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HomeMy WebLinkAbout04-0251RICHARD A. KILLINGER, Executor of the Estate of HELEN L. KILLINGER, Plaintiff PAUL L. KILLINGER, JR., Defendant : IN THE COURT OF COMMON PLEAS OF : : CUMBERLAND COUNTY, PENNSYLVANIA : 2004- CIVIL TERM : CIVIL ACTION - LAW PRAECIPE FOR ISSUANCE OF A WRIT OF SUMMONS TO CURTISR. LONG, PROTHONOTARY: Please issue a Writ of Summons against the defendant, PAUL L. K1LLINGER, JR., and enter my appearance on behalf of the plaintiff, Richard A. Killinger, Executor of the Estate of Helen L. Killinger. ' ~' ' S~4fS'~ /~ Respect~lly submi,ed, 60 West om~e~eet~lisle~A 1~13 (717) 249-2353 ~~5476 Date: J~u~ 20, 2004 To: PAUL L. KILLINGER, JR. Date:l~ f~ ~C) , 2004 You are hereby notified that Richard A. Killinger, Executor of the Estate of Helen L. Killinger, plaintiff, has commenced an action against you which you are required to defend or a default judgment may be entered against you, RICHARD A. KILLINGER, : IN THE COURT OF COMMON PLEAS OF Executor of the Estate of HELEN L. KILLINGER, Plaintiff/Petitioner PAUL L. KILLINGER, JR., : Defendant/Respondent .. : CUMBERLAND COUNTY, PENNSYLVANIA _. · ' NO. 2004. CIVIL TERM : CIVIL ACTION - LAW PETITION FOR APPROVAl, OF SETTLEMENT AND NOW this 16th day of March 2004, come the Petitioner, Richard A. Killinger, Executor of the Estate of Helen L. Killinger, by his attorneys, Irwin & Mci(night, and makes the following Petition for Approval of the Settlement of the civil claims of Paul L. Killinger, Jr.: 1. The petitioner is Richard A. Killinger, Executor of the Estate of Helen L. Killinger, an adult individual residing at 704 Charles Street, Shippensburg, Pennyslvania 17257. He was granted Letters Testamentary on December 11, 2003 at PA 21-03-1020. 2. The Respondent is Paul L. Killinger, Jr., an adult individual residing at 303 Dwelling Court, Shippensburg, Cumberland County, Pennsylvania 17257. 3. The Petitioner seeks approval of a settlement of $100,000.00 from Nationwide Insurance Company and allocates it in the following amounts: A. Wrongful Death ........................................................ $90,000.00 B. Survival Action ......................................................... $10,000.00 A copy of the Release is attached hereto and marked as Exhibit "A" and is made a part of this Petition. This allocation between the Survival Action and the Wrongful Death is based upon the immediate death of the spouse in the traffic accident. She was a passenger in an automobile driven by her husband, Paul L. Killinger, Jr. when he was involved in a one car accident on September 16, 2003. His liability carder has offered the limits of its policy. A copy of the Police Report is attached hereto and marked as Exhibit "B" and is made a part of this Petition. The Death Certificate of Helen L. Killinger is hereto attached and marked as Exhibit "C" and is made a part of this Petition. The Petitioner also seeks approval of the legal fees and expenses to the firm of Irwin & McKnight as follows: A. Legal Fees (25% of Settlement) ................................ $25,000.00 The Petitioner also seeks approval of the Survival Action proceeds as follows: Survival Action .................................................... $10,000.00 (100% of proceeds distributed to surviving spouse) Less prorated costs ........................................................ -3.60 Less prorated legal fees to I&H .............................. -2,500.00 Distribution to Paul L. Killinger, Jr. Estate of Helen L.Killinger .................................. $7,496.40 The Petitioner seeks approval of the Wrongful Death proceeds as follows: Total Wrongful Death proceeds ........................... $90,000.00 Less cost ...................................................................... -12.40 Less legal fees to I&M ......................................... .-22,500.00 Balance for Distribution .................................... $67,467.60 4 o The Petitioner seeks the final distribution of the settlement proceeds as follows: 1. Paul L. Killinger, Jr. (Surviving Spouse) ......... $30,000.00 2. Paul L. Kiillnger, Jr. (Surviving Spouse) ........... 12,500.00 3. Paul B. Killinger ..................................................... 