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HomeMy WebLinkAbout08-6291IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: NO. 08-6291 CivilTe m ESTATE OF EARL L. SWAUGER, Deceased PETITION FOR APPROVAL OF ALLOCATION OF PROCEEDS OF SETTLEMENT OF CLAIMS ASSERTED UNDER THE PENNSYLVANIA WRONGFUL DEATH AND SURVIVAL ACT Petitioner, MARTIN N. FUHRMAN, III, Administrator of the Estate of Earl L. Swauger, deceased, by and through his counsel, Theresa L. Shade Wix, Esquire, of Wix, Wenger & Weidner, respectfully petitions this Honorable Court for an order of Court approving a compromise settlement of claims asserted under the Pennsylvania Wrongful Death and Survival Act and in support thereof avers as follows: Petitioner MARTIN N. FUHRMAN III ("Petitioner') is an adult individual residing at 540 Mountainview Road, Shermansdale, PA 17090 and is the Administrator of the Estate of Earl L. Swauger, deceased, late of Mechanicsburg, Cumberland County, Pennsylvania ("Decedent"). Petitioner is the nephew of the Decedent and was appointed to serve as Administrator of the Estate of Decedent by the Register of Wills of Cumberland County on March 26, 2008, to File Number 2008-00342. 2. Decedent died on October 24, 2007, at the age of 69 years as a result of injuries sustained in an automobile accident that occurred that same day when he was a pedestrian and was struck by a vehicle owned and operated by Wendell Ritchie, Defendant. According to the Police Report, Mr. Ritchie fled the scene of the accident and was later found and interviewed. Mr. Ritchie then confessed to hitting the Decedent. A copy of the Police Accident Report is attached as Exhibit "A". 3. At the time of his death, Decedent resided alone. He is not survived by a wife nor is he survived by children. He is survived by one sister, Sara E. Fuhrman, and one brother, Claire M. Swauger. Decedent did not have a Will. 4. Defendant was insured exclusively under an automobile insurance policy issued by State Farm Insurance Company to Defendant carrying a per person liability limit of $100,000.00 at the time of the accident. Defendant did not have additional insurance coverage. 5. There are no other possible sources of automobile insurance coverage from which to assert any additional claims arising our of Decedent's death. 6. As a consequence of Decedent's death, Petitioner submitted a claim against Defendant to Defendant's insurer State Farm under the Wrongful Death Act and the Survival Act. 7. Defendant's insurer, Sate Farm, offered the policy limits of $100,000.00. 8. Petitioner believes the $100,000.00 offer by State Farm is reasonable under the circumstances. 2 9. An inheritance tax return has not yet been filed. Inheritance tax will be due on the portion of the recovery allocated to the survival action as well as any other estate assets. 10. The estate was duly advertised. 11. Petitioner is aware of a claim against the Estate in the amount of $6,152.88 from the Department of Public Welfare for restitution of medical assistance granted to the Decedent. A copy of the claim is attached hereto and made a part hereof as Exhibit "B" 12. Petitioner is also aware of a claim against the Estate in the amount of $4,067.58 from the Myers Funeral Home, Inc. for funeral expenses. A copy of the claim is attached hereto and made a part hereof as Exhibit "C". 