HomeMy WebLinkAbout08-6012
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants.
No.
CIVIL ACTION - EQUITY
NOTICE TO DEFEND
Pursuant to PA RCP No. 1018.1
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth
in the following pages, you must take action within twenty (20) days after this complaint and
notice are served, by entering a written appearance personally or by attorney and filing in writing
with the court your defenses or objections to the claims set forth against you. You are warned
that if you fail to do so the case may proceed without you and a judgment may be entered against
you by the court without further notice for any money claimed in the complaint or for any other
claim or relief requested by the plaintiff. You may lose money or property or other rights
important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW.
THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE
TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER
LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telephone: (717) 249-3166
(800) 990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. No.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants. CIVIL ACTION - EQUITY
AVISO PARA DEFENDER
Conforme a PA RCP Nfun. 1018.1
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las
demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de
los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando
personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por
escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le
advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede
proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier
otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la
Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos
importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA
SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA
DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES
POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE
AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A
PERSONAS QUE CUALIFICAN.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telefono: (717) 249-3166
(800) 990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. No.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants. CIVIL ACTION - EQUITY
COMPLAINT
AND NOW COMES, Plaintiff, Church of God Home, Inc. ("Plaintiff'), by and through
its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant, Charles
Dinklocker ("Defendant Charles Dinklocker") and Defendant, Raymond Dinklocker ("Defendant
Raymond Dinklocker") (collectively referred-to as "Defendants"), and in support thereof,
provides as follows:
Plaintiff is a Pennsylvania corporation with its principal offices located at 801
North Hanover Street, Carlisle, Pennsylvania 17013.
2. Defendant Raymond Dinklocker is an adult individual who resides at 801 North
Hanover Street, Carlisle, Pennsylvania 17013.
3. Defendant Charles Dinklocker is an adult individual who resides at 50 Mountain
Road, Shermans Dale, Pennsylvania 17090.
4. On or about August 1, 2007, Defendant Raymond Dinklocker, by and through his
attorney-in-fact, Defendant Charles Dinklocker, and Defendant Charles Dinklocker, as
Responsible Party for Defendant Raymond Dinklocker, jointly made application for the
admission of Defendant Raymond Dinklocker to Plaintiff's skilled nursing facility located at 801
North Hanover Street, Carlisle, Pennsylvania 17013.
5. On or about August 7, 2007, Plaintiff, together with Defendant Raymond
Dinklocker, by and through his attorney-in-fact, Defendant Charles Dinklocker, and Defendant
Charles Dinklocker, as Responsible Party for Defendant Raymond Dinklocker, entered into a
written Admission and Care Agreement ("Agreement"). A true and correct copy of the
Agreement is attached hereto as Exhibit "A."
6. Pursuant to the Agreement, Plaintiff agreed to provide Defendant Raymond
Dinklocker with skilled nursing services in exchange for his promise to pay specific monetary
charges for the services that Plaintiff provided to him; and, in the event that he were to receive
Medical Assistance benefits, "to turn over to the Facility any payments received from third
parties to the extent necessary to satisfy the charges under this Agreement." See Exhibit "A."
7. Also pursuant to the Agreement, in exchange for Plaintiff's agreement to provide
skilled nursing services to Defendant Raymond Dinklocker, Defendant Charles Dinklocker, as
Responsible Party for Defendant Raymond Dinklocker, agreed to be "responsible to pay all fees
and costs" for the services that Plaintiff provided to Defendant Raymond Dinklocker "from
Resident's [i. e., from Defendant Raymond Dinklocker's] resources." See Exhibit "A."
8. After Defendant Raymond Dinklocker's admission to Plaintiff's skilled nursing
facility, he allegedly became insolvent. As a result, pursuant to the Agreement, Defendant
Raymond Dinklocker, by and through his attorney-in-fact, Defendant Charles Dinklocker, made
application for Medical Assistance benefits and qualified for same on September 1, 2007.
9. As a condition of Defendant Raymond Dinklocker's receipt of Medical
Assistance benefits according to Medicaid regulations, see 55 Pa. Code § 181.452(e), and as
determined by the Cumberland County Assistance Office ("CAO"), Plaintiff is entitled to receive
2
$1,534.11 from Defendant Raymond Dinklocker's monthly income, which is comprised of
Social Security benefits and a pension. A copy of the most recent notices issued by the CAO
regarding payment of monthly income is attached hereto as Exhibit "B."
10. Further, pursuant to the Agreement, Defendant Raymond Dinklocker is required
to pay Plaintiff from his financial resources for the skilled nursing services provided by Plaintiff.
11. Upon information and belief, Defendant Raymond Dinklocker continues to
receive his monthly Social Security and pension income.
12. Defendant Raymond Dinklocker has failed to turn over his monthly income to
Plaintiff as required by the terms of the Agreement and by Medicaid regulations as a condition of
his receipt of Medical Assistance benefits.
13. Defendant Charles Dinklocker likewise has failed to turn over Defendant
Raymond Dinklocker's monthly income to Plaintiff as required by the terms of the Agreement
and by Medicaid regulations as a condition of Defendant Raymond Dinklocker's receipt of
Medical Assistance benefits.
14. Upon information and belief, Defendant Raymond Dinklocker's monthly income
has been going to his son, Defendant Charles Dinklocker, who has been using said income for
his personal enjoyment.
COUNTI
Plaintiffv. Defendant Raymond Dinklocker
Breach of Contract -- Specific Performance
15. Paragraphs 1 through 14 are hereby incorporated by reference as if fully set forth.
16. Plaintiff has provided skilled nursing care and services to Defendant Raymond
Dinklocker in accordance with the Agreement.
3
17. Defendant Raymond Dinklocker breached the Agreement with Plaintiff when he
refused to turn over to Plaintiff his monthly income, and Defendant Raymond Dinklocker
continues to breach the Agreement with Plaintiff by refusing to turn over to Plaintiff his monthly
income pursuant to the grant of Medical Assistance benefits
18. Defendant Raymond Dinklocker's breach of the Agreement with Plaintiff has
irreparably harmed, and continues to irreparably harm Plaintiff.
19. Defendant Raymond Dinklocker's breach of the Agreement with Plaintiff may
also irreparably harm himself, as his failure to turn over his monthly income to Plaintiff may
result in the discontinuance of his Medical Assistance benefits.
20. Accordingly, only a decree of specific performance will adequately protect the
interests of Plaintiff and provide it with the benefits and/or protections promised under the
Agreement.
WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific
performance of the Agreement by Defendant Raymond Dinklocker.
COUNT II
Plaintiffv. Defendant Charles Dinklocker
Breach of Contract - Specific Performance
21. Paragraphs 1 through 20 are hereby incorporated by reference as if fully set forth.
22. Plaintiff has provided skilled nursing care and services to Defendant Raymond
Dinklocker in accordance with the Agreement.
23. Defendant Charles Dinklocker breached the Agreement with Plaintiff when he
refused to turn over to Plaintiff Defendant Raymond Dinklocker's monthly income, and
4
Defendant Charles Dinklocker continues to breach the Agreement with Plaintiff by refusing to
turn over to Plaintiff Defendant Raymond Dinklocker's monthly income pursuant to the grant of
Medical Assistance benefits.
24. Defendant Charles Dinklocker's breach of the Agreement with Plaintiff has
irreparably harmed, and continues to irreparably harm Plaintiff.
25. Defendant Charles Dinklocker's breach of the Agreement with Plaintiff may also
irreparably harm Defendant Raymond Dinklocker, as the failure of Defendant Charles
Dinklocker to turn over Defendant Raymond Dinklocker's monthly income to Plaintiff may
result in the discontinuance of Medical Assistance benefits for Defendant Raymond Dinklocker.
26. Accordingly, only a decree of specific performance will adequately protect the
interests of Plaintiff and provide it with the benefits and/or protections promised under the
Agreement.
WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific
performance of the Agreement by Defendant Charles Dinklocker.
Dated: ?i
By:
Respectfully submitted,
SCHUTJ BOGAR LLC=
Bradley A. Schutjer
Attorney I.D. No. 75954
(717) 909-5921
Steven E. Bernstein
Attorney I.D. No. 23729
(267) 386-4974
One Liberty Place
1650 Market Street, 36t' Floor
Philadelphia, PA
5
Attorneys for Plaintiff
EXHIBIT "A"
CKJRCH OF GOD HOME, INC_.
ADMISSION AND CARE AGREEMENT
TABLE OF CONTENTS
PAGE
1. PROVISION OF SERVICES .
2. RECURRING CHARGES .
3. NON-RECURRING CHARGES .
. . . .. .27
a. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES
27
5. ADMISSION _
28
6. PERIODIC BILLINGS AND PAYMENT DUE DATE
28
7. CHANGES IN CHARGES . ,
8. PARTICIPATION-IN MEDICARE/MEDICAID PROGRAMS
, 28
9. .OBLIGATIONS OF RESPONSIBLE PARTY
.29
10. READMISSION - BED/ACCOMMODATION HOLD POLICY
,. 2-9
11. REFUNDS . . . . . .
29
12. PERSONAL FINANCES . . ,
13• TERMINATION, TRANSFER OR DISCHARGE
-30
la • THIRD-P_gaTY PAYMENTS
31
15. PERSONAL PROPERTY _ '
•
32
16. RESPONSIBILITIES OF RESIDENT '
17. MISCELLANEOUS PROVISIONS '
.., .
32
CEORCH OF GOD HOME, INC.
ADMISSION AND CARE AGREEMENT
THIS AGREEMENT is made on this 7T*" day of A2&_L_)67) -A od-7by
and between The Church of God Home, Inc., called the "Facility," a
Pennsylvania non-profit corporation located at 801 North Hanover
Street, Carlisle, Cumberland County, Pennsylvania,
and called "Resident"
and #1AALf_S DzA1xjc(xaP_ called "Responsible Party".
The Resident and the Responsible Party reaffirm that the
information provided in the Pre-Admission Questionnaire is true and
correct and understand that the submission of false information may
constitute grounds to terminate this Agreement.' The Resident has
applied for admission to the Facility and the Facility has approved
the. Application for Admission. Therefore, the Facility, The
Resident and Responsible Party agree to the following terms':
1. PROVISION OF SERVICES. The Facility will provide
Resident with:
(a) Skilled nursing care, i.e. professionally supervised
nursing care and related health services under a plan
of services regularly provided under a plan of care
supervised by licensed personnel and, as required by
the Resident's.medical condition, assistance with
activities of daily living.
(b) Accommodations consistent with the level of care
provided to the Resident including heat, air
conditioning,.electricity and hot and cold water.
(c) Bed, bedding, blankets and laundered bed linens, towels
.and wash cloths.
(d) Three meals each day, except as-otherwise medically
indicated.
(e) Activity programs and social services.
2. RECURRING CHARGES. In exchange for the above services,
the Resident shall pay the following recurring charges:
(a) For skilled nursing care: $ A10, Od dollars.per day.
Admission and Care Agreement - continued
-3-. NON-RECURRING CHARGES. The Resident shall pay the
following non-recurring charges:
(a) A security deposit in the amount of thirty-one (31)
times the current daily rate for the level of care
required by the resident, will be billed after
admission day. The amount of the security deposit is
$_foSta.?,-, No interest will be paid on the security
deposit. A security deposit will not be charged to
residents who are receiving benefits for room and board
provided by Medicare, until the Medicare benefit
concludes. An applicant who is covered by Medicaid is
not required to pay a security deposit.
(b) The cost for enrollment in the community ambulance
and ALS (Advance Life Support ) Unit is $__ At This
fee must be paid prior to admission and will be billed
annually to the.-Resident.
a. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES. Resident is
responsible to pay for other services provided by the-Facility
which are not covered by the daily rate/charge . ' A list of such
services /charges, is attached to this Agreement on the "'Chart of
Costs."
The services of a licensed physician and dentist, a
registered pharmacist and licensed pharmacy for the provision of
pharmaceutical supplies, a licensed hospital, and. diagnostic
services, will be made available at the Resident's expense.
THE RESIDENT HAS THE RIGHT TO SELECT HIS/HER OWN PHYSICIAN OR ANY
OTHER SERVICE PROVIDER SO LONG AS THE PHYSICIAN OR OTHER SERVICE
PROVIDER IS PROPERLY LICENSED OR REGISTERED'UNDER THE LAW, AND THAT
ALL APPLICABLE GOVERNMENT RULES AND POLICIES OF THE-FACILITY ARE
MET.
In addition to the Facility's charges, the Resident is
responsible to pay 'all fees and costs -for goods or services
furnished to or for the Resident by anyone other than the Facility
under this Agreement. The responsibility of the Resident to pay
applies to all fees for costs of services provided for the Resident
by any physician, dentist, optometrist,'. therapist, diagnostic or
testing* laboratory; pharmacist, pharmacy, hospital, or any other
person,* facility or entity providing services or goods to or for
the Resident, and for all drugs, medicines, medications,
pharmaceutical supplies, corrective eye lenses, hearing aids,
dentures, hair care, and other personal items or services for the
Resident. SUCH FEES AIM COSTS ARE NOT INCLUDED IN THE HOME' S DAILY
RATE/CHARGE.
Admission and Care Agreement - continued
5. ALDMISSION. The Resident will be admitted, or a bed will
be reserved for Resident, beginning on r-7-o?
P_11 pre-admission charges will be billed after admission, and
recurring charges will begin to accrue as of the above -date.
The Resident may reserve an available bed by paying the
daily rate for the bed reserved. The daily rate for the reserved
bed will continue to accrue and be payable until the reservation is
terminated, even if the Resident does not enter the Home for
whatever reason, including illness, injury, incapacity or death.