4,993.52 Richard A. Killinger .............................................. 4,993.52 Richard A. Killinger, Jr ......................................... 4,993.52 Terry L. Killinger ................................................... 4,993.52 John R. Killinger .................................................... 4~993.52 Total Settlement Distribution ........................... $67,467.60 9. The Pennsylvania Department of Revenue has reviewed this Petition and approved it in a letter dated February 27, 2004, by J. Paul Dibert, Inheritance Tax Division of the Pennsylvania Department of Revenue. A copy of this approval is attached hereto and marked as Exhibit "D" and is made a part of this Petition. WHEREFORE, the Petitioner respectfully request the approval of said Petition with the distribution as set forth above. Date: March 16, 2004 By: Respectfully submitted, IRWIN & McKNIGHT CKnlght, III, ~q. ~ 60 West Pomfret Street [,. x~ Carlisle, Pennsylvania 17013-5'~2fi.2_ J 717-249-2353Supreme Ct ID# 25476 5 VERIFICATION The foregoing document is based upon information which has been gathered by counsel and myself in the preparation of this action. I have read the statements made in this document and they are tree and correct to the best of my knowledge, information and belief. I understand that false statements herein made are subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unswom falsification to authorities. Executor of the Estate of HELEN L. KILLINGER Date: March 16 2004 6 EXHIBIT A RELEASE OF ALL CLAIMS CLAIM NO. 1554713139B30 This Indenture Witnesseth that, in consideration of the sum of One Hundred Thousand Doll ($100,000.00), receipt whereof is hereby acknowledged, for myself and for my heirs, personal re"resentativ .... ars. do hereby release and forever discharge Paul L Killinger Jr. and any other person, firm or corporation charged or chargeable with responsibility or liability, their heirs, representatives and assigns, from any and all claims, demands, damages, costs, expenses, loss of services, actions and causes of action, arising from any act or occurrence up to the present time and particularly on account of all personal injury, disability, property damages, loss or damages of any kind already sustained or that I may hereafter sustain in consequence of an accident that occurred on or about this 16th day of September, 2003, at or near Greene Twp, Franklin Cty, Pa. To procure payment of the said sum, l hereby declare: that I am more than 18 years of age; that no representation about the nature and extent of said injuries, disabilities or damages made by a physician, attorney or agent of any party hereby released, nor any representation regarding the nature and extent of legal liability or financial responsibility of any of the parties hereby released, have induced me to make this settlement; that in determining said sum there has been taken into consideration not only the ascertained injuries, disabilities and damages, but also the possibility that the injuries sustained may be permanent and progressive and recovery therefrom uncertain and indefinite, so that consequences not now anticipated may result from the said accident. I hereby agree that, as a further consideration and inducement for this compromise settlement, this settlement shall apply to all unknown and unanticipated injudes and damages resulting from said accident, casualty or event, as well as to those now disclosed. I understand that the parties hereby released admit no liability of any sort by reason of said accident and that said payment and settlement in compromise is made to terminate further controversy respecting afl claims for damages that I have heretofore asserted or that I or my personal representative might hereafter assert because of the said accident. I further understand that such liability as I may or shall ha~,e incurred, directly or indirectly, in connection with or for damages arising out of the accident to each person or organization released and discharged of liability herein, and to any other person or organization, is expressly reserved to each of them, such liability not being waived, agreed upon, discharged not settled by this release. Signed .and sealed this STATE OF PENNSYLVANIA COUNTY OF CUMBERL~IDss On this 19th dayof JANUARY BEFORE S,GN,NG) (CAUTION - RE. 