13. Since the Decedent had no spouse and no children, Petitioner proposes to allocate the total settlement proceeds of $100,000.00 under the Survival Act. 14. Petitioner proposes the following distribution of proceeds: A. Wix, Wenger & Weidner, Attorneys at Law: $241.60 for reimbursement of costs advanced for the advertising of Decedent's Estate; B. Department of Public Welfare: $6,152.88; C. Myers Funeral Home, Inc.: $4,067.58; D. Estate of Earl L Swauger: $89,537.94 for payment of any claims, debts, inheritance taxes, and attorneys fees of the Estate with the balance to be distributed to the beneficiaries of Decedent's Estate. 3 15. In a letter dated September 4, 2008, a copy of which is attached hereto and made a part hereof as Exhibit "D", the Pennsylvania Department of Revenue agreed to the above allocation and has no objections to the Petition. 16. Counsel for Petitioner believes that the settlement is fair and reasonable under the circumstances. Defendant is clearly liable for the injuries of the Decedent. 17. Subject to Court approval of the allocation of the proceeds of the settlement as set forth in Paragraph 12 hereof, Petitioner has agreed to accept this offer as representing, under the circumstances, a fair and reasonable settlement of the claims. WHEREFORE, Petitioner prays your Honorable Court to enter an order approving the proposed allocation of the proceeds of settlement in accordance with this Petition. Respectfully submitted, PETITIONER: Date: Q-i7 06 artin N. Fuh , , Administrator of The Estate of Earl L Swauger, deceased WIX, WENGER & WEIDNER Date: Q- V ??Q,t?? C?K? WAG Theresa L. Shade Wix, Esq., ID #43089 4705 Duke Street Harrisburg, PA 17109-3041 (717) 652-8455 Attorneys for Petitioner 4 VERIFICATION I, MARTIN N. FUHRMAN, III, Administrator of the Estate of Earl L. Swauger, deceased, certify that the statements made in the foregoing Petition which are within by personal knowledge are true, those which are based on information received from others I believe to be true. I understand that false statements herein are made subject to the penalties of 18 PA. C.S. Section 4904, relating to unswom falsification to authorities, which provides that if I knowingly made false averments, I may be subject to criminal penalties. Date: % ;TIN N. FU , III 9-l?-08 Administrator of the Estate of Earl L. Swauger, deceased CERTIFICATE OF SERVICE AND NOW, this 25th day of September, 2008, I, Gaye Crist, an employee of the firm of Wix, Wenger & Weidner, attorneys for Petitioner, Martin N. Fuhrman, III, hereby certify that I served the within Petition for Approval of Allocation of Proceeds of Settlement of Claims Asserted Under the Pennsylvania Wrongful Death and Survival Act this date by depositing a copy of same in the United States mail, postage prepaid, in Harrisburg, Pennsylvania, addressed as follows: Mr. Bryan Rondon Pennsylvania Department of Revenue Inheritance Tax Division P.O. Box 280601 Harrisburg, PA 17128-0601 Ethan K. Stone, Esq. Summers, McDonnell, Hudock, Guthrie & Skeel, LLP 1017 Mumma Road Lemoyne, PA 17043 WIX, WENGER & WEIDNER 16L.,d Gaye Cri (" State Farm Ins. 2/4/2008 3:18 PM PAGE 3/012 Fax Server 11-14-2007 09:19 KOCH FAX PAGE2 . : Print CRS A0000075 Pap I of 10 9 k I I I I e -? Pa IU CR PENNSYLVANIA ASH REPORTING FORM Crash Number Case Closed Reportable Crash e f771 A00000?5 AA 500 1 0 Yes 19 No d Yes 0 No I ncident Number Police A en Patrol Zane