6. PERIODIC BILLINGS AND PAYMENT DUE DATE..
(a) on the first of.each month, Resident will be billed the
current daily rate for Resident's current level of care
times the number of days in the month: The bill is due
and payable upon receipt.
(b) Miscellaneous charges (refer to "Chart of Costs"
attached to this Agreement) such as hair care, personal
laundry, incontinency, supplies, etc., are additional
charges above the daily rate. These miscellaneous
charges 'will be added to, .and included with,. your
monthly bill. ;-
(c) Pharmacy charges will be billed as a separate part
of the Facility's monthly bill, and will require
a separate check..
(d) Outside providers.will bill directly and separately.'
7. CHANGES IN CHARGES. From time to time,the Facility may
change the amount of its charges. In addition, from time to time,
the Facility may change how and when its charges are -computed,
billed or become due. The Facility reserves the right to make any
such changes at any time." Written notice of any such changes will
be given to the - Resident thirty (30) days in advance of
implementation, unless, the- change is required earlier under any
federal or state law or assistance program.
•8. PARTICIPATION IN "MEDICARE/MEDICAID" PROGRAMS. The
Facility participates in the Medicare program administered pursuant
to Title XVIII of the Federal Social Security Act and the
Pennsylvania Medical Assistance Program ("Medicaid") administered
pursuant to the Pennsylvania state plan and Title XIX of the
Federal Social Security. Act. However, the Facility reserves the
right to withdraw from the Medicare/Medicaid-programs at anytime
in accordance with the law.
Admission and Care Agreement - continued
-9% OBLIGATIONS OF RESPONSIBLE PARTY. The Responsible Party
is responsible for services and supplies that are billed through
the Facility or billed directly to the Resident or Responsible
party by any other provider. The Responsible Party is responsible'
to pay all fees and costs from Resident's resources.
10. READMISSION - BED HOLD POLICY. If the Resident leaves
the Facility for a period of hospitalization, therapeutic leave, or
any other reason, other than the Resident's death, and if the
Resident is not eligible for, or receiving medical assistance, the
Resident's bed will be reserved and charges for the reserved bed
will continue to accrue, unless the Resident or Responsible Party
-otherwise directs in writing. If the Resident or Responsible Party
elects not to reserve a bed, then the Resident will be eligible for
readmission upon the availability of the first bed suitable for the
Resident's level of care.'
If the Resident Is receiving medical assistance benefits
and - the Resident • leaves , the Facility for • a period of
hospitalization or therapeutic leave, the Resident's bed will be
reserved for the applicable maximum number of days paid for the
reserved bed under the Pennsylvania Medical Assistance- Program.
The current =bed reservation period is fifteen (15) days for
hospitalization, regardless of level of care, fifteen (15) days for
therapeutic leave for residents receiving skilled nursing care,.. and
thirty (.30) days for therapeutic leave for residents receiving
intermediate care. The bed reservation period may be subject to
change in'accordance with any changes in the-Medical Assistance
Program. If the period of hospitalization or therapeutic leave
ends within 'the reservation period under the Medical Assistance
Program, the Resident may return to the Facility. If the period of
hospitalization or therapeutic leave exceeds the maximum time for
reservation of a bed under the Pennsylvania. Medical Assistance
program', the Resident- must wait until a suitable bed becomes
available for readmission. The Resident is entitled to the first
available bed suitable for the Resident's level of care if, at the
time of readmission, .the Resident. requires the services provided by
the Horne.
11. REFUNDS. The security deposit for private pay residents,
after deductions for the payment of any outstanding bills owed to
the Facility, will be refunded within thirty (30) days after the
Resident' s. discharge from the Facility or death. Those Nursing
Residents on medical Assistance will receive their refund, if any
due,' within ninety (90) days. There will.be no other refunds, in
the absence of an overpayment, under this Agreement..
12.. PERSONAL FINANCES. The Resident has the right to manage
his/her personal funds. The Resident is and will be responsible to
provide his/her- personal funds. If the Resident elects, the
Resident may designate, in writing, that 'the Facility hold and
manage the Resident's personal funds.. If the 'Resident
Admission and Care Agreement - continued
designates someone other than the Facility to manage his/her
personal funds, the Resident or Responsible Party shall notify the
Facility promptly.. The Resident is not required to make any
designation, and 'is responsible for his/her own personal funds
unless such designation is made.
The Resident may revoke, at any time, the designation of
the Facility as the manager of his/her personal funds by providing
the Facility a written notice signed and dated by the Resident or
Responsible Party.
. If the Resident transfers to the Home, responsibility to
-manage the Resident's personal funds, the Facility will do so in
accordance with the "Rights of Nursing Facility Residents", a copy
of which 'is. provided at the time of your admission, and the
Facility's personal funds management policy. The Facility may
deduct, at any time, charges due to the Facility under this
agreement from. the Resident's personal funds managed by the
Facility. "
13. TERMINATION. TRANSFER OR.DISCHARGE.
(a) By the Resident: The- Resident may terminate this
Agreement upon thirty (30) days written notice to the
Facility. If the Resident leaves the -Facility for any
reason other than a medical emergency or his/her death,
the Resident must -give -written notice to the Facility
at -least thirty (30)* days in advance of the departure/
transfer/discharge or termination of the Agreement.
If advance written notice is not given to the Facility,
there will be due to the Facility its daily and other
charges then in effect for the Resident's current level
of care for the required thirty (30) day notice period.
The charge applies whether or not the Resident remains
at the"Facility during the thirty. (30) day period.
(b) By the Facility_ The Facility may terminate the
Resident's stay and transfer or discharge the Resident
if:
(I) the transfer or discharge is necessary.to
meet the Resident's welfare which cannot
be.met by the Facility;
(II) the Resident's health or condition has
improved sufficiently that'the Resident
no longer needs the services.provided by
the Facility;
(III) the safety or health'of individuals in the
Facility is or otherwise would be endangered.;
Admission and Care Agreement- continued
IV. The charges or other amounts due to the Facility under this Agreement
have not been paid to the Facility or treated as paid to the Facility on the
Resident's behalf by Medical Assistance under the Medical Assistance
Program or by Federal Medicare benefits under Title XVIII of the Federal
Social Security Act; or
V. The Facility ceases to operate.
Tile Facility generally will notify the Resident and Responsible Party or if none. a family
member or legal representative of the Resident, if known to the Facility, at least thirty
(30) days in advance of such a transfer or discharge. However. in any case. describe in
subparagraph (I). (I1) and (III) above, or if the Resident has not resided at the Facility for
at least thirty (30) days. the Facility will give such notice before transfer or discharge as
is practicable under the circumstances.
14. THIRD PARTY PAYMENTS- The Resident may be or may become eligible
to receive financial assistance, reimbursement or other benefits from third-
parties, such as through private insurance, employee benefit plans. Medical
assistance under the Pennsylvania Medical Assistance Program, Medicare
benefits. supplementary medical or other health insurance, supplemental security
income insurance. or old-age survivors' or disability insurance under or pursuant
to the Federal Social Security Act or Program. If the Resident becomes eligible to
receive payments from any third-parties for the stay and care of the Resident, the
Resident/Responsible Party shall, at all times, cooperate fully with the Facility
and each third-party payments. Cooperation includes, when requested, providing
information, signing and delivering documents, and having the Facility
designated by the Social Security Administration as the Resident's representative
payee for receipt of Federal Social Security benefits or any other governmental
assistance, reimbursement or benefits to the extent of all charges due the Facility.
The Resident irrevocably authorizes the Facility to make claims and to take such
other actions as maybe necessary for the Facility's receipt of third-party
payments. To the fullest extent permitted by law. the Resident hereby assigns
now or hereafter payable to the extent of all charges due to the endorse and turn
over to the Facility any payments received from third-parties to the extent
necessary to satisfy the charges under this Agreement.
Admission and Care Agreement- continued
15. PERSONAL PROPERTY- The Resident/ Responsible Party is and will be
responsible to furnish and maintain clothing, jewelry. personal possessions. and
other items of property. The facility may limit the amount or type of property that
the Resident may keep at the facility if there is insufficient space. or if medically
indicated or necessary to protect the rights or welfare of others. All non-clothing
items of value must be recorded on the resident's personal inventory located with
their medical record on the day of admission or any day thereafter. The same is
true if removing an item of value from the resident's room. You are requested to
see the charge nurse regarding resident's personal property. If nametag labels are
needed for clothing items, please leave them at the nursing station.
16. RESPONSIBILITIES OF RESIDENT- The Resident shall comply fully with
all governmental laws and regulations, the provisions of this Agreement and the
facility's existing policies, rules and regulations which may, from time to time.
be altered or amended.
17. MISCELLANEOUS PROVISIONS
a. The Resident and Responsible Party acknowledge that they are adult
individuals and have read and understand the terms of this Agreement.
b. The provisions of this Agreement shall be governed by the laws of the
Commonwealth of Pennsylvania and shall be binding upon and inure to
the benefit of each of the undersigned parties and their respective heirs,
personal representatives, successors and assigned.
c. The various provisions of this Agreement shall be severable one from
another. If any provision of this Agreement is found by competent legal
authority to be invalid, the other provisions shall remain in full force and
effect as if the invalid provision had not been part of this Agreement.
d. The Facility reserves the right to modify unilaterally the terms of this
Agreement to conform to subsequent changes in the law or regulation and
changes in charges. Resident will be provided thirty (;0) days notice of
changes in charges and, if practicable, reasonable notice of any
modifications required by law.
Kestaent/Kesponsible Party
r-7-d
Facility Repfesentative
Date
EXHIBTI'"$°
P.O. BOX 599 ELIGIBLE
33 WESTMINSTER DRIVE NOTICE
CARLISLE PA 17013-0599
CAO RETURN ADDRESS CSLD 0033
*07100000000;
CHURCH OF GOD HOME
ATTN: BILLING OFFICE
801 NORTH HANOVER STREET
CARLISLE PA 17013
PAGE 1 OF I
all ''I
21 0117171 0 PAN 4 00
WORKER: K PEARSON
TELEPHONE (717) 240-2700
MAIL DATE: 04/04/2008
NOT: 9a5 OPT: S TYPE E
iF rou oe Wr UNDERSTAND OUR DECISION OR HAVE ANY
QUESTIONS, PLEASE CONTACr YOUR NONa Ib 014TELY.
You have been determined eligible for benefits effective 09/01/2007 to 09/30/2007.
You are eligible for Non-Money Payment Medicaid coverage including Services in
a Long-Term Care Facility. A PA ACCESS card will be issued unless you have
previously received one. You will be required to make a monthly payment
towards your cost of care. A separate notice showing you the details of this
computation is enclosed- Contact the CAO if you have any questions or
changes to report. When contacting the CAD, please provide your record
number, which is located on the top and bottom of this notice.
Citation: 55 Pa. Code Sections 141.71, 178.1, i8i.1
f1
APR 0 7 2008 U
If you disagree with our decision, you have the right to appeal.
vu. ,, w -h , ono c0 a rair nearlnq. li you are
currently receiving benefits and your oral request for a hearing is received in the
County Assistance Office or your written request is postmarked or received on or
before 04/17/2008 your assistance will continue pending the hearing decision,
except when the change is due to State or Federal law.
RAYMOND G DINKLOCKER
CHURCH OF GOD HOME
80 NORTH HANOVER STREET
CARLISLE PA 17013
CA O ADDRESS
CUMBERLAND CAO
P.O. BOX 599
33 WESTMINSTER DRIVE
CARLISLE PA 17013-0599
MIDPENN LEGAL SERVICES
401-405 LOUTHER STREET
CARLISLE PA 17013
Notice ID: 82934771
N 1111;111111011a =IN
21 0117171 0 PAN 4 00
WORKER K PEARSON
APPEAL: 04/17/2009
TELEPHONE: (717) 240-2700
MAIL DATE: 04/04/2009
NOT: 985 OPT: B TYPE: E
PAMA162A CONTINUED ON REVERSE SIDE PAIMA 162 12103
• THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICEV "
LINE - FIRST'NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9
THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
7?%"I CI L?VIE ur Truss nnommy income Calculation of Contribution toward Cost of Care
812 in Date
01/01/2008
WHOM
02/01/2008
Begin Date
01/01/2008
02/01/2008
Earned Income Gross Monthly Income I&M
Wages, Salary oo .00 Total Earned Income .00 .00
Self Employment .00 .00 Total Unearned Income 1579.11 1579.11
Rental Income .00 .00 Income available first month .00 .00
Other .00 .00 Deductions
Total Earned
Income: ao 00 Personal Needs Allowance 45.00 45.00
Unearned
Income Guardianship Fee .00 .00
Social Security 1288.40 1298.40 Total Allowance for Spouse if 00
Dependant 00
SSI .00 .00 Home Maintenance .00 .00
Veteran's Benefits .00 00 Contribution towards
.
Cost of Care: 1534.11 1534.11
Pension 29x.61 290,61 The LTC facility will deduct the following medical expense from your
contribution towards Cost of Care
Railroad Benefits .00 .00 Medicare Premium .00 .00
orkmen's Comp .00 .00 Other Insurance Premium .00 .013
Black Lung .oo .oo
The LTC facility may deduct additional medical bills
Annuity/Trust including supplemental health insurance premiums,
Payment • 00 .00 provided they are verified.
Interest / Dividend
.10
.10 (1?
, U
Other (Rental, etc.)
.00
.ao
APR 0'? 200
Total Unearned
Income: 1579.11 1579.11 -??
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THE BOTTOM OF THIS FORM.
•---- DETACH HERE
DETACH HERE ---•
Please.check one of the boxes to show which type of hearing you want: F-1 I wtelehp t aone hearing. 1:1 1 want a
face-to-face hearing.