'Y (SEAL) (SEAL) 2004 , before me personally Appeared RICHARD A. KILLINGER , to me ~ to be the person who executed the foregoing instrument, and acknowledged that ,__~.~E ex,~d ¢ s~q.s~__ f~,~ act and deed' C53-9 Release of All Claims EXHIBIT B COMMONWEALTH OF PENNSYLVANIA ~,L~._ CRASH REPORTING FORM AA 500 1 © © CD ;O' o Dispatch Time u?~4 Arrival Time mdl Investigator Reviewer County Name Crash Date (MM-DD-Yyyy) P0527782 Police Agency Patrol Zone Precinct Investigation Date ~F~M-DD-Yyyy) Badge Number Badge Number Approval Date (MM-DD-YYyy) I Municipality Municipali~ Name Day of Wee~ I I o o Crash Time (miff No of Units People In~ured Killed* *If > O0 complete ~ Tue O Sat W ~ (If Yes, Complete School Bus or.zone Form M ~ection 29) C~ Yes (~ No Related CD Yes I~ No School Zone Related O Yes r-~ Murt[-Lea /D~ O 4 Way Intersection O "Y" Intersection '--' Intersect~n CD Off Ramp ~ Midblock Traffic Circle/ O "T" Intersection CD Round About O On Ramp CD Cross)vet Segment (Optional) Route Number Street Name Travel Lanes Speed Limit Street Ending CD Interstate Turnpike (Not Turnpike) C) (EastjWest) Rou~e Number Segment (Optional) Street Name Please Informatior for BOTN Landmarks if Using CD Turnpike State County Spur (~ -tighway CD Roao Travel Lanes Speed Limit Street -Ending Interstate Turnpike Tur~pik~-~- . :c State ~'anina C~ (Not Turnpike) C~ (East/West) CD County - Spur CD -Righv~ay O Road Intersecting Rt Num Or Mile Post Or Intersecting Street Name Or Segment Marker Degrees Minutes Seconds Degrees FZZs~J~.~T~ O Yield Sign O Police Officer o C~Not Applicabre C~ Traffic Signal r--~ Active RR Crossing Flagman ~ Controls C) Other Type TCD CD Flashing Traffic Signal CD Stop Sign Passive RR C) Crossing Controb CD Unknown St L n~ (If "Not Applicable", skip rest of the Lane Closure section) CD Not AppJicable C~ Partially ~ Yes (~ NO C) ~ured Unknown FORM # A~-SO0 Form F O Wed CD Unk Yes I~ No C) Railroad Crossing *_S~ecial_ O Other LocatiQ~ ~ North 1 House Number (if applicable) C~) South C) East For Mid block crashes only Use CD West postal House Number and ma~e sure PrincipaF Roadway Street Name is CD Unknow tilled in if using this option Local Road Private Other/ or Street CD O Road Unknown O North O South CD East C~ west O Unknown Local Road Private ~ Other/ 0FStreet ~ C~ Road '--' Unknowr Feet Or Miles Distance From Crash Scene to Landmark 1 (For Crash between Landmark I and Landmark 2) Minutes Seconds ~.D Functi~nin~l ' C~ No Controls CD Device Function ~g mproperly C~ Device Not Device Functionina Functioning CD Properly ~ Emergency CD Preemptive Signal C) Unknown Lane Closu_l~ CD North C~ East I~ North and South O All Fully CD Unknown Direcdql] C) South CD West O Ea~t and West (N,S.F.W) /~ ~<30 Min C) 30-60Min. C~ 1 3hfs 1~3-6 hfs O6-ghrs CD>ghours CD Unknown _F~-~ ~,':ci,' or E:ock ~) Dirt ! ~pecia!Jun~Zicti:~ Concrete O Slag, ~ravei or O Other ~ ~ Jurisdiction Biacktop Ston~ No Special O Unknown C~) National Park 0 College/University Campus 0 Unknown Please complete Unit Information for each unit involved in a fatal crash. Do not repeat the information in the fields above on multiple ~ages Unit No ' Driver Restrictions Compl/ance C~ No Restrictions/ Not Applicable Restrictions C~ Complied With Restrictions Not 0 Complied With Compliance C~ Unknown o Not a Pennsylvania Driver Unknown Compliance Compliance C~ None Required O Required - ~ Not a Pennsylvania Complied With ~ Driver C~ Required Non Unknown Compliance C~) Compliance C~ Required - Compliance Unknown Driver License Comp/lance 0 Not Licensed 0 Not Required for Vehicle Class o No Valid License for Class I~ Valid License for Class Unk if CDL 0r CDL Required o Not a Pennsylvania Driver Unknown Druq Test Type 0 Blood 0 Other Unknown if Test ~ None 0 Urine 0 Given Drufl Test Results - (Up to Four Results) 0 = No Test Given 5 = Amphetamines l = No Drug Reported 6=PCp 2 = Marl uana 8 = Other 3 = Coca ne 9 = Unknown Test 4 = Opiates Results Unit No Driver Restrictions 0 Restrictions 0 Not a Pennsylvania Compliance Complied With Driver Restrictions Not 0 Unknown No Restrictions/ C~) Complied With ~ Compliance (~) Not Applicable C~Compliance Unknown Driver Endorsement 0 Required - ~ompliance Compiled With O Driver (~ None Required C~) Required - Non 0 Unknown Compliance Compliance C~ Required- Compliance Unknown Driver License m Not Required for (~ Unk if CDL or ~ ~ Vehicle Class -- CDL Required c) No Vatid License for Class C~ Not a Pennsylvania Driver C~ Not Licensed ~ Valid License for ~ Class 0 Unknown Druq Test Type 0 Blood C~ Other C~ None C~ Urine ~ Unknown if Test ~ Given Test Results - (Up to Four Results) 0 = NO Test Given S = Amphetamines ~-~ [~ l=NoDrugReported 6=PCP 2 = Marijuana 8 = Other 3 = Cocaine 9 = Unknown Test [-~ ~"~ 4 = Opiates Results Principle Impact Point C) Non-Collision 11 12 0 Top 0 09~ 0 Undercarriage C~) Towed Unit O 03 07v~06 C~ Unknown 0 CD 030 Avoidance Maneuver No Avoidance (~ Maneuver 0 Braking - Skid Marks Evident Braking - No Skid O Marks, Driver Stated Under Ride Indicator Braking - Other CD Evidence c~Steering - Evidence or Driver Stated C~ Steering and Braking Evidence or Stated Other Avoidance Maneuver Inconclusive Unknown No Underride or Override Underride, No CD Compartment . CD Override, Other Intrusion ~ -" Vehicle Underride, Underride, Unknown if 0 Compartment CD Compartment 0 Underride or Intrusion intrusion Unknown Override Emerqen(y Use Not in Emergency Use Principle Impact Point 0 Non-Collision CD Top CD Undercarriage C~ Towed Unit CD Unknown Lights Flashing C~ Both Lights and Siren Sire~ Sounding 0 Unknown Avoidance Maneuver 0 No Avoidance Maneuver Braking - Skid O Marks Evident Braking - No Skid O Marks, Driver Stated Under Ride Indicator O Braking - Other O Other Avoidance Evidence - Maneuver Steering - Evidence or Driver Stated O Inconclusive Steering and Braking O Unknown Evidence or Stated Underride, No C--~ Override, Other (~ No Underride or CD Compartmsnt Override Intrusion ~ Vehicle Underride, Underride, Unknown if C~ Compartment CD Compartment C~ Underride or Intrusion intrusion Unknown Override EmerqencF Use 0 Lights Flashing (~) Not in Emergency Use C~ Siren Sounding o Both Lights and Siren Unknown FORM # AA-500F (12/02) _J COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA 500 2 -i r Type Unlit Page: (~) Motor Vehicle in Transport C~) Hit & Run 'vehicle C~) Illegally Parked C~) Legally Parked C~) Nor, - Matorized 0 ~de~rldn 0 0 0 Phantom Vehicie p~ ,- Pedestrian on Skate:; BisabJed From O Train (If "Pedestrian" or "Pedestn'an on Skates, in Wheelchair, etc', Complete Form ~, Section 28) Commercial Vehicle 0 te~ CZ) No Yes, Complete Form MI Date of Birth ¢MM-DD-fyyv'~ Telephone Number Zip Unit No First Name Last Name I/ l/l lLI/l l lrl l I¢1 1 I I Address / City / State 303 I)wELu / CouRT' Driver License Number State Class /01372. Alcohol/Druqs Suspected Driver or Pedestrian Physical Condition No O Illegal Drugs O Medication .Alcohol O Alcohol and Drugs O Unknown A/coho/Test Type (~ Test Not Given 0 Breath 0 Other C) Blood C~ Urine C) Unknown Jf Test Given Unknown Alcohol Test Results 0 Test Refused 0 Results ~ J~'] Test Given, · C) Contaminated Results 0 Apparently illegal Drug Normal 0 Use 0 Fatigue 0 Medication C~) Had Been O Sick O Asleep (~ Unknown Drinking Primary Vehicle Code Violation Dmvl ¢/ Charged? Yes ~ No D~iver Presence 1=Driver Operated 3=Driver Fled Scene J~ Vehicle 4=Hit and Run I ]=No Driver 9=Unknown Owner/Driver 00=Not Applicable [[J 01=Private Vehicle Owned/ Leased by Driver Driver Address / City / State / Zip 02=Private Vehicle Not Owned/Leased by Driver 03=Rented Vehicle 07=Municipal Police Veh 08=Other Municipal Government Vehicle 04=State Police Vehicle 05=PENNDOT Vehicle 06=Other State Gov Veh 09=Federal Gov Veh 98=Other 99=Unknown Owner Last Name or Business Name (If Pedestrian, skip this Section Vehicle Make J Ix, c VIN Model Year" '~"g:-- Vehicle Model License Plate _--. Reg. State Est. Speed Vehicle Towed ~owed By Insurance insurance Company Policy No O Un- *Make (see overlay) J Trailin~ Unit No of ~ Ty~e Trailing J LJJ Unlit Units: ~ ~ Direction of ~ 1=Towing Pass Veh 4=Mobile/Modular Home 7=Semi-Trailer ---~ 2=Towing Truck 5=Camper 8=Othe~ 3=Towing Utility Trailer 6=Full Trailer 9=Unknswn 06=Yellow 07=Silver 08=Gold 09=Brown lO=Orange 11 =Purple 12=Other 99=Unknowr