HomeMy WebLinkAbout05-23-08
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT
IN RE: ROBERT G. TRAVER
and .
LOIS j. TRAVER
C7 ~~
0
p ~ _
:,
=~,;
,_rc~~
.,_
~
--< ~
... rT-1 _
~'
N
-7 . ~ ~/
.. '.; l
.`-~.'„
-- ~ .. _.c_
~
-
J
'~ , ,-~
-~
O.C. No. ~ ~ - ~~~~~ 5~ ~~
PETITION FOR REMOVAL OF AGENTS AND APPOINTMENT OF A TRUSTEE
TO FACILITATE THE SALE OF REAL PROPERTY
AND NOW, comes Petitioner, HCR ManorCare -Camp Hill, by and through
its counsel, SCHUTJER BOGAR LLC, and files this Petition for Removal of the
Agents and Appointment of Trustee to Sell Real Property and, in support thereof, avers
the following:
1. Petitioner, HCR ManorCare -Camp Hill ("ManorCare") is a licensed
skilled nursing facility doing business in the Commonwealth of Pennsylvania, with its
principal offices located at 1700 Market Street, Camp Hill, Pennsylvania, 17011.
2. Robert G. Traver ("Mr. Traver') is an adult male, age 81, who currently
resides at ManorCare's skilled nursing facility located at 1700 Market Street, Camp Hill,
Pennsylvania, 17011, and has resided there since December 17, 2004.
3. Lois J. Traver ("Mrs. Traver') is an adult female and wife of Robert G.
Traver, age 74, who currently resides at ManorCare's skilled nursing facility located at
1700 Market Street, Camp Hill, Pennsylvania, 17011, and has resided there since
January 25, 2006.
1
4. Currently, Mr. Traver is indebted to ManorCare in an amount in excess of
Seventy-Seven Thousand Eight Hundred Forty-Three and 50/100 ($77,843.50) Dollard
for skilled nursing services rendered to him by ManorCare, pursuant to an Admission
Agreement dated December 17, 2004, which is attached hereto, made a part hereof and
marked as Exhibit "A".
5. Currently, Mrs. Traver is indebted to ManorCare in an amount in excess
of Seventy-Seven Thousand One Hundred Ninety-Two and 18/100 ($77,192.18) Dollars2
for skilled nursing services rendered to her by ManorCare, pursuant to an Admission
Agreement dated January 25, 2006, which is attached hereto, made a part hereof and
marked as Exhibit "B".
6. At the time of their respective admission to Petitioner's facility, Mrs.
Traver signed the Admission Agreements, and was acting on behalf of Mr. Traver and
herself.
7. Since Mr. and Mrs. Traver's admission to Petitioner's skilled nursing
facility, Powers of Attorney have been executed and acknowledged appointing Anna
Messimer agent of Mr. Traver and appointing Mrs. Traver and Anna Messimer ("Ms.
Messimer") co-agents of Mr. Traver. True and correct copies of the Powers of Attorney
are attached hereto as Exhibits "C" and "D."
~ Because Mr. Traver is a current resident, the outstanding amount owed will continue to increase each
month by approximately $6,500.00.
z Because Lois Traver is a current resident, the outstanding amount owed will continue to increase each
month by approximately $6,500.00.
2
1
8. In total, the Travers currently owe ManorCare in excess of One Hundred
Fifty-Five Thousand Thirty-Five and 68/100 ($155,035.68) Dollars for skilled nursing
services rendered to them by ManorCare.
MEDICAL ASSISTANCE
9. After Mr. Traver's admission to Petitioner ManorCare's skilled nursing
care facility, he apparently became insolvent. As a result, pursuant to the Admission
Agreement marked as Exhibit "A," Petitioner ManorCare notified Mr. Traver of his
contractual duty to make application for Medical Assistance benefits.
10. An application for Medical Assistance benefits was subsequently filed on
behalf of Mr. Traver.
11. On August 24, 2007, the Cumberland County Assistance Office denied the
above-noted application for Mr. Traver based a upon failure "to provide verification of
certain information in order that eligibility could be determined." A true and correct
copy of the August 24, 2007, denial is attached hereto as Exhibit "E."
12. On Apri110, 2008, after the previously lacking verifications had been
provided, the Cumberland County Assistance Office denied Mr. Traver's application
for Medical Assistance benefits due to excess resources in the amount of Five Hundred
Seventy-Six Thousand Six Hundred Seventy-Six and 41/100 ($576,676.41) Dollars,
3
..
including one half of the farm owned jointly with Mrs. Traver on the requested effective
date for benefits. A true and correct copy of the Apri110, 2008 denial is attached hereto
as Exhibit "F."
13. After Mrs. Traver's admission to Petitioner ManorCare's skilled nursing
care facility, she apparently became insolvent. As a result, pursuant to the Admission
Agreement marked as Exhibit "B," Petitioner ManorCare notified Mrs. Traver of her
contractual duty to make application for Medical Assistance benefits.
14. An application for Medical Assistance benefits was subsequently filed on
behalf of Mrs. Traver.
15. On August 27, 2007, the Cumberland County Assistance Office denied the
above-noted application for Mrs. Traver based upon the failure to submit the necessary
documents for a determination of eligibility, and an appeal of that denial is currently
pending before the Bureau of Hearings and Appeals. A true and correct copy of the
August 27, 2007 denial is attached hereto as Exhibit "G."
16. Unless the requisite information and proof of the disposition of the excess
resources occurs Mr. and Mrs. Traver, will be denied Medical Assistance benefits and
any subsequent appeal to the Commonwealth Court would be without merit.
AGENT'S BREACH OF FIDUCIARY DUTIES
17. Pursuant to the terms of the Powers of Attorney documents attached as
Exhibits "C" and "D", as well as the Pennsylvania Statutes, Ms. Messimer agreed, by
4
executing the acknowledgment on each document, to undertake certain fiduciary
duties, including that she would act in the best interests of each of the principals as their
Agent.
18. On or about January 25, 2008, Ms. Messimer, acting as Agent for both Mr.
Traver and Mrs. Traver, transferred a farm property that had previously been owned by
Mr. Traver and Mrs. Traver individually, as equal tenants in common, and as husband
and wife, to Mrs. Traver individually, for One and 00/100 ($1.00) Dollar. A true and
correct copy of the Deed is attached hereto as Exhibit "H."
19. Ms. Messimer has breached her fiduciary duties to Mr. Traver by
transferring the farm property for less than fair market consideration at a time when
Mr. Traver has significant debts incurred for skilled nursing services, and the certain
prospect of future debts for skilled nursing services.
20. Pursuant to 55 Pa. Code ~ 178.51(a) if a good faith effort to sell the farm
property were made, the property would be excluded as an excess resource for a period
of six months, thus allowing Mr. and Mrs. Traver to be afforded Medical Assistance
benefits while the farm is being sold to provide for the remainder of their expenses.
21. Ms. Messimer has breached her fiduciary duties to Mr. Traver and Mrs.
Traver, by failing to list the farm property for sale on the open market at fair market
price with a licensed realtor.
22. All of Ms. Messimer's actions suggest that she does not desire to list the
property for sale and clearly reflect that she is not acting in the best interest of her
parents and principals.
5
23. Although Ms. Messimer has suggested the property is up for sale, it is
currently not listed in accordance with the requirements of the medical assistance
regulations and such current "listing" will not qualify for the waiver.
24. The Agent has failed to perform duties imposed upon her by law, which
failures are specifically cited as grounds for removal by application of 20 Pa. C.S.A.
§§ 5515 and 3182 to this action.
25. Pursuant to 20 Pa. C.S.A. §§ 5515 and 3183, "when necessary to protect the
rights of creditors" this Court has the authority to summarily remove fiduciaries for
failing to satisfy the outstanding debt of the Petitioner when there exist assets great
enough to pay the debt or any other action that may not be in the best interest of the
wards.
POSSIBLE DUAL AGENTS
26. The power of attorney of Mr. Traver appointing Ms. Messimer and Mrs.
Traver as co-agents was executed by Mr. Traver on November 16, 2005, and
acknowledged by Ms. Traver on February 27, 2006, and by Ms. Messimer on February
23, 2006. See Exhibit "C."
27. Pursuant to paragraph D of Mr. Traver's Power of Attorney, all previous
Powers of Attorney were revoked.
6
.,
28. Upon information and belief, in November of 2007, Ronald E. Traver, Mr.
and Mrs. Traver's son, opened a bank account jointly on behalf of himself and Mr.
Traver.
29. To Petitioner's knowledge, Ms. Messimer has taken no efforts to ensure
that Ronald Traver is not acting under a revoked Power of Attorney, and by failing to
do so is not acting for the benefit of Mr. Traver.
HARM TO PRINCIPALS
30. Ms. Messimer's failures to act for the benefit of Mr. and Mrs. Traver have
caused continued denial of Medical Assistance benefits on their behalf.
31. Due to Mr. and Mrs. Traver's failure to qualify for Medical Assistance
benefits, and the failure of Ms. Messimer to make a good faith effort to dispose of the
farm, Mr. and Mrs. Traver face the possibility of being discharged from the skilled
nursing facility in which they are currently receiving much needed skilled nursing
services.
REQUESTED RELIEF
WHEREFORE, Petitioner respectfully requests this Honorable Court, after such
notice to parties in interest that it shall direct, but without a hearing, to summarily
7
remove Anna Messimer as the Agent of Robert G. Traver and Lois J. Traver, and to
appoint a Trustee to facilitate the listing and sale of the aforementioned real property.
Respectfully submitted,
SCHUTJER BOGAR LLC
Dated: ~ ~~ ~
By:
Kirk Sohonage
Attorney I.D. No. 77851
(717) 909 8160
Brandon S. Williams
Attorney I.D. No. 200713
417 Walnut St., 4~" Floor
Harrisburg, PA 17101
(717) 909-5922
Attorneys for Petitioner ManorCare
8
Exxisrr "A"
l
07/27/2007 11:33 7177372189
.~~R 1~d110,-' Cr7Te
MANORCARE,CAMPHILL
ADMISSION AGREEMENT
PAGE 11
Pennsylvania
This Agreement is entered into by and among Nightingale Nursing Home, Inc., d.b.a.
HCR Manor Care ("HCR Manor Care"), the Resident, and the Responsible party, if any, for the
purpose of proviciing for the rights and responsibilities of the parties with respect to the
Resident's stay at this HCR Manor Care's Center ("Center").
Center: Mail rCare Health Services,_Camp HiII
Resident: ~p'b~r~ Tro`v-err`
Responsible Party: ~c S '~',r._~v~, ~
Admission Date: 1~17)a~ Deposit; $ ~_ ~~
Team: This Agreement begins on the day the Residem enters the Center and ends on .the
day •`he Resident is discharged unless the Resident is readmitted within fifteen (15)
days of the Resident's discharge date.
L RIGHTS AND RESPONS.IBILI~ES O.F THE RESIDENT
1.01 Room and Board Rate. For the basic services provided for in Section 3.OI, the
Resident will pay ttie applicable Room and Board Rate set forth on Attachment A hereto. The
Room and $oard Rate is subject to change upon thirty (30) days written notice. The Room and
Board Rate set fotth in Attachment A is payable in advance and is due upon receipt. The
Resident is responsible for the Room and $oard Rate for the day of admission as well as the day
of discharge. This Section will not apply if the Resident is covered under a governmental
program (see Sectic•n 1.05) or by a third party payor or managed care organization (see Section
1.06),
i,02 Mary Charles. The Resident will gay to Center sll charges for additions]
medical, therapeutic; or personal care services or supplies that may be requested by the Resident,
ordered by the attending physician, or provided in the Resident's Plan of Care. The Center
reserves the right to charge for persona! care items of the Resident if necessary for the well-being
of the Resident Su~~h "Ancillary Charges" are described on Attachment B hereto, and ~ curxent
ancillary charge list r; maintained at the Center's business office for review during regular business
hours. Ancillary Chsrges will be included in the Resident's statemeni for the succeeding month,
and are payable in fu.:l, along with the Room and Board Rate upon receipt_
a~i27i20e7
11:33 7177372189
MANORCARE,CAMPHILL
PAGE 12
1.03 ~Ilecti ~ slLate Pa ents_ Payment is due in full. within thirty (30) days of billing. .
Should the Resident's account for any reason be turned over for collection; the Resident will pay
the Center's collection costs, including attorney's fees.
1.04 Indepe dent Providers. The Resident is directly responsible to independent
providers, includi~lg but not limited to, the Resident's attending physicia~t for any health or
personal program ::n accordance with the terms of the program.
I.OS Go•remmental Pro ams. If the Resident is eligible for coverage under any
governmental pro~,ram, such as Medicare, Medicaid, or through the Veterans Administration, and
the Center participates in such program, the Center wiI1 accept payments under such program in
accordance with tf~e terms of the program as set forth in the contract the Center has with. the
program. The Re~~ident is responsible for any eo-insurance, deductibles or non-covered charges,
according to the same terms and conditions applicable to private pay residents. The Resident
must comply with all program requirements. In the event the Resident's coverage under the
governmental program(s) cease for any reason, the Resident will be charged at the Center's rate
for private pay resi~jents in accordance with Sections I.OI and 1.02.
The Center participates in the following programs: _x_Ivfedicare, x~Medicaid and/or VA_
Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the
Resident's care, th~.re is a required co-payment, which Medicare updates yearly. If the Resident
also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable
charges {which are not covered by Medicare Part A), the Resident agrees to pay any required
deductible, any required co-insurance, and any non-covered services according to the same terms
and conditions appGca.ble to private pay residents. The Resident and/or Responsible Party are
responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center
charges such as Room and Board and nursing services are covered, although Medicaid may
require the Resident to pay a portion of the Room and Board Rate from their monthly income.
The Resident agrees to pay on a timely basis, as set forth in this Agreement, the contnibution
amount as deter. mined and periodically adjusted by the State and/or local department(s) handling
Medicaid. If the Resident fails to pay the contribution amount, the Center may take such legal
action as necessary, including requesting a court to order such payment.
1.06 Tturd P~_ocs and Managed Care Or~nizations. If a Resident is a participant
in a plan offered bs~ a third party payor such as a Health Maintenance Organization ("HMO"),
Preferred Provider Organizat;on ("PPO"), provider Sponsored Organization ("PSO"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the
Center has executed a provider agreement, the charges are governed by the applicable agreement.
The Resident is resl-onsible for any co-payments, deductibles or non-covered charges, according
to the same terms and conditions applicable to private pay residents. If the Censer has not
executed a provider agreement with the Resident's third party payor, the Center
07/27/2007
•
11:33 7177372189
MANORCARE,CAMPHILL
~ V 1 J
PAGE 13
will bill the Resident's third party payor ~ a service, but the Resident remains liable for charges
not paid or covered by that third party payor including charges not patd within.a reasonable
period of time_
1.07 ..Private Pa Resident. The Resident is responsible for paying the Center for items
and services provided dozing the stay at the Center and during which time_ihe Resident has not
been determined t:o be eligible for any governmental program or covered under an t "
payor or managed care organization plan. The Resident and/or .Responsible Party will norify the
Center promptly if there is insufficient income or assets to meet the financial obligations to the
Center or to make prompt application to Medicaid for benefits. The ,Resident and/or Responsible
Party will notify the Center in writing when application to Medicaid is made. The Resident and/or
Responsible Party will cooperate full rn a I 'n for Medicaid and in the eligibility deternunation
process. If the Resident i s no Ionger able po pa for care at the Center or to h v
on the Resident's behalf, the Resident wilt be notifted of the Center's intention o discharge the
Resident for non-payment in accordance with this .A.greement, Resident Handbook and state and
federal taws.
1.08 Admission Information_ The Resident and/or Responsible Parry will notify the
Center and provide any needed information regarding ail third
coverages on admission and throughout the Resident's stay including piyes of insurance ccard
identification or verification of eligibility and coverage information_
_. The Resident and/or Responsible Party will provide the Center in writing with
notice within five 5 da s of the Resident's disenrollment, enrollment, change in health care
coverage, failure to pay premium(s) or renewal of insurance cc-verage and a~ cancellations in
coverage as the CrwlLer relies on the information supplied regarding such coverage. The Resident
acknowledges that if the Resident fails to provide such infortraation, the Resident may be
responsible for an~• denied charges due to lack of authorization, ineligibility, non-coverage or
other costs associated with the failure to provide such notice in accordance with the terms and
conditions of this Agreement.