Please check If you require any necessary and reasonable accommodation because of a hearing impalrment or other disability
Please describe your disability:
? Please check if you need an interpreter What language?
NOTE If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
I WANT TO REQUEST A HEARING BECAUSE: (Attach additional pages if necessary.)
IT 51UNATIJRE ADDRESS TELEPHONE NO. DATE
"IMMI 11tr.51UrJATLIHE. ADDRESS TELEPHONE NO. . DATE
FALTC1625 aAll ri? 1912 Nine
THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
BNFT
LINE FIRST NAME ACCESSANDIVIDUAL NUMBER V PKG LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9 02
BNFT
V PKG
THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUI
MEDICAID BENEFITS.
Line Line Line Line Line Line Line Line
GROSS INCOME
Earned:
Unearned:
DEDUCTIONS
Earned Income:
Unearned Income:
Dependant Care
NET (NCOME
Individual Totals:
Additional Deductions
Medical Bills (as deductionk
Patient Pay Amount
Total Household Net Income:
Budget Income Limit:
You are responsible for patient pay amount to providers as
below.
Line Date Pay to: Provider Amount
'he following medical bills have been used as a deduction 'to calculate your, eligibility for Medicaid benefits. The unpaid bills are your
responsibility and will not be covered by Medicaid
Name of Provider Date of Service Amount Name of Provider Date of Service Amount
IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM.
---- DETACH HERE
DETACH HERE ---
Please check one of the boxes to show which I want a I want a
type of hearing you want ED telephone hearing. ? face-to-face hearing.
? ,Please check If you require any necessary and reasonable accommodation because of a hearing impairment or other disability
Describe:
? Please check if you need an interpreter
What language?
NOTE: If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
1 WANT TO REQUEST A HEARING BECAUSE: (Attach additional pages if necessary.)
i
CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE
CLIENT REP. SIGNATURE ADDRESS TELEPHONE NO. DATE
PAMA1825
oe»*? ri
• THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
LINE •-FIRST'NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9
THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
-alcumnon of Gross Monthly Income Calculation of Contribution toward Cost of Care
Begin Date 12/01/2007 Begin Oate 12/01/2007
Eamed Income Gross Monthly Income
Wages, Salary .00 Total Earned Income .00
Self Employment .00 Total Unearned income 1550.21
Rental Income .00 Income available first month .00
Other .00 Deductions
Total Earned
Income: 00 Personal Needs Allowance 45.00
Unearned
Income Guardianship Fee .00
Social Security 1259. so Total Allowance for Spouse / 00
Dependant
SSI .00 Home Maintenance .00
Veteran's Benefits ,00 Contribution towards 1505
21
Cost of Care: .
Pension 290.61 The LTC facility will deduct the following medical expense from your
contribution towards Cost of Care
Railroad Benefits .00 Medicare Premium .00
orkmen's Comp 00 Other Insurance Premium .00
Black Lung .00 The LTC facility may deduct additional medical bills
Annuity/Trust
00 including supplemental health insurance premiums,
rovided the
ifi
d
Payment p
y are ver
e
.
Interest / Dividend
.10 (?
P a Lea
Other (Rental, etc.) .00
Z4?$
Total Unearned
Income: 1550.21 1?r
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THE BOTTOM OF THIS FORM.
•---- DETACH HERE
DETACH HERE ----
Please check one of the boxes to show which type of hearing you want: 1:1 t want a El I want a
telephone hearing, face-to-face hearing.
? Please check if you require any necessary and reasonable accommodation because of a hearing impairment or other disability
Please describe your disability.
? Please check if you need an interpreter What language?
NOTE. If you ask for an interpreter but later get your own Interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
I. WANT TO REQUEST A HEARING BECAUSE. (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE
CLIENT REP.SIGNATURE ADDRESS TELEPHONE NO. DATE
PALTC162B =A rr Tr+ 141 •un.
THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
BNFT
LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER v PKG I LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9 02
BNFT
v PKG
THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOU)
MEDICAID BENEFITS.
Line Line Line Line Line Line Line Line
GROSS INCOME
erne
Unearned:
DEDUCTIONS
Earned Income:
Unearned Income:
Dependant Care
NET INCOME
Individual Totals:
Household Net Income: I You are responsible for patient pay amount to providers as indicated
Additional Deductions below.
Medical Bills (as deductionh. Line Date Pay to: Provider Amount
Patient Pay Amount
Total Household Net Income.
Budget Income Limit
*he following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your
responsibility and will not be covered by Medicaid. I
Name of Provider Date of Service Amount
Name of Provider Date of Service Amount
IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM.
-- DETACH HERE
DETACH HERE ----
Please check one of the boxes to show which type of hearing you want; El I want a E] 1 want a
telephone hearing. face-to-face hearing.
Please check if you require any necessary and reasonable accommodation because of a hearing impairment or other disability
Describe:
? -Please check if you need an interpreter What language?
NOTE: If you ask for an interpreter but later get your own interpreter. please call the Bureau of Hearings
and Appeals 1717) 783-3950
1 WANT TO REQUEST A HEARING BECAUSE: (Attach additional pages if necessary.)
1
CLIENT SIGNATURE
ADDRESS
TELEPHONE NO. DATE
CLIENT REP. SIGNATURE ADDRESS TELEPHONE NO. DATE
PAMAI/N9A
oGS?Y?l1
THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
LINE __FIRST'NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9
THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
atcuiarion or Gross monthly Income Calculation of Contribution toward Cost of Care
Begin Date 11/01/2007 Begin Date 11/01/2007
Earned Income Gross Monthly Income
Wages, Salary .00 Total Earned Income .00
Self Employment .00 Total Unearned Income 1550.21
Rental Income .00 Income available first month .00
Other .00 Deductions
Total Earned
Income: .00 Personal.Needs Allowance 45.00
Unearned
Income Guardianship Fee o0
Social Security 1259.50 Total Allowance for Spouse / 00
Dependant
SSi .00 Home Maintenance .00
Veteran's Benefits .00 Contribution towards 1505
21
Cost of Care: .
Pension 290.61 The LTC facility will deduct the following medical expense from your
contribution towards Cost of Care
Railroad Benefits .00 Medicare, Premium .00
..crkmen's Comp .00 Other Insurance Premium .00
Black Lung .00 The LTC facility may deduct additional medical bills
Annuity/Trust .
including supplemental health insurance premiums,
Payment • 00 provided they are verified.
Interest / Dividend .10 Q
Other (Rental, etc.) .00
G
Total Unearned QeR
Income: 1560.21
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN TH?OM OF TIS FORM.
---- DETACH HERE
DETACH HERE ----
Please check one of the boxes to show which type of hearing you want 1:1 1 want a E] 1 want a
telephone hearing. face-to-face hearing.
? Please check if you require any necessary and reasonable accommodation because of a hearing impairment or other disability.
Please describe your disability.
? Please check if you need an interpreter What language?
NOTE If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals (717) 703-3950
J .WANT TO REQUEST A HEARING BECAUSE (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE
CLIENT REP.SIGNATURE ADDRESS TELEPHONE NO. DATE
PALTC16213 ..Jill .ten .11.1
:1?h,? ?e? ??Q THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
BNFT
LINE FIRST NAME ACCESSIINOI V I DUAL NUMBER v PKG LINE FIRST NAME ACCESSIINDIV[DUAL NUMBER
01 RAYMOND 770199670 9 02
BNFT
V PKG
?...? = THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUF
MEDICAID BENEFITS.
Line Line Line Line Line Line Line Line
GROSS INCOME
Earner
Unearned:
DEDUCTIONS
Earned Income:
Unearned Income:
Dependant Care
NET INCOME
Individual Totals
nauu?Jonvw ivea Income:
Additional Deductions:
Medical Bills (as deduction):
Patient Pay Amount
Total Household Net Income:
Budget Income Limit
You are responsible for patient pay amount to providers as
below.
-Line Date Pay to. Provider Amount
be following medical bills have been used as a deduction to calculate your, eligibility for Medicaid benefits. The unpaid bills are your
responsibility and will not be covered by Medicaid
Name of Provider Date of Service Amount I Name of Provider Date of Service Amount
IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM.
,--- DETACH HERE DETACH HERE -----
1 want a I .want a
Please check one of the boxes to show which type of hearing you want: ? telephone hearing. ? face-to-face hearing.
? Please check if you require any necessary and reasonable accommodation because of a hearing impairment or other disability.
Describe:
? Please check If you need an Interpreter What language?
NOTE: If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals 1717) 793-3950
I WANT TO REQUEST A HEARING BECAUSE: (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP. SIGNATURE ADDRESS TELEPHONE NO. DATE
PAMA1A2R
d;dV34b 71
THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
LWE- FIRST NAME ACCESSl1NDIVIDUAL NUMBER
01 RAYMOND 770199670 9
THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
' -alculation of Gross Monthly Income Calculation of Contribution toward Cost of Care
Begin Date
Earned Income
Wages, Salary 10/01/2007
.00 Begin Date
Gross Monthly Income
Total Earned Income "10/01/2007
.00
Self Employment .00 Total Unearned Income 1550.21
Rental Income .00 Income available first month .00
Other .00 Deductions
Total Earned
Income: .40 Personal Needs Allowance 45.00
Unearned
Income Guardianship Fee .00
Social Security 1259,50 Total Allowance for Spouse /
Dependant 00
SSI .00 Home Maintenance .00
Veteran's Benefits .00 Contribution towards
Cost of Care: 1505.21
Pension 290.61 The LTC facility will deduct the following medical expense from your
contribution towards Cost of Care
Railroad. Benefits .00 Medicare Premium .00
iorkmen's Camp .e0 Other Insurance Premium .00
Black Lung •00 The LTC facility may deduct additional medical bills..
Annuity/Trust
Payment
.00 including supplemental health Insurance premiums,
provided they are verified.
Interest / Dividend
.10 (?
u 1
U
Other. (Rental, etc.) .00 APR 0 7 2008
Total Unearned
Income:
1550.21
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THE BOTTOM OF THIS FORM.
•-- DETACH HERE
DETACH HERE ----
I want a 1 want a
Please check one of the boxes to show which type of hearing you want: ? telephone hearing, ? face-to-face hearing.
? Please check if you require any necessary and reasonable accommodation because of a hearing impairment or other disability.
Please describe your disability-
E-1 Please check if you need an interpreter What language?
'NOTE: If you ask for an interpreter but later get your own Interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
.J WANT TO REQUEST A HEARING BECAUSE. (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS TELEPHONE NO. DATE
CLIENT REP.SIGNATURE ADDRESS TELEPHONE NO. DATE
PALTCta2B
THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
BNFT
LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER V PKG LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9 02
BNFT
V PKG
THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUI
MEDICAID BENEFITS.
Line Line Line Line Line Line Line Line
GROSS INCOME
arn€ eF--
Unearned:
DEDUCTIONS
Earned Income:
Unearned Income:
Dependant Care
NET INCOME
Individual Totals
. wuao?wtu naL nwu111a:
Additional Deductions
Medical Bills (as deduction):
Patient Pay Amount
Total Household Net Income:
Budget Income Limit:
You are responsible for patient pay amount to providers as
belovv:
Line Date Pay. to: Provider Amount
'he following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your
responsibility and will not be covered by Medicaid.
Name of Provider
Date of Service
Amount I Name of Provider Date of Service Amount
IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM.
--- DETACH HERE
DETACH HERE ----•
Please check one of the boxes to show which type of hearing you want Q i want a El 1 want a
telephone hearing. face-to-face hearing.
? Please check if you require any necessary and reasonable accommodation because of a hearing Impairment or other disability.
Describe:
? Please check if you need an interpreter What language?
NOTE: If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
1 WANT TO REQUEST A HEARING BECAUSE: (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP. SIGNATURE ADDRESS TELEPHONE NO. DATE
PAMA 1R9R
a.G7?Y / / l
THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
LINE . FIRS?' NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9
EEJIISIIIIII[610 U* THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
-'alculation of Gross Monthly Income Calculation of Contribution toward Cost of Care
Begin Date 09/01/2001 Begin Date 09/01/2007
Eamed Income Gross Monthly Income MINOR :
Wages, Salary .00 Total Earned Income .00
Self Employment .00 Total Unearned Income 1550.21
Rental Income .00 Income available first month .00
Other .00 Deductions
Total Earned
Income: .00 Personal Needs Allowance 95.00
Unearned
Income Guardianship Fee .00
Social Security 1259.50 Total Allowance for Spouse / 00
Dependant
SSI .00 Home Maintenance .00
Veteran's Benefits .00 Contribution towards 1505
21
Cost of Care: .
Pension 290.61 The LTC facility will deduct the following medical expense from your
contribution towards Cost of Care
Railroad Benefits .00 Medicare Premium 00
/orkmen's Comp .00 Other Insurance Premium .00
Black Lung .00 The LTC facility may deduct additional medical bills
Annuity/Trust including supplemental health insurance premiums,
Payment • 00 provided they are verified.
Interest / Dividend .10 (}
V 6
Other (Rental, etc.) .00 APR 0.7 2008
Total Unearned
Income: 1550. 21
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THE BOTTOM OF THIS FORM.
---- DETACH HERE
DETACH' HERE ----
Please check one of the boxes to show which type of hearing you want El l want a E] 1 want a
telephone hearing. face-to-face hearing.
? Please check -if you require any necessary and reasonable accommodation because of a hearing impairment or other disability.
Please describe your disability:
? Please check if you need an interpreter What language?