Overlay Vehicle Type 05=Large Truck 20=UnicycR.!, Bicycle, J 01=Automobile 06=SUV Tricycle 02=Motorcycle 07=Van 21=Other Padarcyde 03=Bus 10=Snowmobile 22=Horse & Buggy 04=Small Truck 11=Farm Equip 23=Horse & Rider (If "02'; Complete Form 12=Construction Equip 24=Train M, Section 26) ~ ~ 3=ATV 25=Trorley (If "20" or '21'; Complete 18=Other Type Spec Veh 98=Other Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown Damage Indicator Gradient -] 0=None 2=Functional 1=Minor 3=Disabling g:Unknown Tag No Tag Year Tag St 14=Undercardage 15=Towed Unit 99=Unknown _Vehicle Color Ol=Blue 02=Red 03=White 04=Green 05=Black initial Impact Point 00=Non-Corlision 01-12=Clock Points 13=Top 3=Downhill  4=Bottom of Hi 1=Level 5=Top of HB 2=Uphill 9=Unknown Road Aliqnment 1=Straight 2=Curved 9=Unknown 5_oecial Usaqe ~ 12=Commercial Passe~ger O0=Not Applicable Carrier 01=Fire Veh 13=Taxi 02=Ambulance , 21=Tractor Trailer 03=Police 22=Twin Trailer 08=Other Emergency 23=Triple Trailer Vehicle 31 =Modified Veh 11 =Pupil Transport 99=Unknown COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page: P0527782 Type Unit (~) Mot©r Vehicle in T~anslort C) Hit & Run Vehicle C) Illegaily Parked C~) Legally Parked C~ Non Motorizeci Commercial Vehicle C) Pedest!ian in Wheec~air eb 0 0 Train 0 Phantora '/ehide [ 0 '/es (if "Pedestrian" or "Pedestrian on Skates, in Whee/chai6 etc", Complete Form M, Section 28) I (If Yes, Complete Form MI Date of Birth ,'MM-DD-vyy'o Telephone Number Unit No First Name Last Name Delete? o I 1 '1 1 1 Address / City / State Driver License Number zip State Class Alcohol/Druqs Suspected No O Illegal Drugs Alcohol O Alcohol and Drugs Alcohol Test Type (~) Test Not Given 0 Breath 0 Blood 0 Urine Alcohol Test Results O Test Refused [-~ ~]~"~ Test Given, · C) Contaminated Results Owner/Driver 00=Not Applicable  01 =Private Vehicle Owned/ Leased by Driver Same as Owner First Name Driver C) Address / City / State / Zip O Medication 0 Unknown Driver or Pedestrian Physical Condition (~) Apparently Illegal Drug Normal C) Use C) Fatigue C) Had Been C) Sick C) Asleep Drinking Primary Vehicle Code Violation O Other Unknown if Test Given 0 Results 02=Private Vehicle Not Owned/Leased by Driver 03=Rented Vehicle Driver Presence l=Driver Operated Vehicle :!=No Driver O Medication O Unknown 04=State Police Vehicle 05=PENNDOT Vehic e 06=Other State Gov Veh Charged? JO Yes (~ 3=Driver Fled Scene 4=Hit and Run J I g=Unklqown 07=Municipal Police Veh 08=Other Municipal Government Vehicle No 09=Federal Gov Veh 98=Other 99=Unknown Owner Last Namelor Business Name (If Pedestrian, skip this Section) Vehicle Make Vehicle Model To~ed By VIN 'cerise Plate Reg. State Est. Speed Vehicle Towed Policy No *Make Code (see over "1 Trailinq 1=Towing Pass. Veh 4=Mobile/Modular Home 7=Semi-Trailer Onit No of I--~ ~ ~ 2=Towing Truck Trailing Unit S=Camper 8=Othe~ Units: J ('~'J -- I I 3=Towing Utility Trailer 6=Furl Trailer 9=Unknown Direction of ~ .Veh,~,ePos,t,o. IOI ii Overlay Vehicle Color  06=Yellow 07=Silver 08=Gold 01=Blue 09=Brown 02=Red 10=Orange 03=White 11=Purple 04=Green 12=Other OS=Black 99=Unknown I. nitial Impact Point Vehicle Type 05=Large Truck 20=Unicycle, Bicycle,  -7-1 01=Automobile 06=SUV Tricycle 02=Motorcycle 07=Van 21 =Other Pedalcycle 03=Bus _ 10=Snowmobile 22=Horse & Buggy 04=Small Truck- 11=Farm Equip 23=Horse & Rider (If "02'; Complete Form 12=Construction Equip 24=Train M, Section 26) 13=ATV 25=Trorley (if ~20~ or "21", Complete 18=Other Type Spec Veh 98=Other Form M, Section 27) lg=Unk. Type Spec Veh 99=Unknown Damaqe Indicator~: ~ Gradient 00=Non Collision 14=Undercarriage ~ 0=Non~ 2=Functional ~ 01-12=Clock Points 15=Towed Unit J-~J 1=Minor 3=Disabling J,~ 1=Level 13=Top 99=Unknown 9=Unknown 2 =Uphill Tag No Tag Year Tag Bt Special Usaqe  ~ 2=Commercial Passenger 00=Not Applicable Carrier 01=Fire Veh 13=Taxi 02=Ambulance 21=Tractor Trailer 03=Police 22=Twin Trailer 08=Other Emergency 23=Triple Trailer Vehicle 31 =Modified Veh 1 =Pupil Transpor~ 99=Unknown 3=Downhill Road Aliqnment 4=Bottom of Hill ~--~ 1=Straight 5=Top of Hill I~I 2=Curved 9=Unknown 9=Unknown _J COMMONWEALTH OF PENNSYLVANia POLICE CRASH REPORTING FORM A 1 =Driver 8=Other B ~Femaie M =Male U =Unknown C O=Not