1.09 Application ,for Benefits. The Resident and/or Responsible Party will apply for
coverage and to establish eligibility under any governmental, third a
private insurance program. The Center has no obligation to biU anp third ayor, managed care or
the .Responsible Party arid, when licable a y per' Payor other than
managed care organization with whichthe Censer i ~ ndes contractprogram ilvrd party payor or
1.10 Primt Res onsi ill f r Pa a t. Exc t for a
under governmental. programs or other third ~ p yments for services covered
remains primarily Ii;able for per` payor provider agreements, the Resident
any and all charges for which the Center may agree to bill a third
party_ The Resident and/or Responsible Party acknowledge that the insurance company, HMO,
PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies,
equipment, medicati~>ns, and other care and services which may be delivered by the Center or its
subcontractors. This agreement serves as a written notice that the Center has notified the
Resident and/or Responsible Party that services provided at the Center may not be covered by a
07/27/2007 11:33 7177372189
governmental payor, third
Responsible Part}- wilt be
maintained at the Center's
hours.
MANORCARE,CAMPHILL
PAGE 14
party payor or managed care organization. The Resident and/or
responsible for non-covered services. A price Iist of services is
business office and is available for review during regular business
I.I1 Personal Physician The Resident has the right to choose a personal physician,
provided that the I~hysician selected is properly licensed and abides by applicable law and the rules
and policies of the Center. At the time of admission, the Resident must supply the Center with the
name of his/her ~~ersonal physician. If the Resident changes physicians at any time after
admission, the Resident and/or Responsible Party must immediately notify the Center of the new
physician's name. If the physician chosen by the Resident fails to provide needed coverage and
attendance or fail:; to abide by applicable laws and regulations, the Center will caII another
physician to attenc: to the Resident and the fees charged by such physician will be borne by the
Resident.
1.12 Pha-m_ acv, The Resident and/or Responsible Party has the right to choose a
pharmacy of choia., provided the pharmacy selected is properly Icensed, packages and supplies
pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and
has a redication distribution system similar to the Center's ancillary pharmacy's medication
distribution system-
II. RIGHTS ,A.ND RESPONSIB.II<,ZTY OF THE RESPONSIBLE PARTX
2,01 l.e--~;tl- ~,u~. The Responsible Party represents that he/she has .legal access to
the Resident's in.corne or resources and that the documents supporting such authority, if any, have
been delivered to the Center.
202 re:ement to Make Pa meets ehalf of esident. The Responsible Party will
pay promptly from the Resident's iaz¢ome or resources all fees and charges for which the Resident
is liable under this Agreement. The Responsible ,party will incur personal financial liability on
behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident
is liable Lander the al~reement from the Resident's income or resources.
2.03 R~vue~ted Items The Responsible Parry will be personally liable for any services
or products specifically requested by the Responsible Party to be supplied to the Resident, unless
such services or products are covered by a governrnenta[ program,
2.Q4 Exhau ion of Resident's Funds. If the Resident's financial resources change such
that the Resident may be eligible for Medicaid, the Resident and/or Responsible Party must notify
the Center in writing; and must promptly apply for Medicaid benefits. If the Resident and/or
Responsible Party fails to notify the Center in writing or fails to file for Medicaid or provide such
information as .Medicaid representatives may require to qualify the Resident for eligibility to
Medicaid, the Center may end this agreement and transfer or discharge the Resident for
nonpayment upon reasonable and appropriate notice, as provided in Section 4.06• In addition, if
the Responsible Party faits tv notify the Center in writing or fails to file for Medicaid in a timely
4
07/27/2007 11:33
..
7177372189
MANORCARE,CAMPHILL
PAGE 15
and proper mann-:r, the Responsible .Party will be personally Liable for all charges anal fees not
covered by Medi~:aid which otherwise would have been covered had application been made in a
timely and prope~• manner.
2.05 ~toperation for Financial Assistance- .if the Resident is eligible for .Medicaid, the
Responsible Party must provide such information about the Resident's £rnances as Medicaid
representatives require for continued coverage of the Resident and be personally responsible for
any charges denied the Center due to any tack of cooperation. If the .Resident and/or Responsible
Party fail to provide such information as Medicaid representatives require for continued eligibility
for Medicaid pa~~rrtents, and as a result Medicaid does not pay for the Resident's care, the
Resident may be discharged or transferred upon appropriate and reasonable .notice for
nonpayment, as provided in Section 4.06.
2-06 Acre tanCe n Dischar e_ Upon termination of this Agreement as provided in
the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the
Resident from thr, Center. If after notice, the Resident is not removed as requested, then the
Center is authorized and empowered to remove the Resident by reasonable means of
transportation and to deliver the Resident to the residence address of the Responsible Party, if the
Resident's condition permits, who shat) unconditionally be obligated to accept the Resident or
immediately make medically appropriate alternative arrangements and to pay promptly all charges.
2.07 Ad•3itional Respo~t sibiIities The Responsible Party will comply with the other
duties and responsibilities for the Resident and to the Center as set forth in this Agreement,
Resident Handbook, and Attachments.
2-48 mouse of Re ident Funds. In the event that the Responsible Party misappropriates
the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding
the Responsible P<<rty's obligation to make payments on behalf of the Resident under Section 2.02
or for purposes o1' qualifying the resident for Medicaid eligibility, the Responsble Party may be
liable to the Medi<aid agency and/or the Center for care that should have been paid for from the
Resident's income or resources. Such misappropriation of the Residern's income or resources
may also result in the imposition of criminal or civil sanctions against the Responsible Party.
ICI. RIGHTS ~-ND RESIPONSIBILITIES pp' THE CENTER
3.01 Roc-m and Standard Services As part of the Room and Board Rate, the Center
will furnish basic room, board, common facilities, housekeeping, laundered bed linens and
bedding, general nursing care, personal assessment, social services, and such other personal
services as may be required pursuant to the plan of care prepared by the Resident's physician and
the Center, with the Resident's consent, for the health, safety and general well-being of the
Resident.
3.02 ~Oth~~.r~~ "ces_ The Center will act in accordance with the Resident Handbook,
which is incorporated by reference in this Agreement.
5
i
57/27/2007
11:33 7177372189 MANORCARE,CAMPHILL PAGE 16
3.03 .De sit. The Center acknowledges receipt of the Deposit, if any, noted at the
beginning of this •~greement. The Deposit will be applied to the charges for the first. month of the
Resident's stay at the Center.
3.04 funds. Any refund owed to the Resident for advance a
the Center within thirty (30) days after discharge or transfer or within t e timenframe rrequired by
State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) days
of the Center's receipt of the final Medicaid payment for care of the Resident.
n'- GENERAL PROVILSIONS
4.01 Coi~ent to Release oT Information The Resident and/or Responsible Party hereby
consents to the release of the Resident's medical records to the following persons: Center
personnel, attending physicians and consultants; any person, fi
rm, government entity, third party
payor or managed care organization responsible for all or any part of the payment or
reimbursement of the Resident's charges, .including any utilization review or quality assurance
reviews or payment audits performed by such; the personnel of any hospital or other health care
facitity or provider to whom or which the Resident may be transferred; the Center's Liability
insurance carrier; and any person authorized by Law to review the medical records.
4.02 Consent. to Treat. The Resident and/or Responsible Parry consent to the use and
disclosure of Resident's protected health information for the purposes of receiving treatment from
the Center, obtainnig payment for healthcare services provided to Resident, and the Center's own
healthcare operation needs. The Resident and/or Responsible Party, by signing this Agreement,
authorizes the apF~ropriate staff of the Center to perform such functions, care and services
(hereinafter "TreaUnent") as. are necessary to maintain the well-being of the Resident, including
but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and
8~~ nursing care, the administration of medications and treatments, and the performance of
therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as
required from time to time in the exercise of good nursing judgment, subject to any rights
provided to the Resident by federal and/or state law.
As applicable, the undersigned Responsible Party represents that .heJshe .12as the
legal authority to make health care decisions on behalf ofthe Resident, that documents supporting
such authority have been delivered to the Center, and that such Responsible Party consents on
behalf of the Resident to the Treatment described above.
4.03 _ onsent to Photogi-anh_ The Resident and/or Responsible Party consent to the
Center taking a photograph of Resident for use in identi
photograph in the A2edication Administration Record or o he.ctrecodsdand for any o herts~crv ar
uses of the photograph for Center and staff to identify the Resident.
4.04 Notice of ices P icies a d Additional Informati
Responsible Party ac:knowiedge that the items listed below have been explained and have rece~ d
copies of the items or policies and procedures, if applicable. The Resident and/or Responsible
07/27/2007 11:33
7177372189
MANORCARE,CAMPHILL
PAGE 17
Party aclmowled~;e they have had the opportunity to ask questions and questions have been
answered satisfactorily.
a. Assignment for payment of $enefits. See Attachjttent C.
b. 5NF Medicare Determination Notice. See Attachment D.
c Medicare Secondary Payor Questionnaire. See Attachment E.
d. At the request of the Resident andlor Responsible Party, the Center will
maintain the Resident's personal funds in compliance with the laws and
regrlations relating to the Center's management of such .funds- A description
andlor policies and procedures of protection of resident funds and the Personal
Trust Fund Agreement, ,Resident Personal Funds Authorization and any other
related documents. See AttacIunents F-1 and F_~,
e. Center Supplement:
1- Policy and procedure on bedholds, election of bedholds and
readmission,
2• Social Service Agencies and Advocacy Groups addresses and
phone numbers.
3• Name, address and phone number of Ombudsman.
4- .Location in the Center where the names, addresses and telephone
aurnbers of state client advocacy groups, state surErey and
certification agency, the state licettsure oi~ce, the state ombudsman
progcam, the protection and advocacy network and the Medicaid
fraud control unit.
5- The name, specialty and way of contacting the attending physician,
medical director and other physicians who serve the Center.
6. Procedures, name, address and phone number on how to file a
complaint with the state survey and certification agency concerning
resident abuse, neglect, mistreatment and misappropriation of
property.
l: The Resident Handbook,
g. Resident/Patient Rights-
h- Medicare/Medicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments.
7
e7i2712ea7
?1:33 7177372189 MANORCARE,CAMPHILL PAGE 18
i • Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR Manor Care's
Limited Treatment Practices and a copy of the State summary of its laws
governing the Resident's right to direct his/her medical treatment. See
Attachments G-I and G-2.
Privacy Act Notification. See Attachment H_
k. Notice of Information Practices and Receipt of Notice of Information
Practices. See Attachments I-1 and I-2.
1• .Ancillary Services Management Form. See Attachment J.
4,05 went of Benefits. The Resident and/or Res nsible P
payment of authorized government and/or third a a or benefits as described~Srec tons I OS
and 1.06, if any, be made as set forth in Attachmentt Cpto this Agreement either to Resident or on
Resident's behalf for any service furnished by or in the Center. The Resident and/or Responsible
Party authorize tfie Center and any holder of medical or other information to release such
information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third
party payors any information needed to determine these benefits or benefits for related services.
4.Ob Ten inaii Dischar a and T fer. This A
forth below and as set forth in the Resident Handbook under Section Headin~Disch ~ set
The Resident and/~~r Responsible Parry may terminate this g ~e»_
written notice of the Resident's desire to Leave at least seven (~d ys int$d~~~ of the Resident's
departure. If the Resident leaves before the end of that time, the Resident must still pay for each
day of the required notice unless the Center fills the bed before the end of the notice period.
Except in the event of an emergency or death, the Resident will be responsible for all charges for
the Room and Bo,rrd Rate and for all services performed up to the end of the day that the
admission ends_ Ihscharge from the specialized units such as the Transitional Care Unit or
Subacute Unit may require Iess than seven (7} days notice.
If discharge or transfer becomes necessary because the Resident and/or Responsible Party or
someone else abused the Resident's funds, the Center will request that local, state and federal
authorities, as appropriate, investigate, which may result in prosecution.
4.07 Indemnification. The Resident will defend, indemnify and hold the Center harTnless
from arty and all claims, demands, suit and actions made against the Center by any person
resulting from any d_arzzage or injury caused by the Resident to an
person or entity (including the Center), except in the case of negligee e of the Centers employ es
and agents.
e7i27i2ee7
11:33 7177372189 MANORCARE,CAMPHILL PAGE 19
4.08 ~3~es in the Law_ ,qn
or unenforceable ;-s a result of a change in state or federal IAaw~will not ~tzvalidatet he be invalid
provisions of this Agreerxzent and, it is agreed that to the extent ~ ~~~
Center will continue to fulfill their respective obligations under thispAossibte, the Residem and the
Iaw_ _ greemeni consistent with the
THE UNL-ERSIGNEU CERTIFY AND ACKNOWLEDGE THAT THEX HAVE
EACA READ A:KD HNDERSTOOD THI FOREGOING AGREEMENT, AND THAT
THEY ~~ IIAD AN OPPORTUN1Ty TO ASK QUESTIONS AND TAAT ANY
QUESTIONS RAVE BEEN ANSWERED TO THETR SATISFACTION.
Signature ofResi.de•nt:
Date:
Signature of Respo~~sible Party: Q~d~~,~~~~~'~ ~o O
Hate: ~°~ ~ r `~
Center Representative:
Date: c~-- ~~ d
EXHIBTI' "B"
__ __- __.._... _ ... «~. -' I'~rri •Ur\L,Hr~L,L.HI'i('rl1LL f HUC 'fJL
HCP 1l~annr Cage
Pennsylvania
AAMISSION AGREFN~~tT
This Agreement is entered into by and arnong Nghtingale Nursing Home, Inc., d_b.a.
NCR Manor Care 1T`HCR Manor Care"), the Resident, and tI?e Responsil;Ie Party, if any, for the
purpose of providing for the rights and responsibilities of the parties wish respect to fhe
Resident's stay at tlvs HCR Manor Care's Center ("Center")_
Center: ManorCare ~-IeaJth Services, Cam__
Resident: ~4~~S ~~ ~rQ~~~
IZesporrsible 1Par-ty;
Admission Date: ! , 2~ ,
Deposit: $-~gq.._
Term; This Agreement begins on the day the Resident enters the Center and ends an the
day the Resident is discharged unless the Resident is readmitted within fifteen (l5)
days of the Resident's discharge date.
I• RIGHTS A~1VD RESPONSIBT~.,ITIES OF THE RESIDENT
1.OI Room and Board Rate_ For the basic services provided for in Section 3.OI, the
Resident will pay the applicable Room and Board Rate set forth on Attachment A hereto. The
Room and Board Rt-te is subject to change upon thirty (30) days written notice. The Room and
Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The
Resident is responsible for the Room and Board Rate for the day oi"admission as well as the day
of discharge. This Section will not apply if the Resident is covered u.ader a governrnemaI
program (see Sectio:l 1.05) or by a third party payor or managed care organisation (see Section
I.06).
l .02 Ancitlartt Charges_ The Resident will pay to Center alI charges for additional
medical, therapeutic, or personal care services or supplies that rrray be requested by ibe Resident,
ordered by the atter-ding physician, or pro~~ided in the Resident's Plan of Care. The Center
reserves the right to charge for personal care items of the Resident if necessary for the well-being
of the Resident. Such "Ancillary Charges" are described on Attachment S hereto, and a currem
ancillary charge List i:: maintained at the Center's business office for review during regular business
hours_ Ancillary Chr-rges will be included in the Resident's statement for the succeeding month,
and are payable in fiill, slang with the Room and Board Rate upon receipt_
i .03 CoC.ections/Late Pav ents_ Payment is due in fu11 within thirty (30) days of bitIing.
Should the Resident's account far any reason be turned over foz collection, the Resident will pay
the Center's colIect:ion costs, including attorney's fees.
I.04 i~~pendent Providers. The Resident. is directly responsible to independent
providers, including but not limited to, the Resident's attending physician for any health er
personal program iii accordance with the terms of the prograrrt.
I.OS Governmental Programs- if the Resident is ehgrble for coverage under any
governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and
the Center participates in such program, the Center wi11 accept payments under such program in
accordance with the terms of the program as set forth in the contract the Center has with the
program- The Resident is responsible for any co-insurance, deductibles or non-covered charges,
according to the same terms and conditions applicable to private pay residents. The Resident
must comply with all program r.equirementq. In the ez,Pnt uhe Reside,^st's coverage under the
governmental program(s) cease for any reason, the Resident will be charged at the Center's .rate
for private pay residents in accordance with Sections L O I and 1-02_
The Center participsates in the following programs: ___x_Medicare, _x Medicaid and/or VA.
Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay far the
Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident
also participates in Medicare part B, for physical, occupational, or speech therapy or other bt-Ilable
charges (which are not covered by Medicare part A), the Resident agrees to pay any required
deductible, any required co-insurance, and any non-covered services according to the same terms
and conditions applicable to private pay residents. The Resident and/or Responsible party are
responsible for applying lfor i~edicaid 1f the Resident receives Medicaid, mast of the Center
charges such as Room and Board and nursing services are covered, although Medicaid may
require the Resident to pay a portion of tfre Room and Board Rate from their monthly income,
The Resident agree;: to pay on a timely basis, as set forth in this Agreement, the contribution
amount as determinE;d and periodically adjusted by the State and/or Iocal department(s) handling
Medicaid. ~f the Resident .fails to pay the contribution amount, the Center may take such legal
action as necessary, including requesting a court to order such payment-
I.06 Third Pa a ors and Mana eg d Care. Organizations. If a Resident is a participant
in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO")T
Preferred Provider Organization (".I'p0"), Provider Sponsored Organization ("PSQ"), or
Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the
Center has executed a provider agreement, the charges are governed by the applicable agreement.
The Resident is resp~~nsible for any co-payments, deductibles or non-covered charges, according
to the same terms <<nd conditions applicable to private pay residents. If the Center has not
executed a provider agreement with the Resi.dent's third party payor, the Center
z
1 , ~ ~ , cl o ~ rI(a!VUK~,~1h<t , l,Uh1F'H 1LL F'A(~t ~ 4
wi11 bill the Resident's third party payor as a service, but the Resident remains liable for charges
not paid or cover~~ by that third party payor including charges not paid within a reasonable
period of time-
L07 Private Pay Resident- The Resident is responsible for paying the Center for items
and services provided during the stay at the Center and during which time the Resident has net
been determined to be eligible for any governmental program or covered under any third party
payor or managed care organization plan- The Resident and/or Responsible Party will notify the
Center promptly if there is insufficient income or assets to meet the financial obligations to the
Center or to make ,prompt application to Medicaid for benefits. The Resident and/or Responsible
Party wr~i notify the Center in writing when application to Medicaid is made. The Resident and/or
Responsible Party ti~I cooperate fully in applying for Medicaid and in the eligibility determination
process. If the Resident is no longer able to pay for care at the Center or to have payment made
on the Resident's behalf the Resident will be notified of the Center's intention to discharge the
n esid~nt ~r nor--pr.ynient in accordance with this- Aa,-eempnt Resident u~;;;ic;oot: and sate and
federal laws. _ ---..--
i 08 ~~sslon Information. The Resident and/or .Responsible Parry will notify the
Center and provide any needed information regarding all third party payors or governmental
coverages on admission and throughout the .Resident's stay including copies of insurance cards,
identification or verification of eligibility and coverage information.
The Etesident and/or Responsible Paz-ty will provide the Center in writing with
notice within fiv~5~~,s of the Resident's disertrolIment, enrol)rnent, change in health care
coverage, failure to pay p.rernium(s) or renewal, of insurance coverage and any cancellations ira
coverage as the Center relies ort the information
acknowledges that if the Resident fails to pz~o~detedlch ~nformat oil, other Resident maid be
responsible for any denied charges due to Iack of authorization, inetigibitity, non-coverage or
other costs associatE:d with the failure to provide such notice in accordance with the terms and
conditions of this Agreement-
1.09 ,Ap~Ii~;ation for Benefits. The RESident and/or Responsible Party will apply for
coverage and to esta.biish eligibility under any governmental, third party payor, managed care or
private insurance prc~grarn. The Center has no obligation to bill any third party payor other than
the Responsible Party and, when applicable, a governmental program third party payor or
managed care organization with which the Center is under contract.
I. I0 1?rima Res onsibili for Pa ent. Except for payments for services covered
under governmental programs or other third party payor provider agreements, the Resident
remains primarily lia ale for any and all charges for which the Center may agree to bill a third
pay. The Resident andlor Responsible Party actrnowledge that the insurance company, t-hVlp,
PPO, PSO, PI,TO or managed care provider may not pay for non-covered services, supplies,
equipment, medications, and other care and services which may be delivered by the Center or its
subcontractors. Thi; agreement serves as a written notice that the Center has notified the
Resident and/or ResF onsibie Party that services provided at the Center may not be covered by a
3
.. _ .. ~~~ . _ _ . _, _. ~ ~ ~ , ,, ~ «„~ rwrvuKl,HKt_, ~.~arirr~lLt F'AVt b5
governmental pay,~r, third Party payer or managed care orgaruzation_ The Resident and/or
Responsible Party will be responsible for non-covered services. A price list of services is
maintained at the Center's business office and is available for review during regular business
hours.
I.I1 Personal Physician `fie Resident has the right to choose a personal physician,
provided that the physician selected is properly licensed and abides by applicable law and the rules
and policies of the E~enter_ At the time of admission, the Resident must supply the Center with the
name of his/her Personal physician. If the Resident chenges physicians at any time after
admission, the Resident and/or Responsible Party must immediately notify the Center of the new
physician's name If the physician chosen by the Resident fails to provide needed coverage and
attendance or fails to abide by applicable Iaws arzd regulations, the Center will call another
physician to attend to the Resident and the fEes charged by such physician will be borne by the
Resident.
1 I2 Pharmacy. The Resident and/or Responsible Party has the right to choose a
pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies
pharmaceuticals in ,rccordance with state law, abides by the Center's policies and procedures and
has a medication distribution system similar to the Center's ancillary pharmacy's medication
distribution system
T~ 1?JfCE'I'S A`7;~ R.ESf°OP~$>JR~L"I'Y OF THE R.IESPOi~7S;iBLE PARTY
2.OI I..e~al Au----thori~. The Responsible Party represents that .he/she has legal access to
the Resident's income or resources and that the documents supporting such authority, if any, have
been delivered to thr~ Center.
2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party wi11
pay promptly from tie Resident's income or resources all fees and charges for which the Resident
is Iiable under this .Agreement. The Responsible Party wit] incur personal financial liability on
behalf of the Resident should the Responsible Party fats to pay the charges for which the Resident
is Iiable under the agreement from the Resident's income or resources.
2.03 Requested Iterzis. The Responsible Party will be personally liable for any services
or products specificz Ily requested by the Responsible Party to be supplied to the Resident, unless
such services or products are covered by a governmental program.
2.0~ Exhaustion of Resident's fiunds. If the Resident's financial resources change such
that the Resident maybe eligible for Medicaid, the Resident and/or Responsible Party must notify
the Center in writing and must promptly apply for Medicaid benefits. If the Resident and/or
Responsible Party fails to notify the Center in writing or fails to file for 1V.ledicaid or provide such
information as Medicaid representatives may require to qualify the Resident for eligibility to
Medicaid, the Center may end this agreement and transfer or discharge the Resident for
nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if
the Responsible Part}.- fails to notify the Center in writing or fails to file for Medicaid in a timely
4
. _ ..-.. ~~•, ., ~i~irun~,r--~r~Crl.F~~•~rn1LL Y'/-0l7C ~b
and proper manner, the Responsible Party tivill be personally liable for ail charges and fees not
covered by IUledicaid which otherurise would have been covered had application been made in a
timely and proper manner.
2.05 Coc erati n for Financial Assistance. If the Resident is eligible for Medicaid, the
Responsible Party must provide such information abqut tl-rP u e f
representatives regaire for continued coverage of the Resident andtbe personallyarespon be odr
any charges denied the Center due to any lack of cooperation. If the Resident andlor Responsible
Party fail to provide such information as Medicaid representatives require for continued eligibility
for Medicaid payments, and as a result Medicaid does not pay for the Resident's care, the
Resident may be discharged or transferred upon appropriate and reasonable notice for
nonpayment, as provided in Section 4.06.
2.06 AccE, fence U on ischar~e. Upon terrninatioa of this Agreetent as provided in
the Resident Handbook, the Responsible Pa; ty ao oo; to ~,: ~ ;g~ urd pay for the departure of the
Resident from the Center- If af}er notice, the Residentuis not removed as requested, then the
Center is authorized and empowered to rer~nove the Resident by reasonable means of
transportation and to deliver the Resident to the residence address of the Responsible Party, if the
Resident's condition permits, who shat) unconditionally be obligated to accept the Resident or
rmrnediately make medically appropriate alternative arrangements and to pay promptly aII charges.
2.47 Additional Responsibilities. The Responsible Party will comply with the other
duties and responsibi)ities for the Resident and to the Center as set forth in this f~greetnent,
Resident Handbook, and Attachments-
2-08 I17[isuse ofReside t Funds In the event that the Responsible Party misappropriates
the Resident's income or resources or athenvise illegally transfers assets for purposes of avoiding
the Responsible party's obfigation to make payments on behalf of the Resident under Section 2.02
or for purposes of quaIi.fying the resident for Medicaid eligibiliiy, the Responsible Party may be
liable to the Medicaid agency and/or the Confer for care that should have been paid for from the
Resident's income c~r resources. Such misappropriation of the Resident's income or resources
may also result in thf: imposition of criminal or civil sanctions against the Responsible Party_
TXI. RZ~H'Y'S A.I'iI3 RIESFONSTtk3ILI`I'~S 4F THE CENTER
3_QI Raorr.: and Standard Serviced As pan of the Room and Board Rate, the Center
will famish basic nom, board, common facilities, housekeeping, Iaundered bed liners and
bedding, general nursing care, personal assessment, social services, and such other personal
services as may be rE:quired pursuant to the plan of care prepared by the Resident's physician and
the Center, with the Resident's consent, for the health, safety and general. weI)-being of the
Resident.
3`02 Other ervices The Center will act in accordance with the Resident Handbook,
«hich is +ncorporated by reference in this Agreement.
s
e~~~err~r~e~r it:s~ I1Ir.j!"11.~'~ MANORCARE,CAMPHILL PAGE 07
3.03 ~fosit. The Center acknowledges receipt of the Deposit, if any, noted at the
6egiruung of this A,greeznent_ The Deposit will be applied to the charges for the fast month of the
Resident's stay at the Center.
3.04 Refi.tnds_ Any refund awed to the Resident for advance payments will be paid by
the Center within thirty (30} days after discharge or transfer or within the time frame required by
State law. In the case ofMedicaid Residents, any such refund will be paid within thirty (30) days
of the Center's rza:ipt of the final Medicaid payment for care of the Resident.
IV_ GENERAI, RR~V~SIONS
4.01 Consent to Release of Information. The Resident and/or .Responsible Party hereby
consents to the release of the Resident's medical records to the following persons. Center
personnel, atten.dinj~ physicians and consultants; any person, firm, $ov?rrtznent entity, third party
payer or ettanagetf care organization TeC~onsible ~~ ~~~ _
reimbursement of the Resident's charges, including any utilization review or quality a s an4e
reviews or payment. audits performed by such; the personnel of any hospital or other health care
facility or provider to whom or which the Resident may be transferred; the Center's liability
tnsurance carrier, and any person authorized by taw to review the medical records.
4.02 Con,.ent to `freat. The Resident and/or Responsible Party consent to the use attd
disclosure of Resident's protected health information for the purposes of receiving treatment from
the Center, obtaining payment for healthcare services provided to Resident, and the Center's own
healthcare operation needs. The Resident and/or Responsible Party, by signing this Agreemerrt,
authorizes the appropriate staff of the Center io perform such functions, care and services
thereinafter "Treatment") as are necessary to maintain the Weil-being of the Residem, including
but not }invited to, assistance with bathing, hygiene, dressin toilet
genera! nursing care; the administration of rrtedications and tgreatmern ,and the pe ormatace of
therapies, as prescribed by the Resident's personal physician in the Resident's Plaa of Care, or as
required from time to time in the exercise of good nursing judgment, subject to arty rights
provided to the Resi~~ent by federal and/or state law
As applicable, the undersigned Responsible Party represents that he/she has the
legal authority to make health care decisions nn behalf of the Resident, that documents supporting
such authority have been delivered to the Center, and that such Responsible Party consents on
behalf of the Resident to the Treatment described above
4.03 Consf~rn to Photactranh, The Resident and/or Responsible Party consent to the
Center taking a photograph of Resident for use in identifying the Resident, for placement of the
photograph. in the Medication Administration Record or other records and for any other similar.
uses of the photograph for Center anal staffto identify the Resident.
4.04 Notict: of ervices Po ~cies an dditi at Information. The Resident and/or
Responsible party acknowledge that the items listed below have been explained and have received
copses of the items or policies and procedures, if applicable. The Resident and/or Responsible
6
,...._ ..._., _.. ... ~ , , L , , ,, , ~ ~ ~, MrarluKl~AttL, GAMF'H1LL PAGE 08
Party acknowledge they have had the opportunity to ask questions and questions have been
answered satisfact+~rily_
a- Assignment for Payment of Benefits. See Attachment C.
b. SN1Y Medicare Determination Notice. See Attachrrert i.
c- Medicare Secondary payor ~taestiontraire. See Attachment E.
d 4t the request of the Resident and/or Responsible Party, the Center will
maintain the Resident's personal funds in compliance with the laws and
regulations relating to the Center's managemem of such funds. A description
s~nd/or policies and procedures of protection of resident funds and the Persona}
"rust Fund Agreetnent, Resident Personal Funds Authorization and ay nrher
related documents. See Attachments .F-1 and ~_~_
e (;enter Supplement
I ~ Polrcy and procedure on bedholds, election of bedhoIds and
readmi.ssian.
2 Soeiai Service Agencies and Advocacy Groups addresses and
phone numbers.
3- Name, address and phone number of Ombudsman
4. Location in the Center where the names, addresses and telephone
numbers of state client advocacy groups, state sur ev and
certification agency, the state licensure ofi~ce, the state ombudsman
program, the protection and advocacy network and the Medicaid
fraud comrol unit.
5- ~'he nam.e, specialty and way of contacting the attending physician,
.medical. director and other physicians who serve the Center.
6- Procedures, name, address and phone number on .how to file a
complaint with the state survey and certification agency concerning
resident abuse, neglect, mistreatment and nnsappropriation of
property.
}- The Resident Handbook-
g- ResidentlPatient Rights.
h MedicarelMedicaidlnformation and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments.
r~~. ~ r~ ~r~r~r ii: ~,~ i~ ~ ~ ~lLlti~ MANORCARE,CAMPHILL PAGE B9
i. Receipt of information an advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR Manor Care's
Limited Treatment Practices and a copy of the State summary of its taws
governing the Resident's right to direct his/her medical treatment. See
Attachments G-)_ and G-2_
J Privacy Act Notif catipn. See Attachment I-i.
k. Notice of Information Practices and Receipt of Notice of Information
Practices. See Attachments I-1 and I-2.
Ancillary Services Management Form. See Attachment J.
4.05 Assignment of Benefits. The Resident and/or Responsible Party request that
payment of authori; ed government and/or third party payor benefits as described in Sections I.OS
and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on
Resident's behalf fer any service furnished by or in the Center_ The Resident and/or Responsible
Party authorize the: Center and any holder of medical or other information to release such
information to the (:enters far Medicare and Medicaid Services "C1VIS" and its agents and to third
ply payors any inf>rrnatian needed to determine these benefits or benefits for related services.
4.06 Terrrinatio D' char e and Transfer. This Agreement znay be terminated as set
forth below and as set forth in the Resident fTandbook under the Section Heading "discharge"
The Resident and/or Responsible Farty may terminate this Agreement by providing the Center
written notice of the Resident's desire to Leave at Ieast seven (7) days in advance of the Resident's
departure_ If the Resident Leaves before the end of that time, the Resident must stilt pay for each
day of the required notice unless the Center fills the bed before the end of the notice eriod.
Except in the event .}f an emergency or death, the Resident will be responsible for a1I charges for
the .Room and Boa: d Rate and for ail services performed up to the end of the day that the
admission ends_ Discharge from the specialized units such as the Transitional Care Unit or
Subacute Unit may r~~cluire Less than seven (7) days notice.
If discharge or tran~ifer becomes necessary because the Resident and/or Responsible Party or
someone else abused the Resident's funds, the Center will request that Local, state and federal
authorities, as appropriate, investigate, which may result in prosecution.
4.07 Indemnific__ atifln: The Resident wi]I defend, indemnify and hold the Center harmless
from any and alt claims, demands, suit and actions made against the Center by any person
resulting from any df.mage or injury caused by the Resident to any person or the property of any
person or entity (inclradizzg the Center), except in the case of negligence of the Center's employees
and agents.
