.00 0.00
13. On the date of death, was the decedent a fiduciary
(personal representative, trustee, guardian, agent under power
of attorney) or surety on the bond of a fiduciary? . . . . . . . . . . . . . . . . . . . 0 Yes III No
If yes, provide the name of the estate, indicate whether an account has been filed and
confirmed absolutely and all awards performed, or, in the alternative, how the
decedent's estate will be discharged for the decedent's fiduciary administration of the
estate.
14. A. Describe in detail any questions requiring adjudication and state the position ofthe
Petitioner(s) as to each question:
N/A
B. Has notice ofthe question requiring adjudication been given
to the parties identified in Paragraph 9 above? .................. 0 Yes 0 No
IS. If Petitioner(s) has/have knowledge that a share has been assigned, renounced, disclaimed
or attached, provide a copy of the assignment, renunciation, disclaimer or attachment,
together with any relevant supporting documentation.
/-orm OC-O I rer 10. 13. 06
Page 7 of 10
Estate of John F. Peifer, Jr.
, Deceased
16. Had the decedent been adjudicated an incapacitated person? . . . . . . . . . . D Ves IZl No
If yes, attach a copy of the Order if available; otherwise state the Court, term, number,
date, and name of Hearing Judge.
17. A. List or attach a separate list of additional receipts and disbursements since the closing
date of the Account.
N/A
B. Has notice of the additional receipts and disbursements been
given to the parties identified in Paragraph 9 above? ............. DVes D No
18. If a reserve is requested, state amount and purpose.
Amount:
Purpose: N/ A
Ifa reserve is requested for counsel fees, has notice of the
amount of fees to be paid from the reserve been given to the
parties in interest? ........................................ DVes IZl No
I f so, attach a copy of the notice.
19.
Is the Court being asked to direct
the filing of a Schedule of Distribution?
IZlVes DNo
As to real estate only? ........................................ DVes IZl No
Form DC-OI rev. 10.13.06
Page 8 of 10
Estate of John F. Peifer, Jr.
, Deceased
Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties entitled
and suggest(s) that the distributive shares of income and principal (residuary shares being stated
in proportions, not amounts) are as follows:
A. Income:
Proposed Distributee(s)
Amount/Proportion
B. Principal:
Proposed Dlstributee(s)
A mount! Proportion
Department of Public Welfare
$2,326.66
Submitted By:
(All petitioners must sign.
Add additional lines ifnecessary):
-ft~itlJ<AluJtiAC
Patricia A. Haslam
Name of Petitioner:
Name of Petitioner:
Form oc.(} / rev. / ()./3. ()6
Page 9 of 10
Estate of John F. Peifer, Jr.
, Deceased
Verification of Petitioner
(Verification must be by at least one petitioner.)
The undersigned hereby verifies * [that he/,iI<
1 S titf~
tlfltl] that the facts set
of the ab5ve Hamed 198.ne of e<'J''fJtJ. ati""
forth in the foregoing Petition for Adjudication / Statement of Proposed Distribution which are
within the personal knowledge of the Petitioner are true, and as to facts based on the information
of others, the Petitioner, after diligent inquiry, believes them to be true; and that any false
statements herein are made subject to the penalties of 18 Pa. C.S. S 4904 (relating to unsworn
falsification to authorities).
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SIgnature of Petitioner
* Corporate petitioners must complete bracketed information.
Certification of Counsel
The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/
Statement of Proposed Distribution is a true and accurate reproduction of the form Petition
authorized by the Supreme Court, and that no changes to the form have been made beyond the
responses herein.
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f. ~ A "~A'/ i/1h""'/
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Signature of Counsel f#etitioner
Form OC-O! rev. 10.13.06
Page 10 of 10
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21 -07 - 0519
FIRST AND FINAL ACCOUNT OF
Patricia A. Haslam, Executrix of the
EST ATE of JOHN F. PEIFER, JR., Deceased
Late of Middlesex Township, Cumberland County, Pennsylvania
Date of Death:
September 18, 2003
Date of Grant of Letters Testamentary
to Patricia A. Haslam
May 29, 2007
Date of First Advertisement of Letters:
Cumberland Law Journal
The Sentinel
June 8, 2007
June 6, 2007
....>..J
Date of Accounting
September 18, 2003 to
February 22, 2008
PURPOSE OF ACCOUNTING:
Patricia A. Haslam, Executrix, offers this Account to acquaint interested parties with the
transactions that have occurred during this administration.