MBG-2007-10-0472 21404 404 O Agency Name Predntt kirvestigation Date (MM•DD-YYYY) Mechanicsburg Borough -HANICSBt11tG 10 2007 at DM atch Time (mop Arrival Time (mil Inv otor Badge Number 0654 110655 PTLM. DEVIN L. MONTGOMERY 2210 12 Reviewer Badge Number Approval Date (MM-0D-YYYY) _ - -7-71 r J e _ Coun Court Name Municipal[ Municipality' Hem 21 Cumberland 404 Mechanicsburg Borough -? Day?gair=r Sin Thu 0 C:) M F O Crash Date (MM-DD-YYYY) Crash Time (man No of Urdu Pao 1 ured Killed' *If a 00 n an 0 0 C:) r-je C) sat 0 - 24 2(107 110650 2 112 0 111 com or mte s wed Q Unk Woticseee M?S t 291 0 Yes W No SSchoold0u1 0 Yes @I No Zone 0 Vas . No tibia Pnance?TO Yes a No Relate e 0 •1 Way Intersection Q •Y' Intersection Q Muht-Ley 0 Off Ramp 0 Railroad Crossing Intersection QO O Mldblak Traffic Circlet O •T• Intersection 0 Round nlet O On Ramp Q Crossover O Other .. .ai^.-? r .? .. ...4r-??T-J'3S'' Mr?ate... - ... 1.:."_ -MV..Ia? Route Number Segment (Optional) Travel Lams Speed Limit 0 North House Number (if applicable) 0114 0? zs . 0 scuth PIS Street Name Street Ending 9 0 Edit a wi t for Md-block crashes only. Use wre W MAIN S'f n 0 k Roadwat street Name 6 M?ncipal nown Un is" In it 2±1 is option Interstate Turnpike TurnplFe State Cwnty Local Road Private Other/ 0 0 s 0 Sl 0 0 0 0 sz unkmvvn or Street Road (EastilNest) Hi a Raad (Nol Turnpike) Spur RouteROtte Number S meneg t (Optional) Travel Lanes tSpeed Limit ? Q Nash -2 Q South ? ? Street Name Street Ending ? O kast .. ST O Wart HIGH o` CD Unknown e bsterstate Tum ke Turnpike State county Local Road Private Other/ D1°II O (Not Turnpike) © (E21xW'e%) 0 SpuQ Highway O Road or Street O Road O Unknown Intersecting Rt NUM Or Mile Post Or Segment [Worker - AV F + 0 Nonh ?`? 0 r , aft O soot Or Intersecting Street Name St Ending 0 East Please Enter n} mation i - F-- 11110 0 West or RMiles 0 ¢ 4 for BOTH k L d t M k t O S i N O Mil P an mar s H Ttvs Option egmen ar er e os r Intersect ng Rt um r ,r oe 0 ?kxth Distance From Crash Scene to Landmarks 1 0 th Sou E Or Intersecting Street Name St Ending 0 East (For Crash between Landmark 1 and 0 9 c) West Landmark 21 Degrees Minutes Seconds Degree! Minutes Seconds Latitude: Longitude: - Q Yield Sign 0 Pasco Officer or Applicable 0 Traffic Signal Active RR Crossing Flagman 0 Not S Other Type TCD 0 Armilonlin Emergency hi"ce eunctionin 0 N. Controls ID g Q Preemptive Prof y Signal Control" FIaSW9 Traffic C) Signal Q Stop Sign 0 Passive RR 0 Unknown Device Not Device Futctionin 0 Functonat PTo 9 0 Unknown pirify g _ Crossing Controls Lane tined (!i •tict ?tpp/iceb7e". skip rest of the Lane Oosurc sectioN r r; 0 North l? E:lst 0 Noah and South 0 All YV) E (N S C? Not Applicabie O rarxWy 49 Fully 0 Unknown , , . ?lrxt 0 South C] West 10 East and West z3ft Yes O . No 0 t "0 min. a 30-60 Min. Q 1-3 hrs Q 36 hrs Q 69 his O > S+ hours Q Unknown Unknown Q r RM4AA•OWCMW-a PENNDOT COPY 4 Exhibit "A" hl l n•//www.ticlt6.ctatc.na.iis/icons/PTintlma2es/Xm1Fi les/20071053371 DLMBDR752007... 