8
u ~ ~ < r , cuu r i i ..~.~ r 1 ~ ~ ,5 t L1 tS7 MANUKI;AKt , C;ANIf-'H1LL PAGE 1 0
4-o8 C~Fin es in the Law. Any provision of this Agreement that is found to be invalid
or unenforceable f~ a result of a change in state or federal law will not invalidate the remaining
provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the
Center will continue to fulfzIl their respective obligations under this Agreement consistent with the
law.
THE UND~EI2SIGNED CERTIFY AND ACKNOWLEDGE THAT Thy I~A.VE
EACH READ Ai~ID UNDERSTOOD Tl3E FOREfTpING AGREEMENT, AND THAT
TH.E},' RAVE HAD AN OPPOI~tTiJNZTY TO ASK QIIEST"IONS AND TkIAT ANY
QUESTIONS ID1. YE BEEN ANSWERED TO `T'HEIR SATISFACTION_
Signafi~re of Resident: ~ ,~ ~ ~ _ , _ _ ,~ ~ ~ ~~
- _--~ at- _ ~ ~ .~
Signature of Responsible Party:
Date:
Center Representative: ~
Date:
EXHIBIT "C"
05/03/2008 10:32 7177372189 MANORCARE,CAMPHILL PAGE 01/11
. ,_
NO. iCE
TO THE PitINCX~AL
G~4. TiNG A kOVYER Ok' ATTOi2NEX
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE
PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS °f0 HANDLE
YOUR PROPERTY, WT3ICI~MAY INCLUDE POWERS TO SELL ORUTHERWISE
DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE
NOTICE TO YOU OR APPROVAL BY YOU.
THIS t OWER Ox Az T~ORNEY DOES NOT .-uiSiPOSE A 7U) Y ON V OuR
AGENT TO EXERCISF, GRANTED POWERS, BUT WHEN POWERS ARE
EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR
BENEFIT AND TN ,ACCORDANCE WITH TkiTS ROWER OF ATTORNEY.
YOUR AGENT MAX EXERCISE TLIE POWERS GIVEN MERE
THROUGHOUT YOUR LIFETIME, EVEN AFTER YOt] BECOME
INCAPACITATED, UNLESS XOU EXPRESSLY LIMIT THE DL]RATION 4F
THESE POWERS OR'YOU REVOKE THESE POWERS OR A COURT ACTING ON
YOUR I3EHALF TERMINATES XOUR AGENT'S AUTIiORITX.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR
AGFNT'S FUNDS.
A COURT CAN TAKE AWAY'~'ITE POWF,ItS OF YOUR AGENT IF IT FINDS
YOUR AGENT IS NOT AC`T'ING PROPERLY.
THESE POWERS .AND DUTIES OF AN AGENT UNDER A POWER OF
ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA. C. S. CH. 56.
tF THERE IS ANYTHING ABOUT T~TIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CFIOOSING TO
EXPI.,AIN IT TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I
UNDERSTAND ITS CONTENTS.
/~ (fir _~~i~L_
l f~ ~~
ROBERT C... TRAVFR, PRINCIPAL DATE
RFf'FTUFTI AS-GTR-' t~R 1 Gi ~ 42
FRC1M- 71777?1 R9
Tfl-
Srhnt iar Rnrrar T T f'
PGiG11 /G111
05/08/2008 10:32 7177372189 MANORCARE,CAMPHILL PAGE 02/11
DIJR.AELE
GEN~~.2AL POWER. Off' 11~'TQRN~X
I, ROBERT G. TRAVER, now of 1.076 Pinetown Road, Lcwisberry, York County,
rennsyivania 1 X339, appoint my wire, LOTS .I. TRA,vii~~R, now of iu~76 Pinetown. Road.,
Lewisberry, York County, Pennsylvania 1.7339, and,ny daughter; ANNA M. M.FSSIME.R,
now of l 095 Pinetown Road, Lewisbcrry,Pork County, Pennsylvania ] 7339, to a,ct jointly or
individually, as my Co-Agents. If either of tl~e~n predeceases me, resigns as my Agent or fails
to complete the duties as any Agent, then the survivor of thorn shall serve as my Agent. LOTS
J. ?RAVER and ANNA. M. MESS)<MER are refe~xed to as "my Co-.A.gents" in this
document.
if and in the event that both of my Co-Agents predecease me, or do not complete the
duties ;,f^zy true and lu~vfal Co-'1b~rts, then aau :r. such e~~c.,t, lher~byr:~a'~c, coz;.sti ~;tc and
appoint my soxa, RONAJ~D E. TRA,vTR, now of 1100 Pinetown Road, Lewisberry, York
County, Pennsylvania 17339, as my Successor Agent, with all the rights and duties hcrei.nafter
stated.
I intend to create a T)urable Power of Attorney pursuant to 20 Pa. C_S_ Section 5604
(or tk~e corresponding provision of any subsequent state law). Tl~e e.ff..ective date of this Power
is November 16, 2005_ It is my express intent and direction that this Power ofAttorney and
the authority and powers hereby conferred shall not be a.ffeeted by my subsequent disability,
incapacity or incompetency, or the adjudication thereof, or 1 ater uncErCainty as to whether I am
dead or alive, and shall be Rally cxerci.sable notwithstandia~g the same.
My Agent i.s hereby given the fullest possible powers to act on. my behalf, with the
same powers, for all purposes, ar. d with the same validity as I could, if personally present.
Without limiting the general powers herebyalready conferred, ~nyAgent shall havethe
foll.vwing spccifi.c powers, including, but not limited to:
1. To collect and receive any money and assets to which 1 may he entitled; to
deposit cash. and cheeks in. any of my accounts; to endorse for deposit, transferor collection,
i.n my name a.nd for my account any checks payable to my order; to draw and sign checks for
me and in my Warne, including any accounts opened by such Agent in m.y name at any ban),
savings society, money market fund or elsewhere; to receive and apply the proceeds of such
checks as my Agent decm~s best; and., to close accounts.
2. To take all lawful steps to recover, collect and. receive any amounts of. money
now or hereafter owing or payable to rne; and, to compromise and execute releases or other
sufficient discharges for such amounts;
3. To make loans, secured or unsecured, in such amounts, upon :,uch teams, with.
or without interest and to such firms, corporations, and persons as my Agent deems
appropriate;
2
RECEIVED 05-08-'88 10:42 FROCJ- 7177372189
TO-
Schut.ier Boaar LLC
P002/011
05/08/2008 10:32 7177372189 MANORCARE,CAMPHIL<_ PAGE 03/11
4. To institute, prosecute, defend., compromise, or. othei~uise dispose of (and to
appear for me in any proceedings before any tribunal for the enforcement or for the defense
of) any claim, either alone or in conjunction with other persons, relating to ine or to any
property of mine ar any other persons; to obtain, discharge and subLstitute counsel and to
~ ^••^~^ Qi to lie ~^.*_ere~? fnr me to anv gucl! ~Cf'1(1r1(?1" nrclCBEdtn~;
anti„lofi~c appe~ira,u.CC Oi ~ItAVLA CO~AA.~.
and, to compromise or arbitrate any claim. in wll.ich 1 may be interested and for t11at purpose
to enter into agreement or compromise or arbitration anal perform or. enforce any award entered
pursuant to such arbitration;
5. To )ease, sublet, sell, release, hire professional managers, convey or mortgage
any real property awned by me (including my residence) or i~~ whi.ch I have ate interest now
or iz~ the future, upon such terms and conditions and under such covenants as my Agent shall
determine, including the sale of my real estate and to sign, execute anal deliver deeds and
conveyances therefor;
6. To purchase or otherwise acquire anyinterest in and possession ~afreal property
and to accept all deeds for such property oi~. my behalf; and, to manage, repair, improve,
maintain, restore, build, or develop any real. property in which 1 now have or may )gave an
interest in the future;
7. Ta execute, deliver and acknowledge deeds, deeds of tnlst, covenants,
indenturES, agreements, mortgages, hypothccati.ons, bills of lading, bills, bonds, notes, receipts,
evidences of debts, releases and satisfactions ofmortgage, judgnents, ground rents and other
debts;
g. To collect, compromise, endorse, borrow against, hypothecate, release and
remover any promissory note receivable, whether. secured or uiasecured, and any related deed
of trust;
9. To buy, purchase, Bell, repair, alter, manage and dispose of personal property
of every kind and nature at private or public sale and to sign, execute and dcl.iver assignments
and bills of sale therefor;
l0. To enter my safe deposit boxes and to open new safe deposit boxes; to add to
and to removE arty of the contents of any such safe deposit boxes; and, to close any of such
boxes;
11. To borrow money for my account on whatever terms and conditions deemed
advisable, including borrowing money on any insurance policies issued o» m.y life for any
purpose without any obligation on the part of such insurance company to determine the
purpose for such loan or application of. the proceeds, and to pledge, assign. and deliver t11e
policies as security;
12. To apply for and to receive any government, insurance and retirement bcnefats
to which 1 may be entitled and to exercise any right to elect benefits or pa~~'+ent options; to
AF('FT~)FTl Gtr,-f R-' GiR 1 G1 ~ 47 FRf1M- 7177'721 R9
Tfl-
Srhut iPr Rnaar LLC
P003/811
05/02/2008 10:32 7177372189 MANORCARE,CAMPHILL PAGE 04/11
terminate such benefits; to changebcnefi.ciaries or. ownership of suchbenefits; and, to assign
rights or receive cash value in return for the surrender of a.ny or all rights I may have inn life
insurance policies or benefits, annuity policies, plans of benefits, mutual fund and other
divide>ad investment plans and retirement, profit-sharing and employee welfare plans and
v~nCu.. ,
13 _ To take custody of any stocks, bonds and other investments of. all ki nds, to give
orders for the sale, surrender or exchange of any such investments and to receive t11e proceeds
therefrom; to sign and deliver assignments, stock. and bond powers and otl~ter documents
required for a.ny such sale, assigmnent, surrender or. exchange; to give orders for the purchase
of stocks, bonds and other investments o£any kind; to give instructions as to t11e registration
thereof and the trailing of dividends and interest therefrom; and to deposit coupons attached
to any coupon bonds, whether now owned by the or hereafter acquired;
14. To purchase for me United States of America Treasury Bonds of the kind which
are redeemable at par in payment of federal estate taxes; to borrow money artd obtain credit
in my name from any source for such pur~tosc; to make, execute, endorse and deliver
promissory notes, drafts, agreements or other obligations for such bonds and, as security
therefor, to pledge, trortgage and assign. any stocks, bonds, securities, insurance values and
other properties, real. or personal, in which T may have an interest; and, to arrange for the
safekeeping and custody of any such Treasury Bonds;
15. To open, close, or maintain accounts (including accounts on tnargirt or other
leverage device, and accounts in options, calls or futures) with stockbrokers, i.nvestmer~t
counsel, financial advisors, or. other similar agent or intermediary, or through an account held
by my Agent in an on-Line service, aztd to buy, sell, endorse, transfer, hypothecate, leverage,
margin, orborrow against any of the accounts, stock, bonds, capital accounts, futures, option..s
or other securities;
16. To vote at all meetings of shareholders (whether general, regular or special) of
an.y corporation whose shares 1 own, on any questions which. may axZSe at any such tr~eeting,
and to do everything respecting such shares of stock, including the calling of meetings of
directors or stockholders or making and giving consents and ratifications, and any oth..er act
which t could do if personally present, intending hereby to confer upon my Agent full power
artd authority to do (with reference to such shares of stock) everything which i might or could
do as owner of such shares;
17. To continue the operation of any business belonging tv me or in which. i have
a substantial. interest, in such manner as my Agent may deem advisable or. to se1.l, liquidate or
incot}~orate any business (or interest therein) on such terms as my Agent may deem advisablE
and in my best interests;
18. To procure, change, carry or cancel insurance of suchkind and in. such amounts
as my Agent deems advisable to protect from risks affecting property or persons due to
liability, damage or a claim of any sort; to claim anyben.efits or proceeds on m.y bchal£; and,
to purchase medical insurance for any d.epen.dent of mine;
13ECEIVED OS-08-'OS 10:42 FBOM- 7177372189
4
TO-
Schut.ier Boaar LLC
P004/011
05/08/2008 10:32 7177372189 MANORCARE,CAMPHILL PAGE 05/11
19. jfmarried, to join with my spouse or my slx~use's estate in filing income ar gift
tax returns for an}r years for which 1 have n.ot filed. such returns and to consent to any gifts
made by my spouse as being made one-half, by one for gift tax purposes, even though such.
action subjects my assets to additional liabilities;
20. To prepare, sign and file federal., state and local income. gift or other tax and
iz~forrnation returns of all kinds,~clai~?~s for refunds, requests or extensions of tune, petitions
to the United States Tax Court or other courts regarding tax matters and any and all other tax
.related document`, including, without ).i.m.itation, receipts, offers, waivers, consents (i.nclu.ding,
but not limited to, consents and a,grec~nents und.cr. lntern.al Revenue Code (he~-einaf~cr IR.C)
Section 2032A, or its successor), powers of attorney, and closing agreements; to exercise any
elcctioz~s I may have under federal, state and. local tax 1 aws; and, generally to act on my behalf
i.n all tax matters of al.). kinds and for all. periods before all persons representing the internal
Revenue Service and any other taxing authority, includingreceipt of confidential information
and the posting ofbonds.
2l. To make gifts, unlimited in amount, as set forth below, eith.~:r outright or in
trust or, in the case of minors, in accordance with the Uniform Gifts to Minors Act and.,for
gifts made i.n trust, to execute a deed of trust for such purpose designating one or more
persons, including my Agent, as original or successor trustees. This power includes the right
to make addi.tion.s to an existing trust and does not require my Agent to beat the donees
equally or proportionately and may entirely exclude one or more pexrnissible donees. The
pattern followed on the occasion of any such. gift (or gifts) need not be followed on the
occasion of any other gift (or gifts). The power. to make gifts shall be limited to my brothers
and sisters (whether by the whole or half blood), spouse, parents, grandparents, and lineal
descendants and any organizati.oo described in 1RC Section 501(`)(3). My Agent and the
donee of the gift .shall be responsib)e as equity and justice may require to the extent that a gift.
made by my Agent is itaconsistent with t11e prudent planning of my estate or. financial
management of my property, or with my known or probable intent with respect to the
disposition ofmy estate. The ability of my Agent to make gifts of myproperty shall be limited
by and shall onlybe made in conformitywith rnypre-nuptial agreement, if any such agreement
exists.