It is important that the Account be carefully reviewed. Requests for additional
information or questions can be discussed with:
Michael L. Bangs, Esquire
Bangs Law Office
Attorney Identification Number 41263
429 South 18th Street, Camp Hill, P A 17011
(717) 730-7310
SUMMARY OF ACCOUNT
PAGE
PRINCIP AL
Receipts of Principal '" $5,771.36
-'
LESS DISBURSEMENTS
Debts of Decedent 4 $74,603.80
Administrative Expenses 4 $444.70
Attorney's Fees 4 $1,500.00
Administrator's Fee 4 $1,500.00
$78,048.50
INCOME
Receipts of Income 5 $0.00
COMBINED BALANCE ON HAND -$72,277.14
PROPOSED SCHEDULE OF DISTRIBUTION 6
VERIFICATION 7
Page 2
RECEIPTS OF PRINCIPAL
DATE
PRINCIPAL
RECEIPTS
7/12/2007 Close of Citizens Bank Account
$5,771.36
TOT AL PRINCIPAL RECEIPTS
$5,771.36
Page 3
DISBURSEMENTS OF PRINCIPAL
DATE
DEBTS OF DECEDENT
6/6/2007 P A Department of Public Welfare
(This is a claim for restitution of medical assistance granted on behalf of
the decedent per letter of June 6, 2007).
TOTAL DEBTS OF DECEDENT:
DATE
ADMINISTRA TIVE EXPENSES
5/29/2007 Register of Wills (probate fees)
6/22/2007 Cumberland Law Journal (advertising fee)
I 7/6/2007 The Sentinel (advertising fee)
I 8/29/2007 Register of Wills (filing fee for inheritance tax return and inventory)
********* Register of Wills (Accounting filing fee)
TOT AL ADMINISTRATIVE EXPENSES:
DATE
FEES AND COMMISSIONS
Michael L. Bangs, Esquire (attorney fees) (to be paid)
Patricia A. Haslam (Executrix commission) (to be paid)
TOT AL FEES:
TOT AL DISBURSEMENTS OF PRINCIPAL:
$74,603.80
$74,603.80
$83.00
$75.00
$126.70
$30.00
$130.00
$444.70
$1,500.00
$1,500.00
$3,000.00
$78,048.50
Page 4
DATE
RECEIPTS OF INCOME
INCOME
RECEIPTS
__n
TOT AL INCOME RECEIPTS
$0.00
Page 5
PROPOSED SCHEDULE OF DISTRIBUTION OF REMAINING PRINCIPAL AND INCOME
NAME
--
DISTRIBUTION
Patricia A. Haslam
Scott M. Stoner
Stephen J. Stoner
P A Department of Public Welfare
$0.00
$0.00
$0.00
$2,326.66
TOTAL DISTRIBUTIONS TO BENEFICIARIES
$2,326.66
Page 6
AFFIDA VIT
Patricia A. Haslam, Executrix of the Estate of John F. Peifer, Jr., deceased, hereby
declares under oath that she has fully and faithfully discharged the duties of her office; that the
foregoing Account is true and correct and fully discloses all significant transactions occurring
during the accounting period; that all known claims against the estate have been paid in full; that,
to the best of her knowledge, there are no claims now outstanding against the estate; that all taxes
presently due from the estate have been paid; and that more than four months have elapsed since
the first complete advertisement of the granting of letters in this estate.
This statement is made subject to penalties of 18 Pa. C.S.A. Section 4904 relating to
unsworn falsification to authorities.
'--~fJatL,LU'(u a r/j~~ ~1J
Patricia A. Haslam
SUBSCRIBED AND SWORN TO
IJEF71-,1E THIS _bl:i* DA Y
OJ): !nfA{1 tr ' 2008.
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Notary Public
CCll\,i,,10iI)WEALi'H OF FC::NNSYLV/\NlA
Nctari2!Seai ~
VVendy K Sire J.1:J. Nc;;;,:ry Pubilc
a. "'1',_.... "'...."
l'-",r.r '""d '. l'~.'.'...-'.c...u' ~ .