NOTE: If you ask for an Interpreter but later get your own Interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
I WANT TO REQUEST A HEARING BECAUSE (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP.SIGNATURE
TELEPHONE NO. DATE
ADDRESS
a n s.. sse gems
PALTC1628
O9/25/2008 11:21 2541125 CHURCH OF GOD HO PAGE 02/02
-- .• . "'-t, .,,,,,WLsJCJiauydr - rn 'CbY'1O72744
T-991 PO89/009 F-351
VE FICAT.I N
The undersigned hereby velifies that the statements of fact in the foregoing Complaint
are true and correct to the best of my knowledge, infonnation and belief. I understand that an
false stn y
temonts therein arc subject to the POWties contained in 18 Pa. C.S.A. § 4904, relaftg to
u=w'orn falsiSeahon to authorities.
Dated:`? - -t)5
,Sh?(L
Sharon Cramer, SR Bng/AR Specialist
Church of God Home, Inc.
6
r-
L?
W
Cl`J
F'
V
U'
°C-
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Petitioner,
V. No. C .I've +e rAt
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Respondents. CIVIL ACTION - EQUITY
PETITIONER'S BRIEF IN SUPPORT OF
PETITION FOR PRELIlMNARY INJUNCTION
AND NOW COMES, Petitioner, Church of God Home, Inc. ("Petitioner"), by and
through its attorneys, SCHUTJER BOGAR LLC, and files the within Brief in Support of Its
Petition for Preliminary Injunction against Respondent, Charles Dinklocker ("Respondent
Charles Dinklocker") and Respondent, Raymond Dinklocker ("Respondent Raymond
Dinklocker") (collectively referred to as "Respondents"), and in support thereof avers the
following:
1. FACTUAL BACKGROUND AND SUMMARY OF ARGUMENT
On or about August 7, 2007, Respondent Raymond Dinklocker, by and through his son
and attorney-in-fact, Respondent Charles Dinklocker, and Respondent Charles Dinklocker, as
Responsible Party for his father, Respondent Raymond Dinklocker, jointly applied for and made
admission of Respondent Raymond Dinklocker to Petitioner's skilled nursing facility. Since that
date, Respondent Raymond Dinklocker has received the benefits of the terms of the Admission
and Care Agreement ("Agreement") that Respondents entered into with Petitioner, and
Respondents are therefore bound to the terms of the Agreement. The Agreement provided that
Petitioner would provide skilled nursing services to Respondent Charles Dinklocker's father,
Respondent Raymond Dinklocker, in exchange for certain promises made by Respondents.
Specifically, Respondent Raymond Dinklocker agreed to pay Petitioner certain monetary charges
for the services that Petitioner provided to him; and, in the event that he were to receive Medical
Assistance benefits, to turn over to Petitioner any payments Respondent Raymond Dinklocker
received from third parties to the extent necessary to satisfy the charges under the Agreement.
Similarly, in exchange for Petitioner's agreement to provide skilled nursing services to
Respondent Raymond Dinklocker, Respondent Charles Dinklocker agreed to be responsible to
pay all fees and costs for the services that Petitioner provided to Respondent Raymond
Dinklocker "from Resident's " (i.e., from Respondent Raymond Dinklocker's) resources. These
obligations on the parts of Respondents included the turning over to Petitioner of Respondent
Raymond Dinklocker's monthly income, comprised of Social Security benefits and a pension, as
established in Respondent Raymond Dinklocker's approval of Medical Assistance benefits.
As Respondent Raymond Dinklocker was allegedly insolvent, an application for Medical
Assistance benefits was filed with the Cumberland County Assistance Office ("CAO"). His
application was approved, and he received Medical Assistance benefits covering his stay from
the date of his admission to Petitioner's skilled nursing facility. As a condition of Respondent
Raymond Dinklocker's receipt of said benefits, he is required to turn over to Petitioner his
monthly income, less insurance, from his Social Security benefits and pension which, at all times
material, exceeded $1,500.00 per month.
Upon information and belief, Respondent Raymond Dinklocker has continued and
continues to receive his monthly Social Security and pension income, yet, he has failed and
continues to fail to turn over his monthly patient pay obligation to Petitioner, as required by the
terms of the Agreement and by Medicaid regulations as a condition of his Medical Assistance
2
benefits. Likewise, upon information and belief, Respondent Charles Dinklocker has failed and
continues to fail to turn over his father, Respondent Raymond Dinklocker's monthly income to
Petitioner as required by the terms of the Agreement and by Medicaid regulations.
Moreover, to the extent that the required payments of Respondent Raymond Dinklocker's
monthly income are not being made and are instead accumulating as Medical Assistance
resources in excess of Respondent Raymond Dinklocker's allowable Medical Assistance
resource limit, Respondents are jeopardizing Respondent Raymond Dinklocker's receipt of
Medical Assistance benefits. See 55 Pa. Code §§ 178.1(c), stating that a Medical Assistance
recipient whose resources exceed the applicable Medical Assistance resource limit becomes
ineligible for Medical Assistance benefits and "remains resource ineligible until his resources are
equal to or less than, the resource limit." Here, the Medical Assistance resource limit applicable
to Respondent Raymond Dinklocker is $8,000 (see 55 Pa. Code Chapter 178, Appendix A); and
at present, the accumulated balance of unremitted monthly income owed to Petitioner by
Respondent Raymond Dinklocker is in excess of $19,474.72. Accordingly, an injunction is
necessary to compel Respondents to turn over to Petitioner Respondent Raymond Dinklocker's
monthly patient payment obligation so that his Medical Assistance benefits are not discontinued.
II. QUESTION PRESENTED
Is Petitioner entitled to a preliminary injunction?
Suggested Answer: Yes.
M. ARGUMENT
The breaches by Respondents of their respective contractual duties provide this Court
with a sufficient basis to issue the injunction that Petitioner requests. An injunction is an
3
extraordinary remedy, the issuance of which solely is within the trial court's discretion. Soja v.
Factoryville Sportman's Club, 522 A.2d 1129, 1131 (Pa. Super. 1987). The party seeking the
injunction has the burden to establish that:
(1) [T]he injunction is necessary to prevent immediate and irreparable harm that
cannot be adequately compensated by damages;
(2) [G]reater injury would result from refusing an injunction than from granting it,
and concomitantly, that issuance of an injunction will not substantially harm other
interested parties in the proceedings;
(3) [A] preliminary injunction will properly restore the parties to their status as it
existed immediately prior to the alleged wrongful conduct;
(4) [T]he activity it seeks to restrain is actionable [and] ... its right to relief is
clear...;
(5) [T]he injunction it seeks is reasonably suited to abate the existing activity; and
(6) [A] preliminary injunction will not adversely affect the public interest.
Warehime v. Warehime, 860 A.2d 41, 46-47 (Pa. 2004) (internal citations and quotations
omitted). In addition, in order for Petitioner to comply with Pa. R. C.P. 1531(b), Petitioner avers
that a bond in the amount of $100.00 should be adequate to protect Respondents in the event that
it is later determined that the issuance of the instant petition was in error.
Based on the application of the facts before the Court to the aforementioned legal
framework, it is clear that Petitioner is entitled to the relief requested. Accordingly, an
injunction should be granted to order and ensure Respondents' fulfillment of their respective
contractual duties.
4
A. Sufficient legal basis exists for this Court to issue an iniunction.
1. Respondents are in breach of the Agreement.
Respondents have breached the Agreement entered into with Petitioner, the appropriate
remedy for which, on the facts of this case, is an injunction requiring the specific performance of
the Agreement by the parties. Petitioner has provided and continues to provide care and services
to Respondent Raymond Dinklocker in accordance with the terms of the Agreement. However,
Respondent Raymond Dinklocker has not abided by his promise to turn over his monthly income
to Petitioner, in violation of the Agreement and Medicaid regulations. Likewise, Respondent
Charles Dinklocker has not abided by his promise to turn over to Petitioner his father,
Respondent Raymond Dinklocker's monthly income.
B. Petitioner is entitled to an injunction.
1. Respondents' breaches of the Agreement have caused immediate and
irreparable harm to the interests of Petitioner for which a legal
remedy is inadequate.
The very nature of Respondents' breaches of the Agreement, i. e., the failure on the part
of each of the Respondents to turn over to Petitioner Respondent Raymond Dinklocker's
monthly income pursuant to the terms of the Agreement and a condition of Respondent
Raymond Dinklocker's receipt of Medical Assistance benefits under Medicaid regulations,
presents an issue of immediate and irreparable harm to Petitioner.
Respondent Raymond Dinklocker has not and apparently cannot pay for the skilled
nursing care provided to him by Petitioner and Petitioner has incurred significant costs in
providing said care and services. As the failure of Respondents to turn over to Petitioner
Respondent Raymond Dinklocker's monthly income to Petitioner jeopardizes Respondent
Raymond Dinklocker's Medical Assistance eligibility, Petitioner is faced with immediate and
irreparable harm because absent Respondent Raymond Dinklocker's receipt of Medical
Assistance benefits, Petitioner will not be adequately compensated for the care and services it
has provided, and continues to provide to Respondent Raymond Dinklocker.
2. Greater injury will result if the injunction is not granted
The issuance of an injunction under the circumstances of this case also is appropriate
because greater harm would result from the denial of the requested injunction than from the
granting of the same. By denying the injunction, the Court would be allowing Respondents to
remain in violation of the Agreement and Respondent Raymond Dinklocker to remain in
violation of Medicaid regulations, thereby jeopardizing Respondent Raymond Dinklocker's
continued eligibility for Medical Assistance benefits. Should Respondent Raymond Dinklocker's
Medical Assistance benefits be discontinued, due to Respondents' respective breaches of the
Agreement and Respondent Raymond Dinklocker's consequent violation of Medicaid
regulations, Petitioner will be unable to receive reimbursement for the care and services it has
provided and continues to provide to Respondent Raymond Dinklocker.
Conversely, what harm would result to Respondents from the issuance of the requested
injunction? Respondent Raymond Dinklocker will not be harmed by being compelled to turn
over his monthly income to Petitioner in contribution toward the cost of his care, since that is
precisely what Respondent Raymond Dinklocker promised to do under the terms of the
Agreement to satisfy his obligations under Medicaid regulations. Likewise, Respondent Charles
Dinklocker will not be harmed by being compelled to turn over his father, Respondent Raymond
Dinklocker's monthly income to Petitioner, since that is precisely what Respondent Charles
Dinklocker promised to do under the terms of the Agreement. Moreover, to the extent that the
6
requested injunction would ensure the continuation of Respondent Raymond Dinklocker's
eligibility for Medical Assistance benefits, it would benefit both Petitioner and Respondent
Raymond Dinklocker.
Accordingly, greater harm would come to all parties concerned by denying the requested
injunction than by granting same.
3. The requested injunction would restore the parties to the status quo.
The issuance of the injunction will return the parties to the position in which they existed
at the time they entered into the Agreement. Simply put, Respondents, upon entering into the
Agreement with Petitioner, each became contractually obligated to turn over to Petitioner
Respondent Raymond Dinklocker's monthly income pursuant to the terms of the Agreement, as
well as same being a condition of Respondent Raymond Dinklocker's receipt of Medical
Assistance benefits.
Petitioner has fulfilled its duties under the Agreement by providing Respondent Raymond
Dinklocker with skilled nursing services, but Respondents have failed to fulfill their respective
contractual duties. In short, the injunction would require Respondents to perform their
respective obligations under the Agreement and restore the parties to the status quo.
4. Petitioner's right to relief is clear.
As set forth in the Complaint against Respondents (Defendants therein), the right of
Petitioner (Plaintiff therein) to relief could not be clearer. The activity that the injunction seeks
to abate is the ongoing breach of the Agreement which has been effectuated by Respondents'
respective refusals to turn over to Petitioner Respondent Raymond Dinklocker's monthly income
pursuant to the terms of the Agreement and a condition of Respondent Raymond Dinklocker's
7
receipt of Medical Assistance benefits. The contract is clear and Respondents have no excuse for
failing to abide by its terms.
5. The injunction is suited to abate the harm to Petitioner's interests.
An injunction that simply requires Respondents to turn over to Petitioner Respondent
Raymond Dinklocker's monthly income is reasonably limited and abates the harm to Petitioner.
Determining Respondents' compliance with an injunction of such limited scope will not be a
significant burden to the Court because it merely is a question of whether Respondents turn over
to Petitioner the monthly patient payment or whether they continue to withhold it, thereby
perpetuating an ongoing harm to Petitioner's interests, and, ultimately, to the interests of
Respondent Raymond Dinklocker.
6. Granting the injunction is in the public interest.
Petitioner requests the injunction to hold Respondents to their respective contractual
obligations. It is in the public interest both to encourage a party to fulfill duties under a contract
into which that party has willingly and voluntarily entered and to ensure that those institutions
that provide skilled nursing services to its residents are fully compensated. Accordingly, it is
unlikely that Respondents would be able to articulate a reason why the injunction should not be
granted, for such a remedy clearly is not only within Petitioner's interests, but also in the interest
of Respondent Raymond Dinklocker and that of the public.
Remainder of the page intentionally left blank
8
IV. CONCLUSION
Based on the above, Petitioner respectfully requests that this Court issue a decree
directing Respondents to turn over to Petitioner Respondent Raymond Dinklocker's monthly
income, in accordance with Medicaid regulations and the Agreement.