10/28/2007 r , State Farm Ins. 2/4/2008 3:18 PM PAGE 8/012 Fax Server 11-14-2007 09:20 KOCH FAX Print CRS A0000075 L n r I C Q?ALTH OF Pt??R SYLVAPIIA J P1,LWE CRASH REPORnUG FORM Page: AA 500 2 Polka um Only I ` I PACaE7 Page 2 of 1 111111111111 Crash Number A0000075 ?p a MrPVnh? in Q Hit & Run Venda C:) Illegally Parked Q Legally Parked Q Nun - Motorized - Commercial Vehicle = Q Pedestrian Q Pttlestriun on Skala, 0 Disabled From Q Train Q Phantom vehicle Q Yes - No h Wheelchair, etc Previous Crash (if Yet, Complete Form C) (if IPedondan' or "Pedestrlan on Skates, in Wheeekhairr, etc', Complete Form M Section 2 Unit No wrst Name MI Date of Mrth (MM•DO-YYYY) O1 WENDELL U 06 26 1943 Ddete? Last mom n p RITCHIE 7177909701 Address I I Sate Z & 6228 LOCUST STREET LIA'GLESTOWN PA 17112 Driver Umrue Nu*Amr State Class 15 699 700 PA .2 Akohof/Arugs SusDec4ed Delver or taekshtan Owskal Condition Q 15 No O NIegoI 0ri+9s Medication @9 ApHampa ly O L "al pn 'g Q Fatigue Q Medication O Alcohol CJ Alcohol and Drugs Q Oftown 0 Had Been O Sick Q Asleep C:) Unknown Dii in a ftohd Ten 7Moe p a Test Not Givers Q Broath O other Primary yofh a Code Violation Charged. w Unknown if Q ekxxl © Urine Test Given O 'fey O No y Akohof Test Ilestrlts O Test Refused Q Unknown ' Drirrer Preserxe 1.Oriver Operated 3-Drlver Plod Seat* Vehicle 4-Hit and Run O Test G rven, d R lt w ? 0 k n 9 U i D esu s Caitarr rute . now ver - n r 2-No owned Driver 00=NOt Applicable 02=Prlvate Vehide Not 04= State Police Vehicle 07=Municipal Police VPh 09=Federal Gov Veh 01 nPrlvate Vehicle Darned! Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 96=Other U 1 Leased by Driver 03»Rented Vehicle OE=Other State Gov Veh Government Vehicle 99=Unknown Owner First rasrne Owner Lest Name or suslness Nana of Pedestrian ski this Section) Same as KRISTIN); J & NV RITCHIS Address / Chy I State / x1 Vehicle Make "Make Coda 09 5577 BANBRIDGE DR HARRISBURG PA 171127112 Plymouth Vn Modd Year Vehicle Model (wuverlry) -- ? lY3AY28D3RN132975 1994 SUN U mse Plate Rag; State Get. Spoed yahkfe rowed Towed By GTK3972 FA 035 Q Yes a No insurance kre wane Company Polity No dyes Q No O known UNKNOWN T S ap t 1=Towing Pass. Veh 4=Mobile/Modular Home 7aSemi-Trailer Tap No Tap Year f n No. of U U 2=Towing Trvck 5=Camper 8.Other ? Tralling 3-Towing Utility Trailer 6-Full Trailer 9aUnknown Units' u "an of *Vehicle Position 01 •Rfovement U1 *Sea Special Usage _ Overlay Vehh* Color Vehicle Tuna OS=large Truck 20-1 ricvc e. Bicycle, L J 12afnmmPrrial Passenger 06-;Yellow U1 07=Sihrer 01=Automobile 06=SUV Tpde U1 OZ=Motorcyde 07=Van 21?therPedalcyde 00=Fret Applicable 13=T*Cartier 4 Vah 08=Gold 03=9us 10=snowMobile 2241ome & Buggy & R d 02=Ambulance 21 Tractor Trailer 01=81ue 09•Brown i er 04=Smell Truck 1 [=Farm Equip 23-Horst: 03 =Police 22=Twin Trailer 02-Red 10=0range 03eWhite 11=Purple Of -02" Complete form 12-Construction Equip 24-Train M, Section 26) 13=ATV 2S=Traltey 08=Other Emergency 23=Triple isle( ' Vehicle 31=Modified Veh 04aGreen 12=Other wn k Bl k 99 U Of '20' or '21 ', Complete 18=Other Type Spec Veh 48--Other Type Spec Veh 99-Unknown 19=Unk 11 Pupil Transport 99=Unknown n no ac = 05= . Form ht Section 27) frrit/a! G»eact point Damage Mdica?W Gradient 3-Downhill Road Allarraenc 01 DO-Non-Collisiort 14=UndereaTiage int 15-Towed Unit k P 01 112 Cl 2 ?NOne 7`RInR?^al ImMInor 1 1=Lcwe1 4aRottanof Hit ? l 1 1= Straight ? s o - - oc 13-TOO 99=Unknown 2-Uphill 9=Unknovm 9=Unknown FOAM a Maaa (rZOZI PENNDOT COPY htty://www.dot6. state.va.u s/icons/PrintImal:es/XmlFiles/200710 533 7I DLMBDR752007... 