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My Commlssicn Exp;ra::~::;1i;Y 1~~
Perms>'lvania Association of Notaries
REQUEST FOR DISTRIBUTION
Accountant requests that distribution be determined by the Court in accordance with the
Schedule of Proposed Distribution filed as part of this account.
~tiL~ iU (] .lIczafa y,'v
Patricia A. Haslam
Page 7
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16,1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA
SSe
COUNTY OF CUMBERLAND
Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
VIZ:
June 8, June 15 and June 22, 2007
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time, place and character of publication are true.
Peifer, John F., Jr., dec'd.
Late of Middlesex Township.
Executrix: Patricia A. Haslam
c/o Michael L. Bangs, Esquire,
429 South 18th Street, Camp
Hill, PA 17011.
Attorney: Michael L. Bangs, Es-
quire, 429 South 18th Street,
Camp Hill. PA 17011.
.rw, IV
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I
SWORN TO AND SUBSCRIBED before me this
22 day of June. 2007
~d'~
NOTARIAL SEAl
DEBORAH A COLLINS
Notary Public
CARUSLE BORO. CUMBERlAND COUNTY
My Commlsllon exPIres Apr 28, 2010
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Tammy Shoemaker, Classified Advertising Manager, of The Sentinel, of the
County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL,
a newspaper of general circulation in the Borough of Carlisle, County and State
aforesaid, was established December 13th, 1881, since which date THE SENTINEL
has been regularly issued in said County, and that the printed notice or publication
attached hereto is exactly the same as was printed and published in the regular
editions and issues of THE SENTINEL on the following day(s)
Tune 6, 13 & 20,2007
COPY OF NOTICE OF PUBLICATION
ESTATE NOTICE
LETTERS TESTAMENTARY on the Estate of JOHN F.
PEIFER, JR., late of Middlesex Township, County of
Cumberland, Pennsylvania, deceased, were granted
to Patricia A. Haslam on May 30,2007.
All persons knowing themselves to be indebted to said
Estate are requested to make immediate pay.ment,
and those having claims will present them, Without
delay, to the undersigned.
Michael L. Bangs, Esquire
429 South 18th Street
Camp Hill, PA 17011
Affiant further deposes that he/ she is not
interested in the subject matter of the
aforesaid notice or advertisement, and that
all allegations in the foregoing statement
as to time, place and character of
PUbication~~~fa~
Sworn to and subscribed before me this
30th, day of Tune, 2007.
_~A'a)X. ..
NO~
My commission expires: q II /tJt
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Christina L. Wd.fe, NoIaIY PubliC
Carlisle BolO, Curr\beI18r1d County
Wrj Corn/1liSSiOO Expires Sepl1. 2008
Member, Pennsylvania A&soclatlon Of Notaries
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6
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WILL
OF
JOHN F. PEIFER
I, JOHN F. PEIFER, of Cumberland County, Pennsylvania, declare this to be my last
will and revoke any will previously made by me.
ITEM I. I direct that all my just debts and funeral expenses, including my gravemarker
and all expenses of my last illness, and any and all taxes and assessments imposed by any
governmental body as a result of my death, whether on property passing under this will or
otherwise, shall be paid from my residuary estate as soon as practicable after my decease as a
part of the expense of the administration of my estate.
ITEM II. I give and bequeath all of my household goods, automobiles, jewelry, and all
other articles of household and personal use, equipment and ornament, together with all
insurance thereon and relating thereto, in equal shares, to PATRICIA A. HASLAM, SCOTT M.
STONER, and STEPHEN 1. STONER, or to those of their issue, per stirpes, as survive my death
by thirty (30) days.
ITEM III. I give, devise, and bequeath all the rest, residue, and remainder of my
possessions and estate of every nature and wherever ~ituate, in equal shares, to P ATRICLtl.. A.
HASLAM, SCOTT M. STONER, and STEPHEN J. STONER, or to those of their issue, per
stirpes, as survive my death by thirty (30) days.
ITEM IV. I appoint my daughter, PATRICIA A. HASLAM, executrix of this my last
will.