In ured =Kled 2=Major Injury 3=Moderate injury 4=Minor Injury 8=Injury, Unk Severity 9=Unknown if Injury Right Side lO=Sleeper Section of Truckcab 11=In Other Endosed Passenger Or Cargo Area (Back Of Pickup, Etc) 98=Other 99=Unknown Page ~C=F)orle Used / N~)~ ~,pplicable Ol=Shoulde~ Belt Used 04=Child Safety Seat Used 12=Helmet Used Improperly 90=Restraint Used, Type Unknown 99=Unknown Safety Eauioment Two. 00=None Used / Not Applicabre 01=Front Air Bag Deployed (For 7his Seat) 02=Side Air Bag Deployed (For This Seat) 03=Other Type Air Bag Deployed 04=Multiple Air Bags Deployed 05=Motorcycle Eye Protection 06=Bicyclist Wearing Elbow/Knee/Pads lO=Air Bag Not Deployed, Switch On =Air Bag Not Deployed, Switch Off 12=Air Bag Not Deployed, Unk Switch Setting 13=Air Bag Removed (Prior To Crash) 19=Unknown If Air Bag Deployed 9g=Unknown P0527782 ~--r~lb~AppJica ble =Not Ejected 2 =Tota!iy Ejerted 3=Partially Ejected 9=Unknown H 0=Not Ejected / Not Applicable 1=Through Side Door Opening 2=Through Side Window 3=Through Windshield 4=Through Back Door 5=Through Back Door Tailgate Opening 6=Through Roof Opening (Sunroof/ Convertibie Top Down) 7=Through Roof Opening (Convertible Top Up) 9=Unknown Exttlcatlbn. F 0=Not Applicable =Not Extricated 2=Extricated By Mechanical Means 3=Freed By Non - Mechanical Means 8=Other 9=Unknown Unit No Person No Delete? Date of Bir:h (MM-DD-YYYy) A B C D E F G H · Na~e / Addre$~ / Phone [] Same as [ Operator EMS Transport ~ Yes 0 No Unit No Person No Delete? Date of Birth (MM DD-YYYY) A B C D [ F G H I Name / Address / Phone Same as EMS Transport [] Operator Ij''~,EI~' ~0~ KJI. LIi't~,~ I C) Yes (~No Unit No Person No Delete? Date of Birth (MM-DD-YYyy) A B C D E F G H Name / Address / Phone Same as EMS Transport ~Operatorl I (~yes C) No [-~-] ~ Date of Birth (MM-On-YyYYI A B C D E F c, H T ,Jnit.o .ersonNo Delete? ~.~ ~:1 '1 I I I~--~]~~-~F--~-~[~][-~ O - Name / Address / Phone Same as EMS Transpo~ ~Operator[ ] ~Yes ONo Unit .o Person No Date of Birth (MM-DD-YYYY) o FT-I-I- -I' I III Name / Address / Phone Operator ~ EMS Transport C~) Yes C) No Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D o Name / Address / Phone ~ same as [ Operator EMS Transport j C~)Yes 0 NO POLICE CRASH REPORTING FORM Page . Crash Number AA 5004 ) I P0527782 ?ash De$cript on ~ 0=Non-Collision 2=Head On ~.=Angle 6=Sideswipe 8=Hit Pedestrian = ~I'"l 1=Rear End 3=Rear to Rear S=Sidesw~oe (Opposite Dec on) o ~ (Backing) (Same Direction) 7=Pit Fixed Object 9=ether'Unknown = ~_ I~¢lation to Roadway [~ ~=On Travel Lanes 3=Median 5=Outside Trafficway 7=Gore tRamp intersection) ~ ~,ri 2=Shoulder 4=Roadside B=ln Parkiqg Lane 9=Unknown '~ ? Illumination l=Daylight 3=Dark - Street 5=Dawn 8=Other ~ -- 2=Dark - No Lights 0=Dark - Unknown .... Street Lights 4=Dusk Roadway Lighting  1 =No Adverse ~ Weather Conditions 3=Sleet (Hail) 5=Fog 7=Sleet & Fog 9=Unknown ., Conditions ~ 2=Rain 4=Snow 6=Rain & Fog 8=Other Road Surface Conditions ~ 0=Dry 2=Sand, Mud. Did, 4=Slush 6=Ice Patches 8=Other --'~ Oil 7=Water - Stand ng 1=Wet 3=Snow Covered 5=Ice or Moving Harm Event L/R Most? Utility Pole Number Harmful Events (Harm Event) 30=Hit Fence Or Wall UnJtNo 1~[-~ ~---~ (~) J I I J I I I 01=Hit Unit 1 31=Hit Building 02=Hit Unit 2 32=Hd Culvert 03=Hd Unit 3 33=Hit Bridge Pier Or Abutment 05=Hit Unit 5 35=Hit Bridge Rail 06=Hit Other Tr]ffic Unit 36=Hit Boulder Or Obstacle Please Put 3 07=Hit Deer On Roadway 08=Hit Other Animal 37=Hit Impact Attenuator Sequential 38=Hit Fda Hydrant 4 (~) 11=Struck By Unit 1 40=Hit Mail Box 12=Struck By Und 2 41=Hit Traffic island 13=Struck By Unit 3 42=Hit Snow Bank Harm Event L/R Most? Utility Pole Number 14=Struck By Urit 4 43=Hit Temporar~ Construcdon 1 I~ 16:Struck By Other Traffic Unit 48=Hit Oth~r Fixed Object Unit No 21=Hit Tree Or -~hrubber¢- 49=Hit Unknown Fixed Object ~u ~T~ ~--~ [~-] ~ 22=Hit Embankmen~ 50=Overturn/Ro,I Over 2 C) 23=Hit Utility Pole 51=Struck By Thrown Or Falling 24=Hit Traff'c Sign . Object 25=Hit Guard Pair' 52=Pot Holes Or Other PleasePut~-~ [~~~ 26=Hit Guard' Rail End Pavement irregularities Eventa in 3 C) 27=Hit Curb 53=Jacknife Sequential 28=Hit Concrete Or 54=Fire In Vehicle Order ~T~ ~ ~ Longitudinal Farrier 58=Other Non-Collision 4 C) 29=Hd Ditch 99=Unknown Harmful Event First Unit No Harm Event Most Unit No Harm Event DriverActioh'(D) 1?