Respectfully submitted,
Dated: 6 O$
SCHU J-IER BOGAR LLC
By
Bradley A. Schutjer
Attorney I.D. No. 75954
(717) 909-5921
417 Walnut Street, 4th Floor
Harrisburg, PA 17101
Steven E. Bernstein
Attorney I.D. No. 23729
(267) 386-4974
1650 Market St., 36`h Floor
Philadelphia, PA 19103
Attorneys for Petitioner
9
CD -1
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Petitioner,
V.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Respondents
No. C-),?t1 -fc«
CIVIL ACTION - EQUITY
PETITION FOR PRELDIINARY INJUNCTION
AND NOW COMES, Petitioner, Church of God Home, Inc. ("Petitioner"), by and
through its attorneys, SCHUTJER BOGAR LLC, and files the within Petition for Preliminary
Injunction against Respondent, Raymond Dinklocker ("Respondent Raymond Dinklocker") and
Respondent, Charles Dinklocker ("Respondent Charles Dinklocker") (collectively referred-to as
"Respondents"), pursuant to Pa. R.C.P. No. 1531, and, in support thereof, avers the following:
1. On or about October 6, 2008, Petitioner (as Plaintiff) filed a Complaint against
Respondents (as Defendants).
2. The Complaint sets forth equitable claims against each Respondent (Defendant
therein) for breach of his obligations under the Admission and Care Agreement ("Agreement")
that Respondent Raymond Dinklocker, as "Resident", by and through his attorney-in-fact,
Respondent Charles Dinklocker, and Respondent Charles Dinklocker, as "Responsible Party" for
Respondent Raymond Dinklocker, entered into with Petitioner (Plaintiff therein), to wit, the
obligation of each Respondent to turn over to Petitioner Respondent Raymond Dinklocker's
monthly income. See Complaint attached hereto as Exhibit "A."
3. The very nature of Respondents' respective breaches of the Agreement, i. e., the
failure of Respondent Raymond Dinklocker to turn over to Petitioner his monthly Social Security
and pension income pursuant to the terms of the Agreement and his Medical Assistance
eligibility, and the failure of Respondent Charles Dinklocker to turn over to Petitioner his
father's, Respondent Raymond Dinklocker's monthly Social Security and pension income
pursuant to the terms of the Agreement and as a condition of his father's receipt of Medical
Assistance benefits, presents an issue of immediate and irreparable harm to Petitioner, as
Respondent Raymond Dinklocker's eligibility for Medical Assistance benefits may be
discontinued by virtue of Respondents' failure to turn over to Petitioner the necessary monthly
patient pay obligation.
4. The requested injunction would restore the parties to the status quo as it existed
immediately prior to Respondents' respective breaches of the Agreement.
5. Greater injury would result from the denial of the requested injunction than from
the granting of same, as absent a decree ordering Respondents to specifically perform their
respective obligations under the Agreement, Respondent Raymond Dinklocker's Medical
Assistance benefits may be discontinued and Petitioner will not receive reimbursement for the
care and services it has provided, and continues to provide, to Respondent Raymond Dinklocker.
6. Petitioner's right to relief is clear. See Complaint, Exhibit A.
7. Petitioner lacks an adequate remedy at law as, upon information and belief, at all
times material hereto, Respondent Raymond Dinklocker has been financially unable to fully
compensate Petitioner for the care and services that Petitioner has rendered, and continues to
render, to him.
8. A bond in the amount of $100.00 should be adequate in the event that it is later
determined that the issuance of the instant petition was in error.
WHEREFORE, Petitioner respectfully requests that this Honorable Court schedule an
immediate hearing on its request for injunctive relief, and thereafter issue a decree ordering
specific performance by Respondents of their respective obligations under the Agreement to turn
over to Petitioner Respondent Raymond Dinklocker's monthly patient pay obligation.
Respectfully submitted,
SCHUDER BOGAR LLC
Dated: /0 0'Q By.
Bradley A. Schutjer
Attorney I.D. No. 75954
(717) 909-5921
417 Walnut St., 4 h Floor
Harrisburg, PA 17101
Steven E. Bernstein
Attorney I.D. No. 23729
(267) 386-4974
1650 Market St., 36th Floor
Philadelphia, PA 19103
Attorneys for Petitioner
EXHIBIT "A,•
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants.
No.
CIVIL ACTION - EQUITY
NOTICE TO DEFEND
Pursuant to PA RCP No. 1018.1
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth
in the following pages, you must take action within twenty (20) days after this complaint and
notice are served, by entering a written appearance personally or by attorney and filing in writing
with the court your defenses or objections to the claims set forth against you. You are warned
that if you fail to do so the case may proceed without you and a judgment may be entered against
you by the court without further notice for any money claimed in the complaint or for any other
claim or relief requested by the plaintiff. You may lose money or roe
important to you.
p p rty or o er nghts
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW.
THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE
TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER
LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telephone: (717) 249-3166
(800) 990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V.
No.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants. CIVIL ACTION - EQUITY
AVISO PARA DEFENDER
Conforme a PA RCP Num. 1018.1
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las
demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de
los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando
personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por
escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le
advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede
proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier
otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la
Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos
importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA
SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA
DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES
POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE
AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A
PERSONAS QUE CUALIFICAN.
Lawyer Referral Services
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
Telefono: (717) 249-3166
(800) 990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants.
No.
CIVIL ACTION - EQUITY
COMPLAINT
AND NOW COMES, Plaintiff, Church of God Home, Inc. ('Plaintiff), by and through
its attorneys, SCHUDER BOGAR LLC, and files the within Complaint against Defendant, Charles
Dinklocker ("Defendant Charles Dinklocker") and Defendant, Raymond Dinklocker ("Defendant
Raymond Dinklocker") (collectively referred-to as "Defendants'), and in support thereof,
provides as follows:
1 • Plaintiff is a Pennsylvania corporation with its principal offices located at 801
North Hanover Street, Carlisle, Pennsylvania 17013.
2. Defendant Raymond Dinklocker is an adult individual who resides at 801 North
Hanover Street, Carlisle, Pennsylvania 17013.
3. Defendant Charles Dinklocker is an adult individual who resides at 50 Mountain
Road, Sherman Dale, Pennsylvania 17090.
4.
attorney-in-fact, Defendant Charles Dinklocker, and Defendant Charles Dinklocker, as
Responsible Party for Defendant Raymond Dinklocker, jointly made application for the
On or about August 1, 2007, Defendant Raymond Dinklocker, by and through his
admission of Defendant Raymond Dinklocker to Plaintiff's skilled nursing facility located at 801
North Hanover Street, Carlisle, Pennsylvania 17013.
5. On or about August 7, 2007, Plaintiff, together with Defendant Raymond
Dinklocker, by and through his attorney-in-fact, Defendant Charles Dinklocker, and Defendant
Charles Dinklocker, as Responsible Party for Defendant Raymond Dinklocker, entered into a
written Admission and Care Agreement ("Agreement"). A true and correct copy of the
Agreement is attached hereto as Exhibit "A."
6. Pursuant to the Agreement, Plaintiff agreed to provide Defendant Raymond
Dinklocker with skilled nursing services in exchange for his promise to pay specific monetary
charges for the services that Plaintiff provided to him; and, in the event that he were to receive
Medical Assistance benefits, "to turn over to the Facility any payments received from third
parties to the extent necessary to satisfy the charges under this Agreement." See Exhibit "A."
7. Also pursuant to the Agreement, in exchange for Plaintiff's agreement to provide
skilled nursing services to Defendant Raymond Dinklocker, Defendant Charles Dinklocker, as
Responsible Party for Defendant Raymond Dinklocker, agreed to be "responsible to pay all fees
and costs" for the services that Plaintiff provided to Defendant Raymond Dinklocker "from
Resident's [i. e., from Defendant Raymond Dinklocker's] resources." See Exhibit "A."
8. After Defendant Raymond Dinklocker's admission to Plaintiffs skilled nursing
facility, he allegedly became insolvent. As a result, pursuant to the Agreement, Defendant
Raymond Dinklocker, by and through his attorney-in-fact, Defendant Charles Dinklocker, made
application for Medical Assistance benefits and qualified for same on September 1, 2007.
9. As a condition of Defendant Raymond Dinklocker's receipt of Medical
Assistance benefits according to Medicaid regulations, see 55 Pa. Code § 181.452(e), and as
determined by the Cumberland County Assistance Office ("CAO"), Plaintiff is entitled to receive
2
$1,534.11 from Defendant Raymond Dinklocker's monthly income, which is comprised of
Social Security benefits and a pension. A copy of the most recent notices issued by the CAO
regarding payment of monthly income is attached hereto as Exhibit "B."
10. Further, pursuant to the Agreement, Defendant Raymond Dinklocker is required
to pay Plaintiff from his financial resources for the skilled nursing services provided by Plaintiff.
11. Upon information and belief, Defendant Raymond Dinklocker continues to
receive his monthly Social Security and pension income.
12. Defendant Raymond Dinklocker has failed to turn over his monthly income to
Plaintiff as required by the terms of the Agreement and by Medicaid regulations as a condition of
his receipt of Medical Assistance benefits.
13. Defendant Charles Dinklocker likewise has failed to turn over Defendant
Raymond Dinklocker's monthly income to Plaintiff as required by the terms of the Agreement
and by Medicaid regulations as a condition of Defendant Raymond Dinklocker's receipt of
Medical Assistance benefits.
14. Upon information and belief, Defendant Raymond Dinklocker's monthly income
has been going to his son, Defendant Charles Dinklocker, who has been using said income for
his personal enjoyment.
COUNTI
Plaintiffv. Defendant Raymond Dinklocker
Breach of Contract -- Specific Performance
15. Paragraphs 1 through 14 are hereby incorporated by reference as if fully set forth.
16. Plaintiff has provided skilled nursing care and services to Defendant Raymond
Dinklocker in accordance with the Agreement.
IT Defendant Raymond Dinklocker breached the Agreement with Plaintiff when he
refused to turn over to Plaintiff his monthly income, and Defendant Raymond Dinklocker
continues to breach the Agreement with Plaintiff by refusing to turn over to Plaintiff his monthly
income pursuant to the grant of Medical Assistance benefits
18. Defendant Raymond Dinklocker's breach of the Agreement with Plaintiff has
irreparably harmed, and continues to irreparably harm Plaintiff.
19. Defendant Raymond Dinklocker's breach of the Agreement with Plaintiff may
also irreparably harm himself, as his failure to turn over his monthly income to Plaintiff may
result in the discontinuance of his Medical Assistance benefits.
20. Accordingly, only a decree of specific performance will adequately protect the
interests of Plaintiff and provide it with the benefits and/or protections promised under the
Agreement.
WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific
performance of the Agreement by Defendant Raymond Dinklocker.
COUNT II
Plaintiffv. Defendant Charles Dinklocker
Breach of Contract - Specific Performance
21. Paragraphs 1 through 20 are hereby incorporated by reference as if fully set forth.
22. Plaintiff has provided skilled nursing care and services to Defendant Raymond
Dinklocker in accordance with the Agreement.
23. Defendant Charles Dinklocker breached the Agreement with Plaintiff when he
refused to turn over to Plaintiff Defendant Raymond Dinklocker's monthly income, and
4
Defendant Charles Dinklocker continues to breach the Agreement with Plaintiff by refusing to
turn over to Plaintiff Defendant Raymond Dinklocker's monthly income pursuant to the grant of
Medical Assistance benefits.
24. Defendant Charles Dinklocker's breach of the Agreement with Plaintiff has
irreparably harmed, and continues to irreparably harm Plaintiff.
25. Defendant Charles Dinklocker's breach of the Agreement with Plaintiff may also
irreparably harm Defendant Raymond Dinklocker, as the failure of Defendant Charles
Dinklocker to turn over Defendant Raymond Dinklocker's monthly income to Plaintiff may
result in the discontinuance of Medical Assistance benefits for Defendant Raymond Dinklocker.
26. Accordingly, only a decree of specific performance will adequately protect the
interests of Plaintiff and provide it with the benefits and/or protections promised under the
Agreement.
WHEREFORE, Plaintiff seeks a decree from this Honorable Court which orders specific
performance of the Agreement by Defendant Charles Dinklocker.
Dated: -0411-
By:
Respectfully submitted,
SCHUTJ BOGAR LLC=
Bradley A. Schutjer
Attorney I.D. No. 75954
(717) 909-5921
Steven E. Bernstein
Attorney I.D. No. 23729
(267) 386-4974
One Liberty Place
1650 Market Street, 36th Floor
Philadelphia, PA
5
Attorneys for Plaintiff
EXHIBIT °A°
- ' CHMCH OF GOD ROME, INC-.
ADMISSION AND CARE AGREEMENT
TABLE OF CONTENTS
PAGE
1. PROVISION OF SERVICES .
2. RECURRING CHARGES . . . , .
_ 3. .
NON-RECURRING CHARGES . . - 26
a. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES 27
5•
ADMISSION - 27
6. PERIODIC BILLINGS AND PAYMENT DUE DATE .
7.
CHANGES IN CHARGES . . , 28
8• PARTICIPATION-IN MEDICARE/MEDICAID PROGRAMS
9• ,
•
-OBLIGATIONS OF RESPONSIBLE PARTY
- - •_ 28
10.
READMISSION - BED/ACCOMMODATION FOLD POLICY .29
11. •-
..
REFUNDS-
12. •
... -
PERSONAL FINANCES , . . . . 29
•.
13. TERMINATION, TRANSFER OR DISCHARGE
14. THIRD - PARTY PAYMENTS 30
15. PERSONAL PROPERTY - 31
16.
RESPONSIBILITIES OF RESIDENT 32
-
17. MISCELLANEOUS PROVISIONS
32
CEURCH OF GOD HOME, INC.
ADMISSION AND CARE AGREEMETT
THIS AGREEMENT is made on this 7 day of AL)1!-LJ6T mo, by
and between The Church of God Rome, Inc., called the "Facility," a
Pennsylvania non-profit corporation located at 801 North Ranover
Street, Carlisle, Cumberland County, Pennsylvania,
and A_j&6Ao 6-- D,.rj j ocY J'` . called "Resident"
and C #1AA P_:S D1A1KJ_Q(XF1- called "Responsible Party".