22. '1'o execute a deed of trust, designating one or more persons (including n1y
Attorneys-in-Fact) as original or successor trustee(s) and to transfer to the trust any or all
property owned by me as my Agent may decide. The income and principal of the trust m.ay,
but need not, be distributable to me or to the guardian of my estate, or he applied for try
benefit, and upon my death, any remaining principal or unExpended income of the trust may,
but need not, be distributed to my estate. Furthermore, this trust or deed of trust may be
amendable or revocable at any time by me or my Agent, or the trust or deed. of trust may be
irrevocabie by me or my Agent;
23. To add at any time, any or all of th.e property owned by the to any trust in
existence for my benefit when this power was created. The income and principal of the trust
may, but need not, be disUzbutable to me or to the guardian of my estate or be applied for my
5
F3ECEIVED 85-88-' 88 10:42 F130M- ?177372189
TO-
Schutier Boaar LLC
P005/011
05/08/2008 10:32 7177372189 MANORCARE,CAMPHILL PAGE 06/11
benefit during my lifetime and upon pry death any retraining principal and unexpended
income of tl,e trust may, but need. not, be distributed to my estate;
24. To withdraw at~d receive the income or corpus of any trust ovt:r which T may
h.6t"P a rie>`~t of ~~rithrira~~r alp anti tC Y~.^,'1~St and rrn~e).`>`~ tl:~ inCOm= nr CCT-vr,~~c of any 1Ynict urith
respect to which the trustee thereof has the discretionary power to make distributions tome
or on m.y behalf, and to execute a receipt and. relea'sc or a similar document for the property
so received;
25. To convey or release any eontio.gent or expectant interests in property, marital
property rights, and any rights of survivorship in..cident to a. joint tenancy or a tenancy by the
entireties;
26. To elect to take against the will, and conveyances of my spouse. after death; to
disclaim any interest ;.n. property which I am required to disclaim as a result of such elect7on;
to retain any property which. I have the right to elect to .retain; to ftle petitions pertaining to th.e
election, including petitions to extend the time for electing, and petitions for orders, decrees,
and judgments; and, to take all other necessary actions to effectuate the election;
27. To accept and. acquire or release and disclaim on my behatf~ any interest in
property acquired by intestate, testate or inter vivos transfer, including the release or
disclaimer, or acquisition of a~iy interest in property through the exercise or surrender of any
right to revoke a revocable bust;
28. To continue any fiduciary positions to which I have been or may be appointed
including (but clot limited to) persona] representative, trustee, guardian, Agent, and officer or
director of a corporation ox political or governmental body; and, to resigns such positions in
which capacity I azn presently serving or to which I may be appointed;
29. TO HAVE THE AUTHORITY TO GNE CONSFN'I' FOR, A.ND
AUTHORITE, SUCH MEDICAL AND SURGICAL PROCEDURES AND TREATMEN'T'
(INCLUDING LIFE-SUSTAINING TREATMENT), TO BE PERFORNTEI) ON ME AND
TO AUTHORIZE, AIZKANGE FOR, CONSENT TO, WANE AND TERMINATE ANY
AND ALL MEDICAL AND SURGICAL PROCEDURES AND TREATMENT
(INCLUDING LIFE-SUSTAINING TREATMENT) ON MX BEHALF, INCLUDING THE
ADMINISTRATION OF DRUGS OR TO WITHHOLD SUCH CONSENT; PROVIDED
TI-IAT ANY LIVING WILL WHjCH I MAY HAVE THEN IN EFFECT SHALL TAKE
PRECEDENCE OVER THIS PROVISION;
30. To arrange for my entrance into aa~d care at any hospital, nursi ng home, health
center, convalescent home, retirement home, or similar personal care, sheltered care,
intermediate care, or skilled. nursing facility; and, to pay all costs for my care as my Agent,
based on medical advice, determines in good faith to be necessary and for rrty well-being;
G
RECEIVED 05-08-'08 10;42 F130M- 7177372189
TO-
Schut,ier Bogar LLC
P006/011
05/08/2008 10:32 7177372189 MANORCARE,CAMPHILL PAGE 07/11
31. To employ lawyers, investment counsel, accountants, physicians, dentists and
outer persons to rEnder services to me or t~ty estate and to pay the usual and reasonable fees
and compensation. of such persons for their services;
~7 'i'n t}rQ ovt~nt nit nt}l~r\,Vtso F f f~~tl.rol~i CrL.~~~,-loci isl tl:nr ;n4rQ~,r~!:^r j~ pa:wd"r. ?'t?' ~1
of this Power of Attorney, to appoint and substitute under himself and themselves, one or more
substitute or Successor Agent for. any or all the purposes hereita described, pursuant to
Pennsylvania Consolidated Statutes Title 20, Section 5602(b)(3) or the corresponding
provision of any subsequent state law;
33. To make an anatomical gift of all or part of my body or decisions
concerning procedures relating to such gift(s) otr procedures, Either before or after my
death, provided that any such power shall be su.b,ject to and limited by any power
granted to nny surrogate unnder my Living Will;
34. To obtain health information oo. behalf of the principal, including an. accounting
of health care and information disclosures, anal to enforce my rights regarding health care and.
information th.roug}>, all means including, but >,~.ot limited to, f ling complaints and appropriate
appeals, to the maximum extent permitted by 45 C.F.R.. 164.502(g) such that my agent and
Agent shall be considered to act fully in my pl.aee for all issues concerning health care
coverage, insurance, and information under tl~.e Health Insurance Portability and
Accountability Act of 1996, as amended; and,
35_ To direct the conveyance, transfer, or delivery of my meal, including, letter
bills, packages, and correspondence, of whatever rate, type or kind, with such power. as may
be necessary to receive such correspondence, change the address for delivery of such
cot~espondence, or otherwise act in my stead with the federal Postal Service or other
institution handling correspondence.
Accordingly,
A.. Except a,s my Agent may waive a.ny fees, any Agertt shall. be entitled. to receive
for services actua]ly performed hereunder their nonrral and customary charge for performing
similar services during the time the services are perfoz-med.
B. This Power of Attorney maybe accepted anal relied upon by anyone to whom
it is presented until such. person either receives written notice of revocation. by me or has actual
knowledge of my death or the revocation of this Power of Attorney.
C. All actions of my Agent pursuant to this Power of Attorney during nny absence or
any period of my disability or incapacity shall kl.avc the satire effect and inure to tine benefit of
and shall bind me, my heirs, distributees, legal representatives, successors a.nd assigns, as ~f
I were present, anal competent and not disabled, and for the purpose of indv.cirig anyone to act
in accordance with th.e powers I have granted herein, Z hereby represent, w<tmant and agree
that, if this Power of Attorney is terminated or a.t.~tended for any reason, I and my Heirs,
7
RFCFTVFn 05-0R-'08 10:42 FROM- 7177372189
TO-
tttttt^
Schut.ier Boaar LLC
P007/011
05/08/2008 10:32 7177372189 MANORCARE,CAMPHILI_ PAGE 08/11
distributees,l.egalrepresentatives, successors and assigns will hold such partyhannless for, any
loss suffered or liability incu~Ted by such party tivhilc a.cti~zg in accordance with. this Power of
.Attorney prior to that party's receipt of written notice of a~Zy such termination or amendment.
11 f ,-P11nlce all r^.ri4r f:anrr~.l L,r Tlyrabl.° Pn~irars ~~ Att~MPy r},;,t T may 1?3V~
executed and 1 retain the right to revolve or amend this Power of Attorney and to substitute
other attonr~eys-in-fact in place of the Agent appointed. herein.. Amendments to this Power of
Attorney shall. be made in writing by me personally (not by my Agent) and they shall be
attached. to the original of this Power of Attorney.
~. Pucsuant to Pennsylvarxia Consolidated Statutes Title 20, Section 5604(c)(2)
or the corresponding provision of any subsequent state law, if incapacity proceedings for my
estatE or my persona are hcrea~er comtx~enced, I hereby nom.iz~ate, constitute and appoint tb,e
above-described Agent as the guardian of my estate and my person. If and in. the eveztt that
any Agent predeceases me, or does not complete the duties of my true anal lawful Agent, then
and in such event, I hereby nominate, constitute and appoint the above-described Successor
Agetat as the guardians of my estate and ~~y person:
F. I. understand that this Power of Attorney is an important legal document.
Before executing this document, my attorney-at-law explained to me the following:
(1) This document provides my Agent with broad powers to
dispose of., sell, convey anal enctunber my real and personal property;
(2) The powers granted in this Power of Attorney will. become
effective upon. the execution of this document and will exist for an indefinite
period of rime unless I limit their duration by the teens of this Power or revoke
this Power. These powers will continue to exist notwithstanding my
subsequent disability or incapacity; and,
(3) I have the right to revoke or. terminate this Power at aaiy time.
G. Questionspertainingtotheval.idity,constructiona»dpowerscreatedunderthis
Power of Attorney shall be determined in. accordance with the laws of the Commonwealth of
Pennsylvania.. Where herein used, the plural shall include the singular, and the singular. shall
include the plural.
IN WITNESS WHEREOF, and intending to be legallybou.nd hereby, l have signed this
Durable Power of Attorney, this 16'h day of Novembex, 2005.
~~~- ~
~J f ~
(SEAL)
ROBERT G. TRAVER
RECEIVED 05-88-'88 111:42 FROM- 7177372189
TO-
Schut.ier. Boaar LLC
P008/011
05/08/2008 10:32 7177372189 MANORCARE,CAMPHILI_ PAGE 09/11
On this 1.6`'' day of November, 2005, tl,e above-named, ROBERT G. TRAVER, i.~~
our presence declared the preceding instrument consisting of this and ten (10) other
typewritten pages, to he his Power of Atton,ey, and we, in the presence of th.e above-named
p.'l~i,~uRT ~. TU A1~JT~.U~ o~1d :^. r..ti'" pT~S~.^~° Cf pa~12 ntl:~_, 3t tl:: rar~tl£et n4~ 111TH, h~Ve
r ~ ~. /~
subscribed our names as wittiesscs.
Witness's ., i~naivre
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CTJMBERLAND
_~
Witness s Na~nc (print)
~ \ .---~
V (~ ~
Witness's Signature
Witness's Name (print)
SS:
~-^
On this, the ~ ~ _ day of November, 2005, before me, a Notary Public, the
undersigned officer, personally appeared ROBERT G. TRAVER, known. to me (or
satisfactozily proven) to be the person whose nacre is subscribed. to the within Durable Power
of Attorney, and acknowledged that he executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official Seal.
Notary Public
My Commission Expires:
Notar+a- Notary P~~
Vicb~a M. t'is;~, Cot~tY
L lion Exp~AuQ ~' 2006
.~~~~
RT=CRTVFn Gt~i-G1R-` GiR 1 A ~ 42 FROM- 7177:721 R9
9
TO-
Srhut iPr Rnr~ar T.T.C
PG1~9/G111
05/08`2008 10:32 7177372189 MANORCARE,CAMPHILL PAGE 10/11
A,Ci~10WLEDGMENT EXECUTED DY PRIMA. Y ADEN"fS
AN AGENT SHALL HAVE NO AUTHORITY TO i~CT AS AGENT UNDER
THIS POWER OF ATTORNEY UNLESS THE AGENT 13AS FIRST
EXECUTED AND AFFIXED THIS .ACKNOWLEDGIVIENT TO TAE
POWER OF ATTORNEY DOCUMENT:
Wc, .LOTS J. TRAVER az~d ANNA M. MESSI:MER, have each read the attached
power of attorney and are the persons identif ed as the co-agents for the principal. We each
hereby acknowledge that in the absence of a specific provision to the contrary in th.e power
of attorney or in 20 Pa. C. S. when we act as agents:
We shall each exercise tl~e powers for the benefit of the principal;
2. We shall. each keep the assets of the principal separate from our. asset;
We shall each exercise reasonable caution and prudence; and,
4. We shall each keep a full and accurate record of all actions, receipts and
disbursements on behalf of the principal.
-E~~
L IS J. TRA R, Co-Agent Date
NA. M. MESSIME . , Co-Agent
RECEIVED G15-GTR-' GiR 1 R ~ 42 FROM- 71778721 R9
10
o? U
Date
TO-
Srhut iPr Rnaar i.i.C
P4i1Gl/G111
05/08/2008 10:32 7177372189 MANORCARE,CAMPHILL PAGE 11/11
Y
p,,C~1pWL)EDGMENT E~FCUTED >aY SUCCESSOR AGENT
A SUCCESSOR AGENT SHALL HAVE NO AUT~i.ORITY TO ACT
AS AGENT UNDER THIS POWER OT ATTORNEY UNLESS THE
SUCCESSOR AGENT HAS FIRST EXECUTED AND AFFIXED
THIS ACKNOWLEDGMENT TO THE POWER OF A`r'I'ORNF Y
DOCUMENT:
I, RONALD 1L. TRAVER, have read the attached power of attorney and am tlae
person identified as the agent for the principal. thereby 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:
1. I skull eacr exercise the powers for the benefit of the principal;
2. I shall each keep the assets of the principal separate from our assets;
3. I shall. each exercise reasonable caution and prudence;
4. 1 shall each keep a full and accurate record of all actions, receipts and
disbursements on behalf of the principal.
RONALD E. TRAVER,
Successor Agent
pate
ll
RFf'FT11F11 GiS-GiR-`G1R 1f~~42 FR(1M- 7177'7?1Rq Tfl- Srhiitiar Rnr~ar i.T.f: PG111/G111
EXHIBIT "D"
• :1
ii
• ~`.;
fJf` ~'
/. ~ f
V`
NOTICE
TO THE PRINCIPAL
GRANTING A POWER OF ATTORNEY
THE PURPOSE OF TffiS 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 POV~'ER OF ATTORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GNEN HERE -,
THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME ~~ ~ ~
INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF J f1~`
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.
THESE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF
ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA. C. S. CH. 56.
IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASKA 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.
OIS J. TRAVER, PRINCIPAL DATE
~vOT APPl1CASLE FOR PiN NUMBER
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 1
II 11 i ~ I L LLnu ..~Lu ~ .i ~ ~ i
DURABLE
GENERAL POWER OF A'I°rORNEY
I, LOIS J. TRAVER, now of 1076 Pinetown Road, Lew~sberry, York County,
Pennsylvania 17339, appoint my daughter, ANNA M. MESSIMER now of 1095 Pinetown
Road, Lewisberry, York County, Pennsylvania 17339, as myAgent. ANNA M. MESSIMER
is referred to as "my Agent" in this document.
If and in the event that my Agent predeceases me, or does not complete the duties of
my true and lawful Agent, then~d in such event, I hereby make, constitute and appoint my
son, RONALD E. TRAVER, now of 1100 Pinetown Road, Lewisberry, York County,
Pennsylvania 17339, as my Successor Agent, with all the rights and duties hereina$er stated.
I intend to create a Durable Power of Attorney pursuant to 20 Pa. C.S. Section 5604
{or the corresponding provision of any subsequent state law). The effective date of this Power
is November 16, 2(105. It is my express intent and direction that this Power of Attorney and
the authority and powers hereby conferred shall not be affected by my subsequent disability,
incapacity or incompetency, or the adjudication thereof, or later uncertainty as to whether I am
dead or alive, and shall be fully exercisable notwithstanding the same.
My Agent is hereby given the fullest possible powers to act on my behalf, with the
same powers, for all purposes, and with the same validity as I could, if personally present.
`Vithout limiting the general powers hereby already conferred, my Agent shall have the
following specific powers, including, but not limited to:
1. To collect and receive any money and assets to which I may be entitled; to
deposit cash and checks in any of my accounts; to endorse for deposit, transfer or collection,
in my name and for my account any checks payable to my order; to draw and sign checks for
me and in my name, including any accounts opened by such Agent in my name at any bank,
savings society, money market fund or elsewhere; to receive and apply the proceeds of such
checks as my Agent deems best; and, to close accounts.