=Careless Or Illegal Event in Event in 01=Driver Was D stracted 18=Driving On The Wrong t~h the Crash Side Of Road 02=Ddving Using Hand HeEd Phone DO not repeal th]~ inf°¢mati°n on multiple pages 03=Driving Using Hands Free Phone 19=Making Improper - 05=Improper/Careless Turning 20=Making Improper Exit Potential Factor~ (E/R) I 2 3 . 06=Turning From Wrong Lane From Highway 07=Proceeding V~/O 21=Careless Parking/Unparking O0=None 1 ]=Slippery Road Conditions Fee/Snow) Clearance After Stop 22=Over/Under 01=Windy Conditions 12=Substance On Roadway 08=Running Stop Sign Compensation At Curve 02=Sudden Weather Conditions 13=Potholes 09=Running RedLight 23=Speeding 03=Other Weather Conditions 14=Broken Or Cracked Pavement 10=Failure To Respond To 24=DrMng Too Fast For Conditions 04=Deer In Roadway 15=TCD Obstructed Other Traffic Control Device OS=Obstacle On Roadway lB=Soft Shoulder Or Shoulder Drop Off 1 l=TaJl~atin~ 25=Failure To Maintain Proper Speed 06=Other Animal in Roadway 28=Other Roadway Eacio¢ 12=Suaden ~i~wing/Stop bg 2F=Driver Fleeinq Police (Poi Chase) 07=G/are 29=Other Environmental Factor 13=Illegally Stopped On ~ad 27=Driver Inexperienced 08=Work Zone Related 99=Unknown ]4=Careless Passing Or Lane 28=Failure To Use Specialized Equip Change 92=Affected By Physical Condition ~o$$ible Vehicle Fail,res (VI 12=Wipers 98=Other Improper 1 5=Passing NO PassingZone Driving Actions O0=None 06=E×haust 13=Driver Seating/Control 16=Driving The Wrong Way On gg=unknown 01=Tires 07=~eadlights~, 14=Body, Doors, Hood, Etc 1-Way Street 02=Brake System 08=Figna[ LJg,,is IS=Trailer Hitch ~ 03=Steering System 09=Other Lights 16=Wheels Unit r-~-~ iT-~-~ r-~--r-~--j j~-i,~-] iI 04=Suspension 10=Horn 17=Airbags No I'II 171Ol I I I lll 2 3 4 05=Power Train 11=Mirrors 18=Trailer Overloaded 19=Unsecure/Shd~ed 20=improper Towing 21=Obstructed Windshield No 1 2 O0=None 04=Pushing Vehicle 01=Entering Or Crossing At 05=Approaching Or Leaving Vehicle Specified Location 06=Working On Vehicle Indicated Prime Factor Unit No Factor Code 02=Walking, Runn,ng, Jogging, 07=Standing DO not repeat fhi~ inforrnati .... ~ ~ Or Playing 98=Other I 99=Unknown E/R V D P Type, leave Unit No blank J COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM AA 500 5 t ..... ' Page P0527782 Crash Number Witness Name Address Phone Narrative and additional witnesses: Accident Investigation Notification Issued? Property Damage C~ 2 - OE£'~ PH~.£ ?~?Es=_UT/ ~.~? ~,~ uSG. .J~./~ ~ COMMONWEALTH OF PENNSYLVANIA ~' i~ ' POLICE CRASH REPORTING FORM AA 500 N i Po,,c~u~o,ly Narrative and additional witnesses: ..J.. ~ COMMONWEALTH OF PENNSYLVANIA ~'*C POLICECRASH, REPORTING FORM Page AA 500 N t:°~''~ ~'~" Oniy I ~ 22 Narrative and additional witnesses: PSP I A_._~ COMMONWEALTH OF PENNSYLVANIA ~ m POLICE CRASH REPORTING FORM AA 500 N Page Narrative and additional witnesses: 22 , POLICE CRASH REPORTING FORM ~ New , · Crash Number Page AA500I'1 [Po,it.. UseOnly ] ~ C~ContinuationChange/ JP? i(~ I~ ~' I? I''~/ t I?'?l T t 22 PENNSYLVANIA STATE POLICE PUBLIC INFORMATION RELEASE REPORT ~H~m~£J~O/~(~ PUBLIC INFORMATION RELEASE REPORT 2 INCIDENT NO 3. NATURE OF iNCIDENT 4 DATF-~ME OFINCJDENT EXHIBIT C This is to certi~ that the information here given is correctly copied ['-rom an original certificate of death duly filed with me as Local Registrar. The ,origina! certificate will be forwarded to the State Vital Records Office for pem~anent filing. WARNING: It is illegal to duplicate this copy by pl~otostat or photograph. Fee for this certificate, $2.00 P 9450042 No. ~cal R"~gis~rrar r COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT Ot= HEALTH * VITAL RECORDS CERTIFICATE OF DEATH (Coroner) Paul L. Killinger, Jr. ,2~. 011776-L ?~.-~ge~-Brick~r F.H.,InOo,P.O. Box 336, ~bg°,PA 17257 EXHIBIT D COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPARTMENT 280601 HARRISBURG, PA 17128-0601 Telephone 2/27/2004 Marcus A McKnight, III, Esquire Irwin & McKnight West Pomfret Professional Building 60 West Pomfert Street Carlisle, PA 17103-3222 Rc: 717-783-0972 717-783-3467 (fax) jdibert(a2state'pa'ns (e'~(~ ~ ~t~7 ~ 2004 & McKNtGHT Estate of Hclcn L Killinger File Number: 2103-1020 Dear Mr. McKnight: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survivgl action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 82 -year-old-decedent died as a result of a motor vehicle accident. Decedent is survived by the decedent's spouse and 5 adult issue. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the net proceeds of this action, $ 64,467.60 to the wrongful death claim and $ 7,46.40 to the survival claim. Proceeds ora survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merrymam 669 A.2d 1059 (Pa. Cmwlth. 1995). l trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a xwongful death / survival action. SjnceroJy, r'~ ........... J Paul Dibert Business & Trust Valuation Manager Inheritance Tax Division Bureau of Individual Taxes RICHARD A. KILLINGER, Executor of the Estate of HELEN L. KILLINGER, Plaintiff/Petitioner PAUL L. KILLINGER, JR., Defendant/Respondent : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2004- CIVIL TERM : : CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, Marcus A. McKnight, lIl, Esquire, hereby certify that a copy of attached Petition for Approval of Settlement was served upon the following by depositing a true and correct copy of the same in the United States mail, First Class, postage prepaid in Carlisle, Pennsylvania, on the date referenced below and addressed as follows: Paul L. Killinger, Jr. 303 Dwelling Court Shippensburg, PA 17257 Michael Smoluk, Claims Adjuster Allstate Insurance Company Market Claim Office 6345 Flank Drive, Ste. 1000 Harrisburg, PA 17112 By: IRWIN & McKNIGHT Date: March 16, 2004 It^R 1 7 2004 RICHARD A. KILLINGER, Executor of the Estate of HELEN L. KILLINGER, Plaintiff/Petitioner PAUL L. KILLINGER, JR., DefendanffRespondent : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA NO. 2004-.~$1 CIVIL TERM CIVIL ACTION - LAW ORDER OF COURT AND NOW, this I {~ day of~0me--~ , 2004, upon consideration of the attached Petition of the Plaintiff/Petitioner, it is hereby ORDERED that the approval of the settlement of Plaintiff's claims are granted as follows: The Executor, Richard A. Killinger, shall settle for the amount of $100,000.00 on behalf of the Estate of Helen L. Killinger. The settlement proceeds shall be allocated as follows: Wrongful Death ........................................................ $90,000.00 Survival Action ......................................................... $10,000.00 The legal fees and expenses to Irwin & McKnight are approved as follows: Less Legal Fees to Irwin & Mci(night: (25% of Settlement) .................................................. $25,000.00 The distribution of the Survival Action proceeds shall be as follows: Survival Action .................................................... $10,000.00 (100% of proceeds distributed to surviving spouse) Less prorated costs ........................................................ -3.60 Less prorated legal fees to IMH ............................. -2,500.00 Distribution to Paul L. Killinger, Jr. (Surviving Spouse) ............................................... $7,496.40 The distribution of the Wrongful Death proceeds shall be as follows: Total Wrongful Death proceeds ....................................... $90,000.00 Less cost .................................................................................. -12.40 Less legal fees to I&M ..................................................... -22,500.00 Balance for Distribution ................................................ $67,467.60 The final distribution of the settlement proceeds shall be as follows: 1. Paul L. Kiilinger, Jr. (Surviving Spouse) ......... $30,000.00 2. Paul L. KilHnger, Jr. (Surviving Spouse) ........... 12,500.00 Paul B. Killinger ..................................................... 4,993.52 Richard A. Killinger .............................................. 4,993.52 Richard A. Killinger, Jr ......................................... 4,993.52 Terry L. Killinger ................................................... 4,993.52 John R. Killinger .................................................... 4~993.52 Total Settlement Distribution ........................... $67,467.60 Judge