_The Resident and the Responsible Party reaffirm that the
information provided in the Pre-Admission Questionnaire is true and
correct and understand that the submission of false information may
constitute grounds to terminate this Agreement.- The Resident has
applied for admission to the Facility and the Facility has approved
the. Application for Admission. Therefore, the Facility, The
Resident. and Responsible Party agree to the following terms-:
1. PROVISION OF SERVICES. The Facility will provide
Resident with:
(a) Skilled nursing care, i.e. professionally supervised
nursing care and related health services under a plan
of services regularly provided under a plan of care.
supervised by licensed personnel and, as required by
the Resident's.medical condition, assistance with
activities of daily living.
(b) Accommodations consistent with the -level of care
provided to the Resident including heat, air
conditioning,-electricity and hot and cold water.
(c) Bed, bedding, blankets and laundered bed linens, towels
.and wash cloths.
(d) Three meals each day, except as -otherwise medically
indicated.
(e) Activity programs and social services.
2. RECURRING CHARGES. In exchange for the above services,
the Resident shall pay the following recurring charges:
(a) For skilled nursing care: $ .CIO . od -dollars.per day.
Admission and Care Agreement - continued
- -a% NON-RECURRING CHARGES. The Resident shall Day the
following non-recurring charges:
(a) A security deposit in the amount of thirty-one (31)
times the current daily rate for the level of care
required by the resident, will be billed after
admission day. The amount of the security deposit is
$ to S`!Q ,,5m No interest will be
deposit. A security deposit will not aid the
benchargedcttooity
residents who are receiving benefits for room and board
provided by Medicare, until the Medicare benefit
concludes. An applicant who is covered'by Medicaid is
not required to pay a security deposit.
(b) The cost for enrollment in the community ambulance
and ALS (Advance Life Support) Unit is $
fThis
ee must be paid prior to admission and will ebil ed
annually to the .Resident. "
AND a. MISCELLANEOUS CHARGES
responsible to pay far other serv ices pro ceded CI:S . Resident is
which are not covered by the daily rate/charge. ' A list Fof such
services/charges is attached to this Agreement ion the 'Chart of
Costs.,,
The services of a licensed physician and dentist, a
registered pharmacist and licensed pharmacy for the provision of
pharmaceutical supplies, a licensed hospital, and. dia
services, will be made available at the Resident's expense?ostic
THE RESIDENT HAS THE RIGHT TO SELECT HIS/HER OWN PHYSICIAN OR ANY
OTHER SERVICE PROVIDER SO LONG AS THE PIiySICIAN OR OTHER
PROVIDER IS PROPERLY LICENSED OR REGISTERED' SERVICE
ALL APPLICABLE GOVERNMENT RULES AM POLICIES OF THE- PANCILITTY ARE
MET.
In addition to the Facility's charges, the Resident is
responsible to pay -all fees and costs -for goods or services
furnished to or for the Resident by anyone other than the Facility
under this Agreement. The responsibility of the Resident to pay
applies to all fees for costs of services provided for the Resident
by any physician, dentist, optometrist,'. therapist, diagnostic or
test ing*laboratory ; pharmacist, pharmacy, hospital, or any other
person,* facility or entity providing services or goods to or for
the Resident, and for all drugs, medicines, medications,
pharmaceutical supplies, corrective eye lenses, hearing aids,
dentures, hair care, and other personal items or services for the
Resident. SUCH PEES P.ND COSTS ARE NOT INCLUDED IN THE HOME'S DPSLY
RATE / MARGE .
Admission and care x9reement - continued
?5. A=SSION. The Resident will be admitted, or a bed will
be reserved 'for Resident, beginning on L9 - 7 --o7
All pre-admission charges will be billed after admission, and
recurring charges will begin to accrue as of the above -date.
The Resident may reserve an available bed by paying the
daily rate for the bed reserved. The daily rate for the reserved
bed will continue to accrue and be payable until the reservation is
terminated, even if the Resident does not enter the - Home for
whatever reason, including illness, injury, incapacity or death.
6. PERIODIC BILLINGS AND PAYMENT DUE DATE.
(a) On the first of.each month, Resident will be billed the
current daily rate for Resident's current level of care
times the number of days- in the month: The bill is due
and payable upon receipt.
(b) Miscellaneous charges (refer to "Chart of Costs"
attached to this Agreement) such as hair care, personal
laundry, incontinency, supplies, etc., are.additional
charges above the daily rate. These miscellaneous
charges 'will be added to, and included with,. your
monthly bill.
(c) Pharmacy charges will be billed as a separate part
of the Facility's monthly bill, and will require
a separate check..
(d) Outside providers.will bill directly and separately.
7. •CBANGES IN CHARGES. From time to time, the Facility may
change the amount of its charges. In addition, from time to time,
the Facility may change how and when its charges are -computed,
billed or become due. The Facility reserves the right to make any
such changes at any time:, Written notice of any such changes will
be given to the - Resident thirty (30) days in advance of
implementation, unless, the- change is required earlier under aay
f ederal or state law or assistance program.
. a. PARTICIPATION IN "MEDICARE /MEDICAID n PROGRAMS. The
Facility participates in the Medicare program administered pursuant
to Title XVIII .of the Federal Social Security Act and the
Pennsylvania Medical Assistance Program ("Medicaid") administered
pursuant to the Pennsylvania state plan and Title XIX of the
Federal Social Security. Act. However, the Facility reserves the
right to withdraw from the Medicare /Medicaid -programs at any time
in accordance with the law.
Admission and Care Agreement - continued
-9% OBLIGATIONS OF RESPONSIBLE PARTY. The Responsible Party
is responsible for services and supplies that are billed through
the Facility or billed directly to the Resident or Responsible
Party by any other provider. The Responsible Party is responsible
to pay all fees and costs from Resident's resources.
10. READMISSION - BED HOLD POLICY. 'If the Resident leaves
the Facility for a period of hospitalization, therapeutic leave, or
any other reason, other than the Resident's death, and if the
Resident is not eligible for, or receiving medical assistance, the
Resident's bed will be reserved and charges for the reserved bed
will continue to accrue, unless the Resident or Responsible Party
-otherwise directs in writing. If the Resident or Responsible Party
elects not to reserve a bed, then the Resident will be eligible for
readmission upon the availability of the first bed suitable for the
Resident's level of care.
If the Resident Is receiving medical assistance benefits
and - the Resident • leaves. the Facility for • a period of
hospitalization or therapeutic leave, the Resident's bed will be
reserved for the applicable maximum number of days paid for the
reserved bed under the Pennsylvania Medical Assistance, Program.
The current bed reservation period is fifteen (15) days for
hospitalization, regardless of level of care, fifteen (15) days for
therapeutic leave for residents receiving skilled nursing care,.. and
thirty (.30) days for therapeutic leave for residents receiving
intermediate care. The bed reservation period may be subject to
change in accordance with any changes in the-Medical Assistance
Program. If the period of hospitalization or therapeutic leave
ends within 'the reservation period under the Medical Assistance
Program, the Resident may return to the Facility. If the period of
hospitalization or therapeutic leave exceeds the maximum time for
reservation of a bed under the Pennsylvania. Medical Assistance
Program, the Resident must wait until a suitable bed becomes
available for readmission. The Resident is entitled to the first
available bed suitable for the Resident's level of care if, at the
time of readmission, :the Resident requires the services provided by
the Home. ..
11. REFUNDS . The security deposit f or private pay residents,
after deductions for the payment of any outstanding bills owed to
the Facility, will be refunded within thirty (30) days after the
Resident's. discharge from the Facility or death. Those Nursing
Residents on Medical Assistance will receive their refund, if any
due,' within ninety (90) days. There will.be no other refunds, in
the absence of an overpayment, under this Agreement..
12.. PERSONAL FIZFANCES . The Resident has the right to manage
his/her personal funds. The Resident is and will be responsible to
provide his/her- personal funds. If the Resident elects, the
Resident may designate, in writing, that 'the Facility hold and
manage the Resident's personal funds.. If the Resident
Admission and Care Agreement - continued
designates someone other than the Facility to manage his/her
personal funds, the Resident or Responsible Party shall notify the
Facility promptly. The Resident is not required
designation, and "is responsible for his/her to make any
unless such designation is made.
The Resident may revoke, at any time, the designation of
the Facility as the manager of his/her personal funds by providing
the Facility a written notice signed and dated by the Resident or
Responsible Party.
If.the Resident transfers to the Home, responsibility to
-manage the Resident's personal funds, the Facility will do so in
accordance with the "Rights of Nursing Facility Residents", a copy
of which 'is. provided - at the time of your admission, and the
Facility's personal .funds management poli The Facility may
deduct, at any time, charges due to the Facility under this
agreement from. the Resident's personal funds managed by the
Facility.
13. TERMINATION TRANSFER OR DISCHARGE.
(a) By the Resident: The- Resident may terminate this
Agreement upon thirty (30) days written notice to the
Facility. If the Resident leaves the-Facility for any
reason other than a medical emergency or his/her death,
the Resident must give written notice to the. Facility
at -least thirty (30)' days in advance of the departure/
transfer/discharge or termination of the Agreement.
If advance written notice is not given to the Facility,
there will be due to the Facility its daily and other
charges then in effect for the Resident's current level
of care for the required :thirty (30) day notice period.
The charge applies whether or not the Resident remains
at the Facility during the thirty. (30) day period.
(b) By the Facility: The Facility may terminate the
Resident's stay and transfer or discharge the Resident
if:
(I) the transfer or discharge is necessary.to
meet the Resident's welfare which cannot
be.met by the Facility;
(II) the Resident's health or condition has
improved sufficiently that'the Resident
no longer needs the services provided by
the Facility;
(III) the safety or health'of individuals in the
Facility is or otherwise would be endangered.;
Admission and Care Agreement- continued
IV. The charges or other amounts due to the Facility under this Agreement
have not been paid to the Facility or treated as paid to the Facility on the
Resident's behalf by Medical Assistance under the Medical Assistance
Program or by Federal Medicare benefits under Title XV1II of the Federal
Social Security Act; or
V. The Facility ceases to operate.
The Facility generally will notify the Resident and Responsible Party or if none, a family
member or legal representative of the Resident, if known to the Facility, at least thirty
(30) days in advance of such a transfer or discharge. However. in any case. describe in
subparagraph (1). (II) and (III) above, or if the Resident has not resided at the Facility for
at least thirty (30) days. the Facility will give such notice before transfer or discharge as
is practicable under the circumstances.
14. THIRD PARTY PAYMENTS- The Resident may be or may become eligible
to receive financial assistance, reimbursement or other benefits from third
Parties. such as through private insurance, employee benefit plans. Medical
assistance under the Pennsylvania Medical Assistance program, Medicare
benefits. supplementary medical or other health insurance, supplemental security
income insurance. or old-age survivors' or disability insurance under or pursuant
to the Federal Social Security Act or Program. If the Resident becomes eligible to
receive payments from any third-parties for the stay and care of the Resident. the
Resident/Responsible Party shall, at all times, cooperate fully with the Facility
and each third-party payments. Cooperation includes. when requested, providing
information. signing and delivering documents, and having the Facility
designated by the Social Security Administration as the Resident's representative
payee for receipt of Federal Social Security benefits or any other governmental
assistance, reimbursement or benefits to the extent of all charges due the Facility.
The Resident irrevocably authorizes the Facility to make claims and to take such
other actions as maybe necessary for the Facility's receipt of third-party
payments. To the fullest extent permitted by law. the Resident hereby assigns
now or hereafter payable to the extent of all charges due to the endorse and turn
over to the Facility any payments received from third-parties to the extent
necessary to satisfy the charges under this Agreement.
Admission and Care Agreement- continued
15. PERSONAL PROPERTY- The Resident/ Responsible Party is and will be
responsible to furnish and maintain clothing, jewelry. personal possessions. and
other items of property. The facility may limit the amount or type of property that
the Resident may keep at the facility if there is insufficient space. or if medically
indicated or necessary to protect the rights or welfare of others. All non-clothing
items of value must be recorded on the resident's personal inventory located with
their medical record on the day of admission or any day thereafter. The same is
true if removing an item of value from the resident's room. You are requested to
see the charge nurse regarding resident's personal property. If nametag labels are
needed for clothing items, please leave them at the nursing station.
16. RESPONSIBILITIES OF RESIDENT- The Resident shall comply fully with
all governmental laws and regulations, the provisions of this Agreement and the
facility's existing policies, rules and regulations which may, from time to time.
be altered or amended.
17. MISCELLANEOUS PROVISIONS
a. The Resident and Responsible Party acknowledge that they are adult
individuals and have read and understand the terms of this Agreement.
b. The provisions of this Agreement shall be governed by the laws of the
Commonwealth of Pennsylvania and shall be binding upon and inure to
the benefit of each of the undersigned parties and their respective heirs..
personal representatives, successors and assigned.
c. The various provisions of this Agreement shall be severable one from
another. if any provision of this Agreement is found by competent legal
authority to be invalid, the other provisions shall remain in full force and
effect as if the invalid provision had not been part of this Agreement.
d. The Facility reserves the right to modify unilaterally the terns of this
Agreement to conform to subsequent changes in the law or regulation and
changes in charges. Resident will be provided thirty (;0) days notice of
changes in charges and, if practicable, reasonable notice of any
modifications required by law.
t'".)
lent/Responsible Party
+VIYOAO ?r .