2. To take all lawful steps to recover, collect and receive any amounts of money
now or hereafter owing or payable to me; and, to compromise and execute releases or other
sufficient discharges for such amounts;
3. To make loans, secured or unsecured, in such amounts, upon such terms, with
or without interest and to such firms, corporations, and persons as my Agent deems
appropriate;
4. To institute, prosecute, defend, compromise, or otherwise dispose of (and to
appear for me in any proceedings before any tribunal for the enforcement or for the defense
2
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 2
of) any claim, either alone or in conjunction with other persons, relating to me or to any
property of mine or any other persons; to obtain, discharge and substitute counsel and to
authorize appearance of such counsel to be entered for me in any such action or proceeding;
and, to compromise or azbitrate any claim in which I may be interested and for that purpose
to enter into agreement or compromise or arbitration and perform or enforce any award entered
pursuant to such arbitration;
5. To lease, sublet, sell, release, hire professional managers, convey or mortgage
any real property owned by me (including my residence) or in which I have an interes# now
or in the future, upon such terms and conditions and under such covenants as my Agent shalt
determine, including the sale of my real estate and to sign, execute and deliver deeds and
conveyances therefor;
6. Ta purchase or otherwise acquire any interest in and possession of real property
and to accept all deeds for such property on my behalf; and, to manage, repair, improve,
maintain, restore, build, or develop any real property in which I now have or may have an
interest in the future;
7. To execute, deliver and acknowledge deeds, deeds of trust, covenants,
indentures, agreements, mortgages, hypothecations, bills of lading, bills, bonds, notes, receipts,
evidences of debts, releases and satisfactions of mortgage, judgments, ground rents and other
debts;
8. To collect, compromise, endorse, borrow against, hypothecate, release and
recover any promissory note receivable, whether secured ar unsecured, and any related deed
of trust;
9. To buy, purchase, sell, repair, alter, manage and dispose of personal property
of every kind and nature at private or public sale and to sign, execute and deliver assignments
and bills of sale therefar;
10. To enter my safe deposit boxes and to open new safe deposit boxes; to add to
and to remove any of the contents of any such safe deposit boxes; and, to close any of such
boxes;
11. To borrow money for my account on whatever terms and conditions deemed
advisable, including borrowing money on any insurance policies issued on my life for any
purpose without any obligation on the part of such insurance company to determine the
purpose for such loan or application of the proceeds, and to pledge, assign and deliver the
policies as security;
12. To apply for and to receive any government, insurance and retirement benefits
to which I may be entitled and to exercise any right to elect benefits or payment options; to
terminate such benefits; to change beneficiaries or ownership of such benefits; and, to assign
rights or receive cash value in return for the surrender of any or all rights I may have in life
05!12/2008 4:07:15 PM
,, T_.. 17.x._..,...... ,. , _. .. , . , ,
YORK COUNTY
Inst.# 2008012185 -Page 3
insurance policies or benefits, annuity policies, plans of benefits, mutual fund and other
dividend investment plans and retirement, prof t-sharing and employee welfare plans and
benefits;
13. To take custody of any stocks, bonds and other investments of all kinds, to give
orders for the sale, surrender or exchange of any such investments and to receive the proceeds
therefrom; to sign and deliver assignments, stock and bond powers and other documents
required for any such sale, assignment, surrender or exchange; to give orders for the purchase
of stocks, bonds and other investments of any kind; to give instructions as to the registration
thereof and the mailing of dividends and interest therefrom; and to deposit coupons attached
to any coupon bonds, whether now owned by me or hereafter acquired;
14. To purchase for me United States of America Treasury Bonds of the kind which
are redeemable at par in payment of federal estate taxes; to borrow money and obtain credit
in my name from any source for such purpose; to make, execute, endorse and deliver
promissory notes, drafts, agreements or other obligations for such bonds and, as security
therefor, to pledge, mortgage and assign any stocks, bonds, securities, insurance values and
other properties, real or personal, in which I may have an interest; and, to arrange for the
safekeeping and custody of any such Treasury Bonds;
15. To open, close, or maintain accounts (including accounts on margin or other
leverage device, and accounts in options, calls or futures) with stockbrokers, investment
counsel, financial advisors, or other similar agent or intermediary, or through an account held
by my Agent in an on-line service, and to buy, sell, endorse, transfer, hypothecate, leverage,
margin, or borrow against any of the accounts, stock, bonds, capital accounts, futures, options
or other securities;
1 b. To vote at all meetings of shareholders (whether general, regular ar special) of
any corporation whose shares I own, on any questions which may arise at any such meeting,
and to do everything respecting such shares of stack, including the calling of meetings of
directors or stockholders or making and giving consents and ratifications, and any other act
which I could do if personally present, intending hereby to confer upon my Agent full power
and authority to do (with reference to such shares of stock) everything which I might or could
do as owner of such shares;
17. To continue the operation of any business belonging to me or in which I have
a substantial interest, in such manner as my Agent may deem advisable ar to sell, liquidate or
incorporate any business (or interest therein) on such terms as my Agent may deem advisable
and in my best interests;
18. To procure, change, carry or cancel insurance of such kind and in such amounts
as my Agent deems advisable to protect from risks affecting property or persons dne to
liability, damage or a claim of any sort; to claim any benefits or proceeds on my behalf; and,
to purchase medical insurance for any dependent of mine;
4
. i.rT~...„~... ..,... .. .. ,
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 4
19. If married, to join with my spouse or my spouse's estate in filing income or gift
tax returns for any years for which I have not filed such returns and to consent to any gifts
made by my spouse as being made one-half by me for gift tax purposes, even though such
action subjects my assets to additional liabilities;
20. To prepare, sign and file federal, state and local income, gift or other tax and
information returns of all kinds, claims for refunds, requests or extensions of time, petirions
to the United States Tax Court or other courts regarding tax matters and any and all other tax
related documents, including, without limitation, receipts, offers, waivers, consents (including,
but not limited to, consents and agreements under Internal Revenue Code (hereinafter IRC}
Section 2032A, or its successor), powers of attorney, and closing agreements; to exercise any
elections I may have under federal, state and local tax laws; and, generally to act on my behalf
in all tax matters of all kinds and for all periods before all persons representing the internal
Revenue Service and any other taxing authority, including receipt of confidential information
and the posting of bonds.
21. To make gifts, unlimited in amount, as set faith below, either outright or in
trust or, in the case of minors, in accordance with the Uniform Gifts to Minors Act and, for
gigs made in trust, to execute a deed of trust for such purpose designating one or more
persons, including my Agent, as original or successor trustees. This power includes the right
to make additions to an existing trust and does not require my Agent to treat the donees
equally or proportionately and may entirely exclude one or more permissible donees. The
pattern followed on the occasion of any such gift (or gifts) need not be followed on the
occasion of any other gift (or gifts). The power to make gifts shall be limited to my brothers
and sisters (whether by the whole or half blood), spouse, parents, grandparents, and lineal
descendants and any organization described in IRC Section 501(c)(3). My Agent and the
donee of the gift shall be responsible as equity and justice may require to the extent that a gift
made by my Agent is inconsistent with the prudent planning of my estate or financial
management of my property, or with my known or probable intent with respect to the
disposition of my estate. The ability of my Agent to make gifts of my property shall be limited
by and shall only bemade in conformitywith mypre-nuptial agreement, if any such agreement
exists.
22. To execute a deed of trust, designating one or more persons (including my
Agents) as original or successor trustees) and to transfer to the trust any or all property owned
by me as my Agent may decide. The income and principal of the trust may, but need not, be
distributable to me or to the guardian of my estate, or be applied for my benefit, and upon my
death, any remaining principal or unexpended income of the trust may, but need not, be
distributed to my estate. Furthermore, this trust or deed of trust may be amendable or
revocable at anytime by me or my Agent, or the trust or deed of trust maybe irrevocable by
me or my Agent;
23. To add at any time, any or all of the property owned by me to any trust in
existence for my benefit when this power was created. The income and principal of the trust
may, but need not, be distributable to me or to the guardian of my estate or be applied for my
5
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 5
N 4 11 ILL 4lul uiLL I .li i ~
beneft during my lifetime and upon my death any remaining principal and unexpended
income of the trust may, but need not, be distributed to my estate;
24. To withdraw and receive the income or corpus of any trust over which I may
have a right of withdrawal, and to request and receive the income or corpus of any trust with
respect to which the trustee thereof has the discretionary power to make distributions to me
or on my behalf, and to execute a receipt and release or a similar document for the property
so received;
25. To convey or release any contingent or expectant interests in property, marital
property rights, and any rights of survivorship incident to a joint tenancy or a tenancy by the
entireties;
26. To elect to take against the will and conveyances of my spouse after death; to
disclaim any interest in property which I am required to disclaim as a result of such election;
to retain any property which 1 have the right to elect to retain; to file petitions pertaining to the
election, including petitions to extend the time for electing, and petitions for orders, decrees,
and judgments; and, to take all other necessary actions to effectuate the election;
27. To accept and acquire or release and disclaim on my behalf any interest in
property acquired by intestate, testate or inter vivos transfer, including the release or
disclaimer, or acquisition of any interest in property through the exercise or surrender of any
right to revoke a revocable trust;
28. To continue any fiduciary positions to which I have been or may be appointed
including (but not limited to) personal representative, trustee, guardian, Agent, and officer or
director of a corporation or political or governmental body; and, to resign such positions in
which capacity I am presently serving or to which I may be appointed;
29. TO HAVE THE AUTHORITY TO GIVE CONSENT FOR, AND
AUTHORIZE, SUCH MEDICAL AND SURGICAL PROCEDURES AND TREATMENT
(INCLUDING LIFE-SUSTAINING TREATMENT), TO BE PERFORMED ON ME AND
TO AUTHORIZE, A.RR.ANGE FOR, CONSENT TO, WAIVE AND TERMINATE ANY
AND ALL MEDICAL AND SURGICAL PROCEDURES AND TREATMENT
(INCLUDING LIFE-SUSTAINING TREATMENT) ON MY BEHALF, INCLUDING THE
ADMII~IISTRATION OF DRUGS OR TO WITHHOLD SUCH CONSENT; PROVIDED
THAT ANY LIVING WILL WHICH I MAY HAVE THEN IN EFFECT SHALL TAKE
PRECEDENCE OVER THIS PROVISION;
30. To arrange for my entrance into and care at any hospital, nursing home, health
center, convalescent home, retirement home, or similar personal care, sheltered cage,
intermediate care, or skilled nursing facility; and, to pay all costs for my care as my Agent,
based on medical advice, determines in good faith to be necessary and for my well-being;
3 I . To employ lawyers, investment counsel, accountants, physicians, dentists and
6
n... _ ~.~. ~r_.. m . .
05/12!2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 6
other persons to render services to me or my estate and to pay the usual and reasonable fees
and compensation of such persons for their services;
32. To the extent not otherwise effectively provided in the introductory paragraph
of this Power of Attorney, to appoint and substitute under himself and themselves, one or more
substitute or successor Agents for any or all the purposes herein described, pursuant to
Pennsylvania Consolidated Statutes Title 20, Section 5602{b)(3} or the corresponding
provision of any subsequent state law;
33. To make an anatomical gift of all or part of my body or decisions
concerning procedures relating to such gift(s) or procedures, either before or after my
death, provided that any such power shall be subject to and limited by any power
granted to my surrogate under my Living Will;
34. To obtain health information on behalf of the principal, including an accounting
of health care and information disclosures, and to enforce my rights regarding health care and
information through all means including, but not limited to, filing complaints and appropriate
appeals, to the maximum extent permitted by 45 C.F.R. 164.502(g) such that my agent and
Agent shall be considered to act fully in my place for all issues concerning health care
coverage, insurance, and information under the Health Insurance Portability and
Accountability Act of 1996, as amended; and,
35. To direct the conveyance, transfer, or delivery of my mail, including, letter
bills, packages, and correspondence, of whatever rate, type or kind, with such power as may
be necessary to receive such correspondence, change the address for delivery of such
correspondence, or otherwise act in my stead with the federal Postal Service or other
institution handling correspondence.
Accordingly,
A. Except as my Agent may waive any fees, my Agent shall be entitled to receive
for services actually performed hereunder their normal and customary charge far performing
similar services during the time the services are performed.
B. This Power of Attorney maybe accepted and relied upon by anyone to whom
it is presented until such person either receives written notice of revocation by me or has actual
knowledge of my death or the revocation of this Power of Attorney.
C. All actions of my Agent pursuant to this Power of Attorney during my absence
or any period of my disability or incapacity shall have the same effect and inure to the benefit
of and shall bind me, my heirs, distributees, legal representatives, successors and assigns, as
if I were present, and competent and not disabled, and for the purpose of inducing anyone to
actin accordance with the powers I have granted herein, I hereby represent, warrant and agree
that, if this Power of Attorney is terminated or amended for any reason, I and my heirs,
distributees, legal representatives, successors and assigns will hold suchpartyharmless for any
7
,, „ . ~ ,.~_~i.__...T... .. , . , _ , .
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 7
ll li 1~ lit tYlJU fi1k1 IV I_J
loss suffered or liability incurred by such party while acting in accordance with this Power of
Attorney prior to that party's receipt of written notice of any such termination or amendment.
D. I revoke all prior General or Durable Powers of Attorney that I may have
executed and I retain the right to revoke or amend this Power of Attorney and to substitute
other Agents in place of the Agent appointed herein. Amendments to this Power of Attorney
shall be made in writing by me personally (not by my Agent) and they shall be attached to the
original of this Power of Attorney.
E. Pursuant to Pennsylvazua Consolidated Statutes Title 20, Section 5604(c)(2)
or the corresponding provision of any subsequent state law, if incapacity proceedings for my
estate or my person are hereafter commenced, I hereby nominate, constitute and appoint the
above-described Agent as the guardian of my estate and my person. If and in the event that
my Agent predeceases me, or does not complete the duties of my true and lawful Agent, then
and in such event, I hereby nominate, constitute and appoint the above-described Successor
Agents as the guardians of my estate and my person.
F. I understand that this Power of Attorney is an important legal document.
Before executing this document, my attorney-at-law explained to me the following:
(1) This document provides my Agent with broad powers to
dispose of, sell, convey and encumber my real and personal property;
(2) The powers granted in this Power of Attorney will become
effective upon the execution of this document and will exist for an indefinite
period of time unless I limit their duration by the terms of this Power or revoke
this Power. These powers will continue to exist notwithstanding my
subsequent disability or incapacity; and,
(3) I have the right to revoke or terminate this Power at any time.
G. Questions pertaining to the validity, construction and powers created under this
Power of Attorney shall be determined in accordance with the laws of the Commonwealth of
Pennsylvania. Where herein used, the plural shall include the singular, and the singular shall
include the plural.
IN WITNESS WHEREOF, and intending to be legally bound hereby, I have signed this
Durable Power of Attorney, this 16~' day of November, 2005.
~~ (SEAL)
LOIS J. TRAVER
„.
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 8
On this 16~' day of November, 2005, the above-named, LOIS J. TRAVER, in our
presence declared the preceding instrument consisting of this and ten {10) other typewritten
pages, to be her Power of Attorney, and we, in the presence of the above-named LOIS J.
TRAVER, and in the presence of each other, at the request of her, have subscribed our names
as witnesses.
V ~\
Witness's Signature
Witness's Name (nri~tl
Name (print}
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SS:
r~
On this, the ~ ~ day of November, 2005, before me, a Notary Public, the
undersigned oi~cer, personally appeared LOIS J. TRAVER, known to me {or satisfactorily
proven) to be the person whose name is subscribed to the within Durable Power of Attorney,
and acknowledged that she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official Seal.
_ v `.
Notary Public
My Commission Expires:
+4ty ~ ~y
or>! E,q~ea,gtrg. 2T 2006
+Nen-ber ~ ~
9
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 9
~ i ~ I 1 N 1~ l i Ilk~ku. Nl1 ~ It I J
ACKNOWLEDGMENT EXECUTED BY PRIMARY AGENT
AN AGENT SHALL HAVE NO AUTHORITY TO ACT AS AGENT
UNDER THIS POWER OF ATTORNEY UNLESS THE AGENT HAS
FIRST EXECUTED AND AFFIXED THIS ACKNOWLEDGMENT
TO THE POWER OF ATTORNEY DOCUMENT:
I, ANNA M. MESSIMER, 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:
1. I shall exercise the powers for the benefit of the principal;
2. I shall keep the assets of the principal separate from my assets;
3. I shall exercise reasonable caution and prudence; and,
4. I shall keep a full and accurate record of all actions, receipts and
disbursements on behalf of the principal.
~~ ~~~~~
A M. MESSIMER, Agent Date
10
. r . _ ~.i ~.~._...,~ .. ...... ... ,. .
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 10
~ ~ 11 0. l u Ii L41W ubY 1 n ~ ~
ACKNOWLEDGMENT EXECUTED SY SUCCESSOR AGENT
A SUCCESSOR AGENT SHALL HAVE NO AUTHORITY TO ACT
AS AGENT UNDER THIS POWER OF ATTORNEY UNLESS THE
SUCCESSOR AGENT HAS FIRST EXECUTED AND AFFIXED
THIS ACKNOWLEDGMENT TO THE POWER OF ATTORNEY
DOCUMENT:
I, RONALD E. TRAVER, 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:
1. I shall each exercise the powers for the benefit of the principal;
2.. I shall each keep the assets of the principal separate from our assets;
3. I shall each exercise reasonable caution and prudence; and,
4. I shall each keep a full and accurate record of all actions, receipts and
disbursements on behalf of the principal.
RONALD E. TRAVER,
Successor Agent
11
.. ~,~.Tf.. _~... ...r , .~ ..
05/12/2008 4:07:15 PM YORK COUNTY
Date
Inst.# 2008012185 -Page 11
i . li I I ~ I L LLl ~.Alu , di i
YORK COITNTY RECORDER OF DEEDS
28 EAST MARKET STREET
YORK, PA 17401
Randi L. Reisinger -Recorder
Gloria A. Fleming -Deputy
Instrument Number - 2008012185
Recorded On 2/28/2008 At 10:34:02 AM
* Instrument Type - POWER OF ATTORNEY
Invoice Number - 752400
* Grantor - TRAVER, LOIS J
* Grantee - MES5IMER, ANNA M
User - BKB
* Customer - GATES HALBRUNER & HATCH P C
* FEES
STATE WRIT TAX $0.50
RECORDING FEE5 $27.00
COUNTY ARCHIVES FEE $2.00
ROD ARCHIVES FEE $3.00
TOTAL PAID $32.50
Book - 1950 Starting Page - 2094
* Total Pages - I2
* Received By: MAIL
i Certify This Document To Be
Recorded In York County, Pe.
F~
~'oou~
THIS IS A CERTIFICATION PAGE
PLEASE DO NOT DETACH
THIS PAGE IS NOW PART OF THIS LEGAL DOCUMENT
-Information denoted by an asterisk may change during the verification process and rosy not be reflected on this page.
Book: 1950 Page: 2105
.. , _
, ,, , .. i.~.rl....,,,,.