I
ITEM V. In addition to the other powers and authorities granted to my personal
representatives by Pennsylvania law and by the other terms and provisions of this will, I hereby
give to my personal representatives the following powers and authorities effective without court
approval and until actual distribution of all property: to compromise any claim or controversy; to
make distribution in cash or in kind, or partly in cash and partly in kind, and in such manner as
my personal representatives may determine and at valuations finally to be fixed by them; to
invest in all forms of property, including any stock or other securities in any corporate fiduciary
or its successor without restriction to investments authorized for Pennsylvania fiduciaries, as my
personal representatives deem proper, without regard to any principle of risk or diversification; to
retain any or all assets of my estate, real or personal, without regard to any principle of risk or
diversification; to sell at public or private sale, to exchange, or to lease for any period of time,
any real or personal property and to give options for sales, exchanges, or leases, for such prices
and upon such terms or conditions as my personal representatives deem proper; and to allocate
receipts and expenses to principal or income or partly to each as my personal representatives
deem proper in their sole discretion.
ITEM VI. I direct that my personal represent~tives and fiduciaries shall not be required
to give bond for the faithful performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand this
day of
AJar) ( ((
, 1997.
X I~~ p~
JOHNarPEIFER
2
The preceding instrument, consisting of this and TWO other typewritten pages, each
identified by the signature of the testator was on the date thereof signed, published, and declared
by JOHN F. PEIFER, the testator therein named, as and for his last will, in the presence of us,
who at his request, in his presence, and in the presence of each other, have subscribed our names
as witnesses hereto.
~~~. f/-rg-?7
Vi ~:A << I)
3
COMMONWEALTH OF PENNSYLVANIA
)
( SS:
)
COUNTY OF CUMBERLAND
The undersigned, being the testator whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, does hereby acknowledge that I signed and
executed the foregoing instrument as my last will, that I signed it willingly; and that I signed it as my
free and voluntary act for the purposes therein expressed.
~i-rQ~J
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Sworn or affirmed to and acknowledged
t.b~7\.s.l~e.a.:. ~;~. :c~. ta.t.~L....~.. :... ~F;
1 ~ 11 fI i t(i i ;\ CJ.lGjll (
Notary Publi NOTARiM SEAl
IWENOY S. CHESIRO, Notary Public
lOwer All.ttI Twp., Cvmbetiond Co., PA
My CommluiOfl Expires May 10, 1999
COMMONWEAL TH OF PENNSYLVANIA )
( SS:
COUNTY OF CUMBERLAND )
WE, niAtzvuu I ~To~ and ~J.ICHf.t-L L - f21AJJ6~ , the witnesses whose
names are signed to the attached or foregoing instrument, being duly qualified according to law, do
depose and say that we were present and saw the testator sign and execute the instrument as his last will;
that he signed it willingly and that he executed it as his free and voluntary act for the purposes therein
expressed; that each of us in the hearing and sight of the testator signed the will as witnesses; and that to
the best of our knowledge, the testator was at that time 18 or more years of age, of sound mind, and
under no constraint or undue influence.
4
COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO. 21- 07 - -510
ESTATE of JOHN F. PEIFER, JR., Deceased
Late of Middlesex Township, Cumberland County, Pennsylvania
CERTIFICATION OF SERVICE
MICHAEL L. BANGS, being duly sworn according to law, deposes and says as follows:
1. That he is the attorney for Patricia A. Haslam, Executrix of the Estate of John F.
Peifer, Jr..
2. That on February 27,2008, written notice of the time of presentation of the Account
and Proposed Schedule of Distribution and the character thereof was given to all parties in
interest as shown on Exhibit A attached hereto at least twenty (20) days prior to the date fixed for
the confirmation of the Account in accordance with and as required by Section 3503 of the PEF
Code.
MICHAEL L. BANGS
f'.. '
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-"-r
Patricia A. Haslam
486 Adam Lane
Mechanicsburg, P A 17050
Scott M. Stoner
1 01 7 Dogwood Lane
Enola, P A 17025
Stephen J. Stoner
1604 Airport Road
Mechanicsburg, P A 17055
PA Department of Public Welfare
Bureau of Financial Operations
Division of Third Party Liability
Estate Recovery Program
Post Office Box 8486
Harrisburg, P A 17105-8486
EXHIBIT A