Resi
Facility
D,Al,p, L, c , E /,-*
entative
7-d
Date
EXHIBIT "g„
P.O. Box 599
13'WESTMINSTER DRIVE ELIGIBLE
CARLISLE PA 17013-0599 NOTICE
CAO RETURN ADDRESS CSLD 0033
PAGE 1 OF 1
21 0117171 0 PAN 4 00
'07100000000+
CHURCH OF GOD HOME
ATTN: BILLING OFFICE
801 NORTH HANOVER STREET
CARLISLE PA 17013
K PEARSON
TELEPHONE (717) 240-2700
MAIL DATE: 04/04/2008
NOT. 985 OPT: B TYPE E
IF YOU W Wr UNDERSTAND CUP DECISION OR HAVE AMY
OUESTIMS, PLEASE CONTACT YOUR NON(ER INKMIATELY.
You have been determined eligible for benefits effective 09/01/2007 to 09/30/2007
You are eligible for Non-Money Payment Medicaid coverage including Services in
a Long-Term Care Facility. A PA ACCESS card will be issued unless you have
previously received one. You will be required to make a monthly payment
towards your cost of care. A separate notice showing you the details of this
computation is enclosed. Contact the CAO if you have any questions or
changes to report. When contacting the CAC, please provide your record
number, which is located on the top and bottom of this notice.
Citation: 5S Pa. Code Sections 141.71, 178.1, 181.1
If you' disagree with our decision, you have the right to appeal.
for a complete exoainvri.,., .,s _
?.. a?wy rCCelYFng benefits and -- - '- ° 'Q" "O?'n it you are
ur oral County Assistance Office or your written written ?e quest fora hearing is received in the
before 04/17/2008
your
quest Is postmarked or received on or assistance except when the change is due to State or will Fecontinue deral lawe?ing the hearing decision,
RAYMOND G DINKLOCKER
CHURCH OF GOD HOME
80 NORTH HANOVER STREET
CARLISLE PA 17013
.? N.
CUMBERLAND CAO
P.O. BOX 599
33 WESTMINSTER DRIVE
CARLISLE PA 17013-0599
MIDPENN LEGAL SERVICES
401-405 LOUTHER STREET
CARLISLE PA 17013
Notice ID: 82934771
21 0117171 0 PAN 4 00
WORKER K PEARSON
APPEAL: 04/17/2008
TELEPHONE (717) 240-2700
MAIL DATE: 04/04/2008
NOT. 985 OPT: B Type E
PAMA162A CONTINUED ON REVERSE SIDE
PAIMA 162 12163
THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICEV 1
LINE ,- FIRST'NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9
gu THE FOLLOWING AMOUNTS WERE USED
LONG TERM CARE ILTC1 TO COMPUTE YOUR MONTHLY CONTRIBUTION
O
.
1aiculation of Gross Monthly Income T
WARDS YOUR COST OF
Calculation of Contribution toward C
t
te
'
01/01/20pg 02/01/2008 os
of Care
Be in Date
f
In
come 47
01/01/2008 02/02/2008
r Gross Monthly Income
alary 00 - - -
00 Total Earned Income 00
Self Employment .oo
00
00
Total Unearned Income 1579
11
Rental Income .
1579.11
00
.00
Income available first month
Other .00
. 00
00 .00 Deductions
Total Earned
Income: .00 .00 Personal Needs Allowance
Unearned 45.00 45.00
Income Guardianship Fee
-.Y-_.
Social Security 1288.40 1258.40 . oo . eo
Total Allowance for Spouse /
Dependant 00 00
SSl
00 .00 •.- -
Home Maintenance
Veteran's Benefits .00 .00 .00 .DO
Contribution towards
Cost of Care: 1534.11 1534.11
Pension 290.61 290.61 The LTC facility will deduct the following medical expense from
your
contribution towards Cost of Care
Railroad Benefits
00
.
00 Medicare Premium 00
orkmen's Comp 00 .oo
00 Other Insurance Premium 00
Black Lung .
.oo
.40
00
The LTC facility may deduct additi
Annuity/Trust
Payment .00 •00 onal medical bills
including supplemental health insurance
Premiums,
provided they are verified
Interest / Dividend .10
.10 .
R (1[?
Other (Rental, etc.) 00
.00
T APR Q ZQ?$
otal Unearned
Income: 1579.11 1579.11
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN
THE BOTTOM OF THIS FORM.
DETACH HERE
Ptease.eheck one of the boxes to show which DETACH HERE •--•
type of hearing you want: El I telepho want n a hearin
1:1 i want a f
? Please
h
k If
c
g.
ec
ace-
to-face hearing.
you require any necessary and reasonable accommodation because of ahearing impairmen
Please describe your disability.
t or other disability
? Please check if you need an interpreter What language?
NOTE If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
I WANT TO REQUEST A HEARING BECAUSE (Attach additional pages if
necessary.)
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP.SIGNATURE ADDRESS
TELEPHONE NO.
DATE
ALTC182B
bad 7r Leo tuna
9 11141 91'W THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION
ON THE FRONT OF THIS NOTICE
LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER BNFT
V PKG LINE FIRST NAME ACCE55lINDIVIDUAL NUMBER V PKBNFT
02 RAYMOND 770199670
G
9 02
THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE D
MEDICAID BENEFITS. ETERMINATION OF YOUI
Line Line Line
GROSS INCOME Line Line Line
Earne : Line Line
Unearned:
DEDUCTIONS
Earned Income:
Unearned Income:
Dependant Care
NET INCOME
Individual Total
Additional Deductions:
Medical Bills (as deductionl:
Patient Pay Amount
Total Household Net Income:
Budget Income Limit
'he fnlln-i-
t save Deed used as a deduction 'to calculate your eligibility for Medicaid benefits The u
responsibility and will not be covered by Medicaid
npaid bills are your
Name of Provider
Date of Service Amount I Name of Provider
Date of Service Amount
IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM.
--- DETACH HERE
Please check one of the boxes to show which DETACH HERE---
type of hearing you want: 1:1 ! want a ? l want a
hearing.
El Please Describe: check If you require any necessary and reasonable accommodation becausenof
Describe:
a hearing im aa'e-to-face hearing.
p ment or other disability
? Please check if you need an
• interpreter
What language?
NOTE if you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals T27 78_ 3_ I WANT TO REQUEST A HEARING BECAUSE (Attach additional pages if necessary.)
CLIENT SIGNATi lcc
ADDRESS
CLIENT RFP 6
You are responsible for
below patient pay amount to providers as
Line Date P to: Provider
Amount
TELEPHONE NO. DATE
4MA162B
- Auurlt55
TELEPHONE NO. DATE
THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICEy ?1
LINE - FIRST NAME ACCESS/INDIVIDUAL NUMBER
01 RAYMOND 770199670 9
m THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
alculation of Gross Monthly Income Calculation of Contribution toward Cost of Care
Begin Date 12/01/2007
Be in Date
Earned Income 12/01/2007
Gross Monthly Income
Wages, Salary 00 -
Total Earned Income ao
Self Employment 00
Tots) Unearned income 1550.21
Rental Income o0
Income available first month .00
Other
00
Deductions
Total Earned
Income: .00 Personal Needs Allowance
Unearned as. ao
Income Guardianship Fee
Social Security
_ .00
1259.50 Total Allowance for Spouse /
SSI Dependant .00
.00 Home Marntenance
Veteran's Benefits
.00 .ao
Contribution towards
Cost of Cars: 1505.21
Pension 290.61 The LTC facility will deduct the following medical expense fr
Railroad Benefits om your
contribution towards Cost of Care
00
Medicare • Premium
. orkmen's Comp .00
ao
Other Insurance Premium .00
Black Lung
Annuity/Trust
P o0
The LTC facility may deduct additional medical bills
including supplemental health i
ayment
.00 nsurance premiums,
provided they are verified.
Interest / Dividend .10 ?
LC
Other (Rental, etc.) .oD D
Total Unearned
Income: 1550.21
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THE BOTTOM OF THIS FORM.
--- DETACH HERE
DETACH HERE
Please check one of the boxes to show which type of hearing you want El t telepho want n a ? 1 faca- want a
Please check if you require any necessary and reasonable accommodation because of a hearing impairment or others
to-faca El disability
Please describe your disability, ? Please check if you need an interpreter What language?
NOTE. If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
t, WANT TO REQUEST A HEARING BECAUSE. (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS
. TELEPHONE NO. DATE
CLIENT REP.SIGNATURE ADDRESS
TELEPHONE NO. DATE
ALTC162B
O A n Tt 16.1 1 ,,A,
• THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
LINE FIRST NAME ACCESSIINDIVIDUAL NUMBER BNFT
V PKG ? LINE EIRSr menno qCC
01 RAYMOND 770199670 9 02
ESSIINDIVIDUAL NUMBER v
SNFT
PKG
THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUI
MEDICAID BENEFITS.
Line Line Line Line Line
GROSS INCOME Line Line Line
Earned
Unearned
DEDUCTIONS
Earned Income:
Unearned Income:
Dependant Care
NET INCOME
Individual Totals:
MM-
Additional Deductions: you are responsible for patient pay amount to providers as indicated
Medical Bills (as deduction): below:
Patient Pay Amount: Line Data M 12L Provider Amount
Total Household Net Income:
Budget Income Limit:
'he following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your I
responsibility and will not be covered by Medicaid.
Name of Provider Date of Service Amount
Name of Provider Date of Service Amount
IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM.
- DETACH HERE
Please check one of the boxes to show which type DETACH HERE ---•
ype of hearing you want: El I t "want a ? I want a
Please check if elephone hearing. face-to-face hearing.
you require any necessary and reasonable accommodation because of a hearing impairment or other disability
Describe:
? 'Please check if you need an interpreter What language?
NOTE If you ask for an Interpreter 6ut later get your own interpreter, please call the Bureau of Hearings
and Appeals _(71_) 783_3s50
1 WANT TO REQUEST A HEARING BECAUSE (Attach additional pages if necessary.)
i
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP. SIGNATURE ADDRESS
TELEPHONE NO. DATE
eMe7ao%
THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE ri
LINE. FIRST'NAME ACCESSIINDIVIDUAL NUMBER
dl. RAYMCND 770199670 9
_ THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
'alcuiation of Gross Monthly Income Calculation of Contribution toward Cost of Care
Begin Date 11/01/2007 Begin Date 11/01/2007
Earned Inc--- Gross Monthly Income
Wages, Salary 00
Total Earned Income .00
Self Employment
.00 Total Unearned Income 1550.21
Rental Income 00
. Income available first month .00
Other
00
Deductions
Total Earned
Income: • 00 Personal.Needs Allowance
45.00
Unearned
Income Guardianship Fee
_ .0o
Social Security 1259.50 Total Allowance for Spouse /
Deoendant .00
SSi
.00
Veteran's Benefits .00
Pension 290.6i
Railroad Benefits
00
..orkmen's Comp 00
Black Lung .00
Annuity/Trust
Payment .00
Interest / Dividend
.10
Other (Rental, etc.) .00
Total Unearned
Income: 1550.21
C?
?' peR o? rove
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THJOM OF THIS FORM.
DETACH HERE
DETACH HERE
Please check one of the boxes to show which ----
to-face hearing.
type of hearing you want; ? I welepho ant n a hearing. 1:1 1 want a fce- E-1 Please check if you require any necessary and reasonable accommodation because of ahearing impairmen
Please describe your disability.
t or other disability.
? Please check if you need an interpreter What language?
NOTE If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals (717) 793-3950
[ WANT TO REQUEST A HEARING BECAUSE. (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP-SIGNATURE ADDRESS
TELEPHONE NO. DATE
4LTC162B
ewu rr vw •an?
Home Maintenance o0
Contribution towards
Cost of Cars: isps.21
The LTC facility will deduct the following medical expense from your
contribution towards Cost of Care
Medicare. Premium 1 .00
Other Insurance Premiurn
.00
The LTC facility may deduct additional medical bills
including supplemental health insurance premiums,
provided they are verified.
• THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
BNFT
LINE FIRST NAME ACCESS/INDIVIDUAL NUMBER v PK
G
LINE FIRST NAME ACCESSIIND
0-1 RAYMOND 770199670 9 02
IVIDUAL NUMBER V
BNFT
PKG
• = THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUF
MEDICAID BENEFITS.
Line Line Line Line Line Line
GROSS INCOME Line Line
Earned:
Unearned:
DEDUCTIONS
Earned Income:
Unearned Income:
Dependant Care
NET INCOME
Individual Totals:
Household Net Income: F
Additional D
nsible for
eductions: patient pay amount to providers as indicated
Medical Bills (as deduction): Patient Pay Amount Pay to• Provider Amount
Total Household Net Income:
Budget Income Limit
he following medical bills have been used as a deduction to calculate your, eligibility for Medicaid benefits. The unpaid bills are your
responsibility and will not be covered by Medicaid
Name of Provider
Date of Service
Amount
Name of Provider Date of Service Amount
IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM.
-- DETACH HERE
Please check one of the boxes to show which DETACH HERE -----
type of hearing you want ? I telephone want a hearing. 1:1 I .want a
to-face heg.
E-1 Please check if you require any necessary and reasonable accommodation because of ahearing impairmen
Describe:
t or otheradisability.
? Please check If you need an interpreter What language?
NOTE If you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals _(717) 783-3950
I WANT TO REQUEST A HEARING BECAUSE: (Attach additional pages if necessary.)
i '
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP. SIGNATURE ADDRESS
TELEPHONE NO. DATE
AMA1Roi;
ETHE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOdZ9J
TICE 71
t INE- FIRST NAME ACCESSIINDIVIDUAL NUMBER
01 RAYMOND 770199670 9
THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
'alculation of Gross Monthly Income Calculation of Contribution toward Cost of Care
Begin Date 10/01/2007 Begin Date 10/01/2007
Earned Income ME11 Sim
Gross Monthly Income
Wages, Salary .00 Total Earned Income
.oo
Self Employment 00 Total Unearned Income
1550.21
Rental Income .00 Income available first month
.ao
Other .00
Deductions
Total Earned
Income: .00 Personal Needs Allowance
45.00
Unearned
Income Guardianship Fee .00
Social Security 1259.50 Total Allowance for Spouse /
Dependant •00
SSA -00 Home Maintenance
.00
Veteran's Benefits .00 Contribution towards
Cost of Care: isos.zl
Pension 290.61 The LTC facility v ill deduct the following medical expense from your
contribution towards Cost of Care
Railroad. Benefits .00 Medicare Premium
.00
Workmen's Comp .00 Other Insurance Premium .00
Black Lung .00
The LTC facility may deduct additional medical bills.