05/12/2008 4:07:15 PM YORK COUNTY Inst.# 2008012185 -Page 12
EXHIBIT "E"
w
09/11/2007 10:11 7177372189
^ ASSISTANCE
CMECK
~ MEDICAL
ASSISTANCE
^ FOOO
STAMPS
NOTICE 'TO APPLICANT
7177372189
MANORCARE,CAMPHILL
CUMBERLANb CAO
33 WESTMINSTER DRIVE
PO BOX 599
CARLISLE, PA 17013-0599
P. 002
PAGE 02
Attar the fir4t cheek which may be a special amount you wilt recoivo 3
fJ Twice a Month ^ Once a Month ^ In the Mail Ll At the FSank
~ n You have a patient pay liability of S
- for the period beginning ___~ and ending ^ Fttective Date
You wqr receive $ for the month(s) pf then you will receive foo0 sta _
a month from to ~ ^ In the Mail p At the Bank reps in the amora,t of 3
,/ Level of care authorized you are expet~d to pay $ ~ a monh toward
__-_ your rare.
RobaA
NAME
NAME
-- - - I m,a4 la) I „~a,~~ ..~ 042 Opt D
You have boon determined ineligible for Medicaid inducting services In a Long Terrn Care Facility. You were asked to provide verification of certain
it'lfotmation in order that eftglbitlry could !>e determined. as Of 08/2at20o7 We have not received any of the requested verification. A copy Orthe orlglna!
pending Nst is alt2ched. As a reminde•, you must be ab-e tv verify where ali excess resources have been spent as of your last verlFlcation.
Number of Pereone
TOTAL GROSS MONTHLY INCOME
t3ROSS MONTHLY [7EPENDENT C/~RE COSTS
GROSS MEDICat_ crsra
EleGric GAtNago/Treah
Gse tJUtlty Installation
Oil Other
.GROSS UTILITY COSTS/UTIUTY 3"ANDARO" $
-.._
RENTlMORTGAGE ~ $
TAXES $
INSURANCE C03T ON HOME $
TOTAL. SHELTER COST m
CO RECORD NUM6ER (,q~' CTR per, 01ST
21 0112071 LTt; 00
(-
Robert Traver ~,
clo Manor Care Camp Elill
1700 Market Street
Camp Hill PA 17011
GROSS MONTHLY INCOME
MONTHLY DEPENDENT C~
NtYrlbtlr Ot PerSOnS
Ot Arsons
Name
TOTAL t3ROSS MONTHLY INL
NET MONTHLY INCOME/NET
INCOME LIMIT
L ~
J
M you do not understand our derision a'ryave any y„~~r,s ~~~ ~i INO/lR3r.
~CUEN7' ^ ~1f'pEAL COPY
c~nrtk $
SEMI-ANNUAL INCOME $
~ ~~ 08/24/07 717-240-2707
3r8nature Oate Telephone Number
LEGAL Ht3LP IS AVFrfLAeLE AT
LEGAL SERVICES INC.
8 IRVINE ROW
CARLISLE, PA 17013-0000
(717) 243-9400
^ CASE RECORC) COPY Pates ts2 troy
.. ~.
ExxisTT "F"
NOTICE TO APPLICANT
YOUR REGENT APPLICATION HAS BEEN REVIEWED AND YOUR ELIGIBILITY
HASsBEEN DETERMINED FOR THE BENEFITS SHOWN BELOW
!~1 -_ .
CUMBERLAND CAO
33 WESTMINSTER DRIVE
PO BOX 599
CARLISLE, PA 17013-0599
^ ASSISTANCE After the first check which may be a special amount you will receive $
CHECK ^ Twice a Month ^ Once a Month ^ In the Mail ^ At the Bank
^/ MEDICAL / ^ You have a patient pay liability of $
ASSISTANCE for the period beginning and ending ^ Effective Date
^ FOOD You will receive $ for the month(s) of then you will receive food stamps in the amount of $
STAMPS a month from to ^ In the Mail ^ At the Bank
~ NURSaNG HOR4E CAPE / Level of care authorized you are expected to pay $ a month toward your care.
~O 'IAL TH R
^ SERVICES ^ ec
THE FOLLOWING PERSONS ARE INCLUDED
NO. NAP~tE CHECK STAMPS ASST. SERVICE N NAME H K STAM S A T. VI
01 Robert Traver
~ ~ ~ s ~ _ ~ RegulaGorh 78 1 Reason Code 079 Opt D
Robert Traver has been determined ineligible for Medicaid including services in a Long Term Care facility due to excess resources. As of 06/01!07 requested
effective date, the total countable resources incuding Mr. Traver's half of the farm owned jointly with his spouse on that date were: $576,676.41. The limit for
Mr. Traver, based on his income is $8000. (NOTE: The total shown above excludes verified medical expenses paid after 06/01/2007 totalling $7,526.44)
D FOOD STAMPS Number of Persons ~ Q ASSISTANCE CHECK Number of Petsons
Name EARNED INCOME Name EARNED IN COME
$ $
$ $
$ $
Name UNEARNED INCOME Name UNEARNED I NCOME
I $ $
$ $
$ $
TOTAL GROSS MONTHLY INCOME $ TOTAL GROSS MONTHLY INCOME $
GROSS MONTHLY DEPENDENT CARE COSTS $ GROSS MONTHLY DEPENDENT CARE COSTS $
GROSS MEDICAL COSTS $
'
Telephone WaterlSewage I~ MEDICAL ASSISTANCE Number of Persons
Electric GarbagelTrash Name EARNED IN COME
Gas Utility Installation $
Gil Other $
GROSS UTILITY COSTS/UTILITY STANDARD` $ $
RENT/MORTGAGE $ Name UNEARNED~ NCOME
TAXES $ $
INSURANCE COST ON HOME $ $
TOTAL SHELTER COST $ $
TOTAL GROSS MONTHLY INCOME $
NET MONTHLY INCOME/NET SEMI-ANNUAL INCOME $
INCOME LIMIT $
CO RECORD NUMBER CAT CTRDIG DIST
21 0112071 LTC 00
i-
Shutjer/Bogar, LLC
ATTN: Brandon Williams
417 Walnut Street
4th Floor
Harrisburg PA 17101
' ~ ~ ~iV 04/10/08
Worke
1
t- ~
If you do not understand our decision or have any questions, contacf your worker.
CLIENT ^ APPEAL COPY
~,
717-240-2707
is Signature U'~ Date Telephone Number
LEGAL HELP IS AVAILABLE AT
LEGAL SERVICES INC.
8 IRVINE ROW
CARLISLE, PA 17013-0000
(717) 243-9400
^ CASE RECORD COPY PAlFS 162 ?!o~
EXHIBIT "G"
Rx Date/Time
,2008-02-19
-.._. ., I I _ I -V ~_pen„ Fnlount yoU will
~' rV,< ~ T'Nice a Molttn t,l.,r
- .~-~ I I _I 0.?cr iW~lith _ In the ~d~il _..--.
- Al the Baak
~:1ti~'CAL I i I ~ I vc~ h~'~° a pau~~t .~,.y I~ukacy of : ~- - . --..
A ;SISTAMCt; ~ / ~ for :he period to m,cin - --~
~ FOCf) I ~~9 g - .~ ?nd enrTirlg ~ CtiFCavo O.;te f
_ -~~ '/au will re.:ei~e 5_ _ 'r L'?~ ntor[n(s; o` -_.. ~ 1
:i IAi;IF$ __ - Ulen you Nill rx@iv8'OOC s;,;irOS Ir. l.'d,'~T:i~.~^f is j -~
,- a month from _ co- L.i Ir, fire Adail ~ Rt the 8snk
~ M a~:irnlG HGWE (:4FEI / L=vel of i~ve authonced _
~` ~JC'.V` "~(- I - --- you 3rr3 exFaCteC to pay $ a :n,; Yl• b~ ver,' • r. ~s
"HE FOLLOV~;ING PER°ONS ARE INCLUt)EO ^ - - 1~ -
FEB-19-2008(TUE) 11:36
16:50
PJOTICE TO APP~tCAA17
~; .. _
', ~ . • _
co ~- ~ s- :o a
.~ - •
~- ~ ! ~ ,Pr~_ L T- ~- 1 ,S'er the hrst cht:Ck whirh ~• ~ ~
UI I I_C s 7r3ver - - i . !__~-SJiQlF- ~ ~. :r_~~;.f+ „~=.( y?~_-_ .o,rF -~~:.~ ~'~---'~--
-~~ ~ T~ _
_ _ I
.--___.~ --J-- -~. ~ I •___-r....._..+.. _.-._-..t_ -_-_ __._
-. j -...~-_ ~ I I i ~ -_ .~_.-a._.._-_; -__.a-.._I ~____.
• t • : 7 ~
'125.98 (e) _ 042 Opt D
You have tin determined ineligible for Medicaid including services in a Lang Term Care raciliry_ You were rewested to provl`de t3i,~ information !n order
to show eligibility. As of G8/27l2007 we have not received any of the requested verifrcation. A copy Of the original pending list Is attachrd to this nonce.
i ~--~--•
1~ ,r.. ~~ OU,r+r
.:ROSR I!'rlrTMv, ~rcrc,r,-r~e .,...° = T._~'~"-
_U!S i~r;i'r ci~
c,c ^Aannr t,sre Clamp Hui
1700 Market Street
Camp Hill P.a 17011
r car ~1ri : SG •.!; h,/c13Y, l JUi JHas.4;n ;.>• 6 5 ~r; y ~: ~ ~~ gncn °.:„nlacr ~ -, r r. ;rY.=r
P 017
_. p' ~ 7/25 -
CUMBERI_ANC CAC
(33 WE$~NiIt~STER i~RIL'L
~ PC BOX 5?9
~ CARLISLE, PAPA 77J13-~5gg
f LEGAL SERVICES fNC.
fl 8 IRVINE ROV'J
CARUSL~, PA 17013-0000
I (717) 243-9300
EXHIBIT "I3"
Px Date/Time MRR-13-2008!THU) 13 17 717 731 9627 P 002
` 03%13/2008 13:40 717-731-9627 GATES HALBRUNER HATC PAGE 02/13
York County
Fairview Township
Parcel No.: 490000F0072B000000
270000F0063A000000
27000000720000000
270000F0067B000000
Prepaced By and Returned Tq:
Clifton R. Guise, Esquire
Gates, Halbruner & Hatch, P,C.
_ - Tali"1Vluinina Roatl; ~uii.e I60 . -
Lemoyne, Penunsylvania 17043
r1
%,
_ _~~
C~ ~,
` , ,.
~ `- •' ~ ,.
._. , , ;~
... ~~
<'~-' j~.
.~ } .~ P.,
fE:COfi(-::ii ~=,r~ .,ii.i_C~~ i1F~'lt,r
THIS DEED
MADE T~-LE this the ~ S~ day of January in the year two thousand eight (2008)
~~
HETWEEN ROBERT G. TRAVER, individually, and TOTS .I. TRAVFR,
individually, as equal tenants in common, and as .l.~usband and wife,
hereinafter called:
Grantors, /O
AND LOIS J. TRAVE~ individually, hereinafter referred to as: ~~
J
Grantee,
WITNESSETi~, that in consideration. of ONE AND NO/] 00 ($1 AO) T~ollar in hand
paid, the .receipt whereof is hereby acknowledged, the said Grantors do hereby rant and
convey to the said Grantee:
PARCEL )(
ALL THOSE THREE TRACTS of ].and, each of which is situate partially in the
Township of Wamngton, and partially in the Township of Fairview, all. in the County of
York, and Commonwealth of Pennsylvania, being more particularly bounded and
described as follows, to wit:
1
Rx Oate/Time MRR-13-2008(TNU) 13:17 717 731 9627
03/13/2008 13:40 717-731-9627 GATES HALBRUNER HATC
TRACT NO. I:
$EGINNING at stones at comer of land now or formerly of Holbert A. Myers and Clara
I3yerts and extending thence along lands now or formerly of Clara Byerts, South eighty-
scvcn and on.e-half (87'/z) degrees, .East fity-four (54) perches to stones at lands now or
formerly of Lffie Cassel; thence along lands now or formierly of Effie Cassel, South
sixty-eight and one-half (68 %2) degrees East fifty-five (55) perches to stone; thence along
same South eighty-six and one-half (86'/x) degrees East fifty and flue-tenths (50-5/10)
perches tv stone at land now or formerly of Lydia A. Leese; these along land now or
formerly of Lydia A. Lees, South twenty and one-half (20%) degrees, West one hundred
thirty-two (132) perches to dogwood at land now or formerly of 1Vlartin Laird Estate;
thence along land now or formerly of Martin Laird Estate, South seventy-seven azzd one-
half (77'/Z) degrees, West one hundred three (]03} perches to a point; thence along land
.now or formerly of Elijah Krone and Holbert A. Myers, North four (4) degrees, West one
hundred and seventy (170) perches tv stones and the place of IiEGINN.ING.
CONTAINING one huzldred seventeen {117) acres and one .hundred forty-two (1.42)
perches.
BEING more commonly ]mown as 1076 Pinetown Road, Lcwisbetry, Pennsylvania.
EXCEP'I`I1~TG NEVEI<t"I'HELESS, all the following conveyances and any other adverse
conveyances which appear of public record but are not detailed herein:
(1.} The Deed fzom Robert G. Traver anal Lois J. Traver,
husband and wife, dated Septerrlber 4, 1942, and recorded in the Office
of the Recorder of Deeds in and for York County, Pennsylvania in
Record Book 31-V, at page 361 granted and conveyed onto to John W.
Sl~af~er and Adella M. Shaffer, his wife.
(2) The Deed from Robert G. Traver acrd Lois J. Traver,
husband and wife, dated December 12, 1975 and recorded in the
Office of the Recorder of Deeds in and for York County,
Pennsylvania, in Record Book 69T, at page 1.145, granted and
conveyed unto William K. Traver and Ray E. Hykes, Administrators
of the Estate of Gilbert A. Traver, deceased.
(3) The Deed fronn Robert G. Traver and Lois J. Traver,
husband and wife, dated February 4, 1981 and recorded in the Office
of the Recorder of Deeds in and for, York County, Pennsylvania, in
Record Book 82Q, at page 708, granted and conveyed unto Ronald E.
Traver and Dorothy L_ Traver, his wife.
P 003
PAGE 03/13
2
Rx Date/Time MAR-13-2008(THU) 13:17 717 731 9627
~ 03/13/2008 13:40 717-731-9627 GATES HALBRUNER HATC
(4) The Deed from .Robert G. Traver and Lois J, Traver,
husband and wife, dated October 20, ] 992 and recorded in the Office
of the Recorder of Deeds in and for York County, Pennsylvania, i,n
Record Book 493, at page 397, granted and conveyed unto Ronald E.
Traver and Dorothy L. Traver, his wife.
(5) The Deed from Robert G. Traver and Lois J. Traver,
husband and wife, dated March 26, 1998 and recorded in the Office of
the Recorder of Deeds in and for York County, Pennsylvania, in
Record Book 1319, at page 3920, granted and conveyed unto John M.
Feambaugb and Donna L. Fearnbaugh, husband and. wife.
(6) The Decd from Robert G. Traver and Lois J. Traver,
husband and. wife, dated February S, 1999 and recorded in the pffice
of the Recorder of Deeds in and for York County, Pennsylvania, in
Record Book ] 353, at page 4328, granted and conveyed, unto Harry L.
Aitkcns and Cristen R. Aitkens, husband and. wife.
(7) The Deed from Robert G. Traver and Lois J. Traver,
husband and wife, dated June 6, 2001 and recorded in the Office of the
Recorder of Deeds in and fvr York County, Pennsylvania, in Record
Book 1441, at page 3735, granted and conveyed unto George S.
Crirtend,on, Jr_ and. Keran L. Crittendon, husband and wife.
(8) The Deed from Robert G. Traver, individually, and Lois J.
Traver, individually, as equal tenants in common, dated. Septernber 7,
2001 and recorded in the Office o.f the Recorder of Deeds in and for
York County, Pennsylvania, in Record Book 1456, at page 6219,
granted and conveyed unto Steven R. Krall and Barbara E. Krall,
husband. and wife.
(9) The Deed from Robert G. Traver, individually, and Lois J.
Traver, individually, as equal tenants in common, dated November 15,
2001. and recorded in the Office of the Recorder o.f Deeds in, and for
York County, Pennsylvania, in Record Book 1465, at page 4305,
granted and conveyed unto Larry A. Herren and Donna L. Herren,
husband and wife.