Annuity/Trust oo including supplemental health Insurance premiums,
Payment provided they are verified.
Interest / Dividend 10 [l
Other. (Rental, etc.) .00
APR d H ZQO?
Total Unearned 1
Income: 1550.21
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THE BOTTOM OF THIS FORM.
-° DETACH HERE
DETACH HERE ----
Please check one of the boxes to show which ED I want a ? I want a
type of hearing you want: telephone hearing, face-to-face hearing.
? Please check if you require any necessary and reasonable accommodation because of a hearing impairment or other disability.
Please describe your disability-
El Please check if you need an interpreter ' What language?
NOTE If you ask for an interpreter but later get your own Interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
._1 WANT TO REQUEST A HEARING BECAUSE: (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
I CLIENT REP.SIGNATURE ADDRESS TELEPHONE NO. DATE
PALTC1628
• THE FOLLOWING PERSON(S) ARE AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE
LINE fiflST NAME ACCESS/ INDIVIDUAL NUMBER V PKGT
I LINE FIRST NAME ACCE55lINDIViDUAL NUMBER V PKGT
01 RAYMOND 770199670 9 02
PE(Rilli THE FOLLOWING PERSON(S) INCOME OR FINANCIAL INFORMATION WERE INCLUDED IN THE DETERMINATION OF YOUI
MEDICAID BENEFITS.
Line Line Line Line
GROSS INCOME Line Line Line Line
Earner-`
Unearned:
DEDUCTIONS
Earns Income:
Unearned Income:
Dependant Care
NET INCOME
Individual Tots:
Household Net Income You are responsible for
Additional Deductions patient pay amount to providers as indicated
Medical Bills (as deduction): belovv
Patient Pay Amount L'me Date P . to: P ovider
Total Household Net Income: Amount
Budget Income Limit:
he following medical bills have been used as a deduction to calculate your eligibility for Medicaid benefits. The unpaid bills are your
responsibility and will not be covered by Medicaid.
Name* of Provider Date of Service Amount
Name of Provider Date of Service
Amount
IF YOU WISH TO APPEAL, PLEASE COMPLETE AND RETURN THE BOTTOM PORTION OF THIS FORM.
DETACH HERE
DETACH HERE
Please check one of the boxes to show which type of hearing you want El ! want a ---•
? I want a
El Please check if you require any necessary and reasonable accommodation becausenof aahring. earing impairment or otheradisabili
Describe: ty
? Please check if you need an interpreter What language?
NOTE: if you ask for an interpreter but later get your own interpreter, please call the Bureau of Hearings
and Appeals _(717)793-3950
1 WANT TO REQUEST A HEARING BECAUSE (Attach additional pages If necessary.)
CUENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP. SIGNATURE ADDRESS
TELEPHONE NO. DATE
AMA iR9R
THE FOLLOWING PERSON IS AFFECTED BY THE ACTION ON THE FRONT OF THIS NOTICE l
LINE FIRS- NAME ACCESSIINDIWDUAL NUMBER
01 RAYMOND 770199670 9
THE FOLLOWING AMOUNTS WERE USED TO COMPUTE YOUR MONTHLY CONTRIBUTION TOWARDS YOUR COST OF
LONG TERM CARE (LTC).
"alculation of Gross Monthly Income Calculation of Contribution toward Cost of Care
( Begin Date 09/01/2007
rned Income
' _ U9/01/2007
2 - Gross Monthly Income
ge
s, Salary
:W
00
Total Earned Income
00
Self Employment .00 Total Unearned Income
1550.21
Rental Income • 00 Income available first month
.00
Other .Do
Deductions
Total Earned
Income: • 00 Personal Needs Allowance
45.00
Unearned
Income
! Guardianship Fee .00
Social Security 12 59.50 Total Allowance for Spouse /
Dependant .00
SSI .00 Home Maintenance
.00
Veteran's Benefits .00 Contribution towards
Cost of Care: 1SO5.21
Pension 290.61 The LTC facility will deduct the following medical expense from your
contribution towards Cost of Care
Railroad Benefits .00 Medicare Premium
.ao
/orkmen's Comp DD
Other Insurance Premium
.00
Black Lung _oo
The LTC facility ma
d
d
Ann
/T
it y
e
uct additional medical bills
i
l
u
y
rust
P 00 nc
uding supplemental health insurance premiums
ayment ,
provided they are verified.
Interest /Dividend • to
?If
Other (Rental, etc.) .DD
APR 0 7 2008
T
l
ota
Unearned
Income: 1550.21 0_
IF YOU WISH TO APPEAL THE ABOVE COMPUTATION, PLEASE COMPLETE AND RETURN THE BOTTOM OF THIS FORM.
-- DETACH HERE
DETACH' HERE
Please check one of the boxes to show which type of hearin I want a 1 want a
g you want: ? telephone hearing 1:1 face-to-face hearing.
? Please check-if you require any necessary and reasonable accommodation because of a hearing impairment or other disability.
Please describe your disability:
? Please check if you need an interpreter What language?
NOTE If you ask for an interpreter but later get your oven Interpreter, please call the Bureau of Hearings
and Appeals (717) 783-3950
1 WANT TO REQUEST A HEARING BECAUSE (Attach additional pages if necessary.)
CLIENT SIGNATURE ADDRESS
TELEPHONE NO. DATE
CLIENT REP.SIGNATURE ADDRESS TELEPHONE NO. DATE
NLTC1628
a w n Tn +s? uns
T-991 p009/0091:-351
VE CAT, N
The undersigned hereby verifies that the statements of fact in the foregoing
Co 1 .
Are true and correct to the best of MY knowledge inf ? a?rrt
, orrnation and belief. I understand that any
false statements therein are subject to the
Penalties contained in I8 Pa. C.S.A. § 4904, relating to
"amOrn &Lsificatlon to authorities.
Aated:9 ?-?
Sharon Cmer, SR BillinValk Specialist
Chinch of God Home, Inc.
6
-y
i
c rl
Ful.
Off' 16 2008(.0
V.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Respondents.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Petitioner,
No. #j-
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CIVIL ACTION - EQUITY
111-19-0
AND NOW, this /6 7Z;f day of , 2008, a hearing in
the above-captioned matter on Petitioner's Petition for Preliminary Injunction is scheduled for
/a , 2008, at 3 d _k_.m. in Court Room
No. , Cumberland County Courthouse, J , Pennsylvania.
BY THE COURT:
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants.
No. 08-6012
CIVIL ACTION - EQUITY
MOTION FOR CONTINUANCE
AND NOW COMES Plaintiff, Church of God Home, Inc., ("Plaintiff') and
moves for a continuance of the hearing on the Preliminary Injunction, and in support
thereof states:
1. On October 7, 2008, a Complaint and a Petition for Preliminary Injunction
was filed in the above-captioned matter.
2. On October 16, 2008, this Honorable Court entered an Order scheduling a
hearing on Petitioner's Petition for Preliminary Injunction for November 6, 2008, at 9:30
a.m.
3. Service of the Complaint, Petition for Preliminary Injunction, and Order
scheduling hearing on Preliminary Injunction was made on Defendant Raymond
Dinklocker on October 29, 2008.
4. To date, despite using its best efforts to do so, Petitioner has been unable
to effectuate service on Defendant Charles Dinklocker.
WHEREFORE, Petitioner respectfully requests a brief continuance so that service
on Defendant Charles Dinklocker may be effectuated.
Respectfully submitted,
Schutjer Bogar, LLC
Dated:
B /
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1.
Bradley A. Schutjer
Attorney I.D. No. 75954
(717) 909-5921
Amanda L. Short
Attorney I.D. No. 202938
(267) 207-2871
One Liberty Place
1650 Market Street, 36`h Floor
Philadelphia, PA 19103
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IN THE COURT OF COMMON PLEAS, CUMBERLAND COUNTY, PENNSYLVANIA
AFFIDAVIT OF SERVICE
CHURCH OF GOD HOME INC. RAYMOND DINKLOCKER et al.
(PLAINTIFF) VS. (DEFENDANT)
CASE and/or DOCKET: 08-6012
Id, declare that I am a Pennsylvania State Constable and/or a Process Server, in and
for tfle County of Berks, that I am not a party to this action, not an employee of a party to this action, or an
attorney to the action, and that within the boundaries of the state were service was effected. I was
authorized by law to perform the said service..
SERVICE UPON: RAYMOND VINKLOCKER
ADDRESS: 801 N. HANOVER ST. CARLISLE PA 17013
ON: 0 I ;A )Og AT: 21 D p yri 11
Description: approx. age 3 height 55 5 weight p5•race JJf- sex F hair
With documents: COMPLAINT, PETITION FOR PRELIMINARY INJUNCTION AND BRIEF IN
SUPPORT OF PRELIMINARY INJUNCTION
Manner of Service
By handing to:
? DEFENDANT WAS PERSONALLY SERVED.
? ADULT WITH WHOM THE SAID DEFENDANT RESIDES.
Name Relationship
ADULT IN CHARGE OF DEFENDANTS RESIDEN E. k2.1^
Name ?. S Relationship S
? POSTED PROPERTY
? AGENT OR PERSON IN CHARGE OF PLACE OF BUSINESS.
Name Title
? MILITARY STATUS: NO / YES BRANCH
`, I` COMMENTS:
r'2SidES.
1h Wh?Lh X M"
DEFENDANT WAS NOT SERVED BECAUSE:
MOVED UNKNOWN _ NO ANSWER -VACANT -OTHER:
4,1 is f6'r C? o f o d ?}m'rie CL y\-V,R1 `J
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SERVICE WAS ATTEMPTED ON THE FOLLOWING DATES / TIMES:
SWORN TO AND SUBSCRIBED
BEFORE ME THIS a_l DAY OF
0 C?-p JQ 1g , 2008
NOTARY
*CONSLE/PR-OCESS SERVER
COMMONWEALTH OF PENNSYLVANIA
E.M.A?MAE,RVICES, P.O. BOX 26534 COLLEGEVILLE PA 19426 LLC
TERESA A. MINZOLA, Notary Public
Washin(iton Twp., Berks County
h4y Commission Expires Derem!jer 5,
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
V. No. 08-6012
0 R I G'IN', A L
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants. CIVIL ACTION - EQUITY
ORDER
AND NOW this S,- day of November, 2008, it is hereby ORDERED that
Petitioner's Motion for Continuance is GRANTED and the Hearing on Petitioner's
Petition for Preliminary Injunction is hereby continued.
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.
Petitioner,
V.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants
No. 08-6012
CIVIL ACTION - EQUITY
PRAECIPE FOR WITHDRAWAL OF PETITION FOR PRELIMINARY
INNNCTION
A Petition for Preliminary Injunction has been filed in the above-referenced
matter and is scheduled for presentation on Tuesday, December 9, 2008. As this
matter has been resolved, kindly withdraw the above-referenced Petition for
Preliminary Injunction without prejudice.
Respectfully submitted,
Dated: «- k?o?6
SCHUTJER BOGAR LLC
By:
Bradley Schutjer
Attorney I.D. No. 75954
(717) 909-5921
417 Walnut St, 4th Floor
Harrisburg, PA 17101
Amanda L. Short
Attorney I.D. No. 202938
(267) 207-2871
One Liberty Place
1650 Market Street, 36`h Floor
Philadelphia, PA 19103
Attorneys for Petitioner
CERTIFICATE OF SERVICE
I, the undersigned, hereby certify that on this day I have served a true and correct
copy of Petitioner's Praecipe to Withdraw Petition for Preliminary Injunction, via United
States, First Class Mail upon the following:
Raymond Dinklocker
801 North Hanover Street
Carlisle, PA 17013
(Respondent)
Charles Dinklocker
50 Mountain Road
Shermans Dale, PA 17090
(Respondent)
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Date:
Tamara L. McLendon, Paralegal
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.
Petitioner,
V.
RAYMOND DINKLOCKER and
CHARLES DINKLOCKER,
Defendants.
No. 08-6012
CIVIL ACTION - EQUITY
PRAECIPE TO WITHDRAW, DISCONTINUE AND END
As this matter has been resolved, kindly withdraw the above-referenced
action, without prejudice.
Respectfully submitted,
Dated: /Laq
SCHUTJER BOGAR LLC
By:
Bradley Sc utjer
Attorney I.D. No. 75954
(717) 909-5921
417 Walnut St, 4th Floor
Harrisburg, PA 17101
Amanda L. Short
Attorney I.D. No. 202938
(267) 207-2871
One Liberty Place
1650 Market Street, 36" Floor
Philadelphia, PA 19103
Attorneys for Petitioner
CERTIFICATE OF SERVICE
I, the undersigned, hereby certify that on this day I have served a true and correct
copy of Petitioner's Praecipe to Withdraw, Discontinue, and End, via United States, First
Class Mail upon the following:
Raymond Dinklocker
801 North Hanover Street
Carlisle, PA 17013
(Defendant)
Charles Dinklocker
50 Mountain Road
Shermans Dale, PA 17090
(Defendant)
Date- ?,A-VJIIIW 40 /
Tamara L. McLendon, Paralegal
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