SEiNG TIDE MAJOR PORTION OF TRACT 1 OF THE SAME PRFMiSES which
Robert G. Traver and Lois J_ Traver, husband and wife, by Deed dated April 27, 2000,
and recorded in the OKce of the Recorder of Deeds in and for Fork County,
Pennsylvania, in Record Book 1397, at page 8654, granted and conveyed unto Robert G.
Traver, individually, and Lois J. Traver, ind.ividuall.y, as equal tenants in common, and
not as tenants by the entireties, grantors herein.
P OOd
PAGE 04/13
3
Rx Date/Time MPR-13-2008(THU) 13:17 717 731 9627
03/13/2008 13:40 717-731-9627 GATES HALBRUNER HATC
ALSO SE)<NG THE SAME MAJOR PORTION OF THE PREMISES which .Ray E.
Hykes and William K Traver, Adm,inastrators of the Estate of Gilbert A. Traver,
deceased, by Deed dated February 16, 1975 and recorded in the Office of the Recorder of
Deeds in and for York County Pennsylvania in Record Book 69T at page 1142, granted
and conveyed unto Robert G. Traver and Lois J. Traver, husband and wife.
TRACT NO. z:
BEGF.INNING at a marked red oak near a h.iekory, at corner of lands now oz formerly of
Anne Donovan; thence by lands now o.r fonneTly of Anne Donovan and Kate Jennings
North twenty-six (26) degees, East one hundred ten (IIO) perches to stones; thence
North seventy-three (73) degrees, West one hundred ,nine (109) perches to stones; thence
South an:e (1) degree, East eighteen and five-tenths (1.8.5) perches to a stake; thence by
lands now or formerly of William Donovan North fifty-eight (58) degrees, West forty-
nine and five-tenths (49.5) perches to stones; thence by ]ands now or formerly of William
H. Snavely North seven (7) degrees, East sixty-eight and six-tenths (68.6) perches to
stone; thence South seventy-four (74) degees, East sixty-eight and five-tenths (68.5)
perches to stones; thence by lands now or formerly of Leonard Shaffer and. Clara F3yerts
North eighty-eight (88) degrees, East one hundred eight-one and eight-tea.ihs (181.8)
perches to stones; thence by lands now or formerly of Silas Laird South nine (9) degrees,
East on.e hundred twenty (120) perches to stones; thence by lands n.ow or formerly of
Eliza Crone and Lydia Leas, South seventy-nine (79) degz'ees, West forty-one and fivc-
tcnths (41.5) perches to stones; thence South (9) degrees East fifty-two (52) perches to
stones; thence by lands now or formerly of Margaret Sutton and John Grove South
seventy (70) degrees, West thirty-three and five-tenths (33.5) perches to stones; thence
South eighteen and one-half (18'/2) degrees, West forty (40) perches to white oak; thence
by lands now .or formerly of ~4nne Donovan North eight-two {82) degrees, West ninety-
eigl~,t {98) perches to the place of BEGINNING.
CONTA)<NING two hundred twenty-seven (227) acres and eighty-four (84) perches,
neat measure.
BEING more conmonly known as l Ol4 Pinetown Road, Lewisberry, Pennsylvania.
EXCEPT>rNG NEVERTHELESS, all the following conveyances anal any other adverse
conveyances which appear ofpublic record but are not detailed herein:
(1) The Deed from Robert G. Traver and Lois 1. Traver,
husband anal wife, dated February 4, 1.981 and recorded in the Office
of the Recorrder of Deeds in and :for York County, Pennsylvania, in
Record. Book 82S, at page 164, granted and conveyed unto john C_
Stremnael and lVlary J. Strernmel, husband and wife.
P 005
PAGE 05/13
4
Rx Date/Time MAR-13-2008(THU) 13:17 717 731 9627
03%13/2008 13:40 717-731-9627 GATES HALBRUNER HATC
(2} The Deed from Robert G- Traver and Lois J. Traver,
husband and wife, dated December. 3, 1987 end recorded in the Office
of the Recorder of Deeds in and for York County, Pennsylvania, i.n,
Record Book 97U, at page 193, gamed and conveyed unto James B.
Leonard, Jr. and Valerie R..Leonard, his wife.
(3) The Deed from Robert G. Traver and Lois J. Traver,
husband and wife, dated June 29, 1990 and recorded in the Office o.f
the Recorder of Deeds in and for York County, Pennsylvania, in
Record Book 106U, at page 721, granted and conveyed unto Harry hl.
Fox, .Tr. and Ann G. Fox, husband and wife.
(4) The Deed from Robert G. Traver anal Lois J. Traver,
husband and wife, dated February 22, 1994 and recorded in the Office
of the Recorder of Decd,s in and for York County, Pennsylvania, in
Record $ook 836, at page 237, granted and conveyed unto Betty J.
Ruby, unremarried widow.
(5) The Deed from Robert G. Traver and .Lois J. Traver,
husband and wife, dated January 21, 1999 and recorded in the Office
of the ,Recorder of Deeds in anal for York County, Pennsylvania, in
Record Book 1351, at page 4970, granted and conveyed unto Larry A
Herren and Donna L.1-iezren, husband and wife.
(6) The Deed from Robert G. Traver and Lais J. Traver,
husband and wife, dated 1~pril 27, 2000 and recorded in the office of
the Recorder of Deeds in and for York County, Pennsylvania, i.n.
Record Book 1397, at page 1951, granted and conveyed unto .A.nna M.
Traver, single person.
(~ The Deed from Robert G. Traver and Lois J. Traver,
husband and wife, dated. February 2, 2001 and recorded in the Office
of the :Recorder of T7eeds in and for York County, Pennsylvania, in
Record Book 1424, at page 6326, granted and conveyed unto Ronald
E. Eppley and Nikki L. Eppley, husband anal wife.
(8) The Deed from Robert G. Traver, individually, and Lois J.
Traver, individually, as equal tenants in common, dated July 11, 2003
and recorded in the Office of The Recorder of Deeds in and for York
County, Pennsylvania, in Record Book 1590, at page 5180, granted
and conveyed unto Gregory A. Reigle and Judy A. Reigle, husband
and wife.
P 006
PAGE 06/13
5
Rx Oate/Time MRR-13-2008(THU) 13 17 717 731 9627
03/13/2008 13:40 717-731-9627 GATES HALBRUNER HATC
(9) The Deed from Robert G. Traver and Lois J. Traver,
husband and wife, dated September 22, 2006 and recorded in the
Office of the Recorder ot'Deed in and for York County, Pennsylvania,
in Record Book 1843, at page 6286, gamed and conveyed uxito Roger
I.. Hughes and Talirija L. Hughes, husband and wife.
IBE.iNG TIkJE MAJOR PORTION OF TRACT 2 OF TH.E SAME )PREMISES which
Robert G. Traver and .Lois J. Traver, husband and wife, by .Deed dated April 27, 2000,
and recorded in the Office of the Recorder of Deeds in. and for York County,
.Pennsylvania, in Record Book 1397, at page 8656, granted and conveyed unto Robert G.
Traver, individually, and Lois 7. Traver, individually, as equal tenants in common, and
not as tenants by the entireties, gantors herein.
TRACT N0.3:
ALL THE FOLLOWING tract of meadow J.and, located partly in Fairview Township
and partly in Warrington Township, York County, Pennsylvania, adjoining other lands
now or formerly of Mary Partliemer, anal other lands now or formerly of Gilbert A
Traver.
CONTAINING six (6) acres and sixty (60) perches, neat measure, (more or less).
,BE)<NG vacant land on 1?inetown Road, Lewisbenry, Pennsylvania.
BEING TRACT 3 OF THE SAME PREMISES which Robert G. Traver and Lois J.
Traver, husband and wife, by Deed dated April 27, 2000, and recorded in. tlae Office of
the Recorder of Deeds in and for York County, Petln..eylvania, in Record Book 1397, at
page 8656, granted and conveyed unto Robert G. Traver, irrdividuaily, and Lois J. Traver,
individually, as equal tenants in common, and not as tenants by tb.e entireties, grantors
herein.
PARCEL 1<I
ALL TDAT FOLLOWING tract of .meadowland situate partly in the Township of
lrairview, and partly in the TownsMp of Warrington, all in the County of York and
Commonruealth of Penrisylvan.ia, being more particularly bounded and described as
follows, to wit:
ADJOINING property formerly of Frank Miller, now or formerly of Haines; formerly of
David. Boyer, now or formerly of G.A. Traver; and now or formerly of Mary Parthemer;
and other lands now or formerly of Gilbert A. Traver.
CONTAINING a total of l 1 '/< acres, more or less.
BEING vacant land on Pinetown Road, Lewisbcrry, Pennsylvania.
P 007
PAGE 07/13
6
Rx Date/Time MRR-13-2008(THU) 13:17 717 731 9627
03/13/2008 13:40 717-731-9627 GATES HALBRUNER HATC
BEING THE SAME PREMISES which Robert G. Traver and Lois J. Traver, husband
and wife, by Deed dated October 23, 1989, and recorded zn the Office of the Recorder of
Deeds in and for York County, Pennsylvania, in Record Book 104J, at page 714, granted
grad conveyed unto ,Robert G. 'Traver and Lois J. Traver, husband and wife
herein. This Parcel includes a portion of the lands conveyed an this Deed as p~ elrI
Tract 3.
PARCEL III
AL>(, TI3AT CERTA,T.N tract of land situate in the Township of Fairview, County of
York and Commonwealth of Pennsylvania, being more particularly bounded and
described as .follows, to wit:
BEGINNING at a steel pin which is set on the line which extends along the wecterrunost
property line of lands of the Grantors herein, at its joinder with lands of the Grantees
hcse~in, said pin being located on.e hundred ,fii#fiy-two and forty-four ,hundredths feet
(152.44') from a nail set in the centerline of Pinetown Road; thence continuuing along the
westerrnrnost boundary of lands of the Crrantors herein, and along other .lands of the
Grantees herein, North zero degrees eight minutes forty seconds East (N 00° 8' 40" E),
for a distance of ninety-,five and seventy-two hundredths feet (95.72') to a steel pin;
thence continuing along lands of the Grantees, South ei
minutes fily seconds East (S 84° 42' S0" F), for a distance of threeohundr~ forty~s.i~c and
fifty hundredths feet (346.50') to a steel pin.; thence extending along lands of the Grantors
herein, Soudr sev~ty-nine degrees thirty one minutes fifty-two seconds West (g 79~ 31'
52" W), for a distance of three hundred fifty-one and eleven hundredths feet (351.11'), to
a steel pin at Ian.ds of the Grantees herein, said. pin ~x~Iarking the place of BEGINNING_
CONTA>rNING 0.379 Actes, and being designated as Parcel No. 2 on a final plan of
subdivision prepared far John C. Strcmmel and Mary J, Strc~nmel, by Donald 1r. Worley,
Register Surveyor, dated May 6, 1977, revised June 26, 1978, and recorded in the pffice
of the Recorder of Deeds in and for York County, Pennsylvania in .Plan Book AA, at
page 404.
BEING known. as Traver ,Drive, Lewisbezry, Pennsylvania.
BE>(1VG THE SAME PREM)<SES which John C_ Strcmmel and Mary J_ Strernrnel,
husband and wife, by Deed dated February 4, 1981, and recorded in the Office of the
Recorder of Deeds in and for York County, Pennsylvania, in Record $ook 82Q, at page
713, granted and conveyed unto Robert G. Traver and .Lois J. Traver, husband and wife,
grantors herein.
Robert G. Traver. one of the Grantors herein, by this reed hereby quitclaims and releases
any and all other rights which he may .have to any and. al] other real estate not set forth
above which he may own that is situated in York County as of the date of this Deed and
further Robert G. Traver further releases any marital interest which he may have in any
grad all real estate which Lois J. Traver, his wife, possesses an interest.
P. 008
PAGE 08/13
Rx Oate/Time MRR-13-2008(THU) 13: i7 717 731 9627
'` 03/13/2008 13:40 717-731-9627 GATES HALBRUNER HATC
THIS TRANSACTION IS EXEMPT FROM REALTX TRANSFER TA,7~
BECAUSE )(T CONSTITUTES A CONVEYANCE FROM HUSBANA AND WIFE
TO Wi)F'E AND IS THEREFORE EXEMPT FRO1V.[ REALTX TRANSFER TAX.
SUBJECT, )EitOWEVER, io such recorded easements, restrictions and conditions that
may apply to the afore-described tracts of. )and.
UNDER AND SUBJECT to any coning ordinances and any encroachments, rights-of
way, easements or other prescriptive uses as may be revealed by a physical inspection of
the premises.
TOGETHER with all an,d singular buildings and improvennents, ways, waters, water-
courses, rights, liberties, privileges, hereditaments and appurtenances and whatsoever
tk~ereunto belonging or in anywise appertaining, and the reversions and remainders, rents,
issues, and profits thereof; and all the estate, right, title, interest, property, claim and
demand whatsoever of the said parties of the first part, in. Iaw, equity or othezwise,
howsoever, in and to tb.e same and every part thereof.
TO HAVE AND TO HOLD the said lots or pieces of ground above described, with the
messuage or tenement thereon erected, hei-editatnents and premises hereby granted, or
mentioned and intended so to be, with the appurtenances, unto the said Grantees, their
heirs and assigns, to and for the only proper use and behoof of the said Grantees, their
heirs and assigns, .forever.
AND Grantors, for themselves, their successors andlor Assigns, do h.ercby covemant,
pronuse, grant and agree, to and with, the Crrantees, Choir heirs and assigns, by these
presents, that Grantors, and their successors andlor assigns, the said above-mentioned and
described m.essuages and tracts of land, hereditaments and appurtenances, hereby granted
or mentioned, or intended so to be, unto Grantees, their hens and assigns, against
Grantors, and their successors and/or assigns, agaiixst all and every other person anal
persons whomsoever, lawfully claiming or to claim the carne or any part thereof, by,
fro~x~, or under him/her, them, or any of them, SHALL AND WILL
SPECIALLYWARR.ANT ANA FOR EVER )DEFEND BY THESE >PRESEIVTS.
P. 009
PAGE 09/13
8
Rx Date/Time MRR-13-2008(THU) 13:17 717 731 9627
03'/13/2008 13:40 717-731-9627 P 010
GATES HALBRUNER HATC PAGE 10/13
IN WITNESS WHEREOF, the said Granxors have to these Presents set their
hand acrd seal. Dated the day and year first above written.
'VVITNFSS:
f~'"_
~ ~ .~
~i~
COMMONWEALTH OF PENNSYT,,VA,NIA
COUNTY OF _~~_
/ . ~.^~
OBER'I" G. TRgV R .~ Tom-'
By his attorney in fact
Anna .1~. Messimer
. +`~a A
I~OIS J. TR,rA,VER
By her attor»ey in fact
Anna M. Messimer
SS.
On this, the o~ j~" day of January, 2008, before me, a Notary .Public, the
undersigned officer, personally appeared ROBER~• G. TRAV~R, by his Attorney in
Fact, Anna M. M~siiaaer and LOIS .I. TRAVER, ~y her Attorney in Fart, A.>~liua. M.
Messimler, whose name is subscribed to the within peed and that s.he executed the same
for the purposes therein contained.
iN WITNESS WI-II:IZEOF, I hereunto set m}~ hand and. official Seal.
~~ ~_
/ ~
Notary Public
My Commission Expires:
COMMONWEALTii GF PENNSYLVANIA
Notarial Seal
Traci 1.. Shor;dan, Notary public
Lemoyne Born, (:'umberiand County
My COfimission Expires peC,15, 2009
Memhr..r. Ppnne~4~-y:~:, As6ncig;ipn of N
Oldrie5
9
~ Rx Qate/Time MRR-13-2008(THU) 13:17 717 731 9627
03/13/2008 13:40 717-731-9627 P 011
GATES HALBRUNER HATC PAGE 11/13
C~~TXI~'ZCATE OF RESIDENCE
I hereby ce.rli~Fy that the present residence
of the Grantees herein is as follows:
Lois J. Traver
c/o Anna M. Messinger
1095 Pinetown Road
Lewisberry, PA 17339
orncy for Grantee
10
r
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on this date, a true and correct copy of the
foregoing Petition for Removal of the Agents and Appointment of Trustee to Sell Real
Property was served via first-class United States mail, postage prepaid upon the
following:
Lowell R. Gates, Esquire
GATES, HALBRUNER 8z HATCH, P.C.
1013 Mumma Road, Suite 100
Lemoyne, PA 17043
(Attorney for Anna Messimer)
Date:
J
Y~
Chrisf~Long, Paralegal