10/28/2007 State Farm Ins. 2/4/2008 3:18 PM PAGE 4/012 Fax Server 11 1 11-14-2007 09:19 KOCH FAX Print CKS A0000075 It 1, COi ALTH OF PEWNSYLVANIA I - DIOLKE CRASH REPORTING FORA Page: AA 500 2 'a- u- " E:1 PAGE3 page s of 1 U ??????I?? Cnsh Numbs A0000075 Motor Vehicle in jypp a Transport d Hit & nun Vehicle Q Ilkg?ly Parked Q Legally Parked 0 Non -Motorized Comrnarefii' Vehicle p?nT Pedestrian on Skates. Disabled km Pedestrian O O O Train O Phantom Vehicle O Yes a No in Wheechair, ok Prcviws Crash (!f Yes, Complete Form C) Of "Pedestrian' or "Pedestrian on Skate; in Wheelchair, etc', Com lets Form M Section 2d Unit No First Name MI Date of Birth (W+DD-Y`" 02 FARL L? 03 20 1938 Last Name Telephone Num er Delete? O SWAUGER 7176084926 Address ! l stab zi e ]25 WEST MAIN SMEET MEC:HANIC:SBURG PA 17055 DrWer Lltxrtse Number state Can AkohaflDrtras Sttmected Driver orPrOstrfen Phvsiof t onAlon NO Illegal Drugs Q Medication e l AtlY Ca 'Ult?* Dru9 Q Fatigue Q Medication O Akohd 0 Akohd and Drugs O Unknown O H ad been Q Sick O Asleep Q Urll 101 D rinking o Akohd TesLTvne 0 last Not Given O Breath O Other Pd many Vehide jCade Viofaeion Charged? O Mood Q Urine 0 Tnkk estnGo If C:) Yes O No y Afcoh& Test Resu/tr Q Test Refused Q Re ^ON!^ Results D'ifte Pretailte 1=driver Operated 3-Driver Red Scene l a y 0 C Vehicle 4-Hit and Run or rt r+in tad Rasuits I I• 2^Fto Driver 9-Unknown 0w w#Vrftler 00=Idol Applicable 02=Private Vehicle Not Oa=State Police Vehlde D )_Mu6dpal Police Veh 09=Federal Gov Veh 01=Private Vehicle 0VW1ed( OwnedilLemed by Driver 05-PEWNDOT Vehicle 08--Other Municipal "-OO r leased by Driver 03dtented Vehicle 06--0ther State Gov Veh Government vehicle 99=Unknown same a, Owner First Nance Owner Last Name or Business Name (if Pedestrian, ski thft $talorr) Driver Co Address i CRY I State I Zip Vehicle Malta 'Matte Code VIN Model Year Vrlllde model (see overlay) Lkeedt Plata NOV' State Est Speed Vehlde Towed Towed s 000 C7 Yes CD No Insurance Insurance Company Policy No a Q Yes ONO O k wn Tratfrnq T 1=Towing Pass. Veh 4=Mobile/Modular Hume Memi•Traiier Tag No Tag Year Tag St Tniling? Unit ?`Towing Truck Sdamper 8=Other I I • Units: 3=Towing Utility Trailer ticmFull Trailer 9-Unknow .Y r Dim of El •Vehide Poshion ? *Movement ? rl Ovv rl a Saecae/ Gsaoe e y e Vehicle Color VehJd? TY[re 05=Large Truck 20=Unicycle, bicycle, 12=Commercial Passenger 06=Yelknv 07=Silvor r? ot=Automobile: 06-SUV Tricycle 1 02=Motorcycle 07=Van 21=Other Pedalcycte 00¦NotApplica* carrier 01=Fire Veh i3=taxi OB=Cvold 03=Bus 10*Svwmobi1e 72=Horse & Buggy 02uArntx,Iance 21-Tractor Trailer 01-Blue 09a8rown 04v5mall Truck 11 =Farm Equip 23=Horse & Rider 03=Police 22=Twin Trailer 02=Red 10=Orange 03=White 11=Purple (if '02', Complete Form 12=Comtruction Equip Z4;'Train At Section 761 13=ATV - 2S=Trolley 08=Other Emergency 23-1riple Trailer Vehicle 37=Modified Veh 04=Green 12=Other 05 =Black 99=Unknown (if '70' er 21", Complete I3wMer Type Spec Veh 08--Other , Form M, Section 27) 19=Unk. Type Spat; Veh 99=unknown t t =Pupil Transport 99-Unknown 1111W 111100d Paint Damage Indicator Mraftnt 3=Do"h1I) NW A#AM-PW WmNon-Colfision 14--Undercarriage 0=None 7=Functional 1=14rnor 3=Disabling 1=Level 4?Ottom Of Hill 0 5=Top of Hill ? 1=5traight 2?urved 01-12=Clock Points 1S=Towed Unrt 9mUnknpwn 2=Uphill 9=Unknown 9=UnkAovvi% 13-Top 99-Unknown _ FOr1M r M OwtiYNa) PENNDOT COPY http://www.dot6.state.Ila.us/icons/Printlmages/Xmll, iles/20071053371 DLMBDR752007... 10/28/2007 StAte Farm ins. 2/4/2008 3:18 PM PAGE 11-14-2007 09:20 KOCH FAX Print CRS A0000075 9/012 Fax Server PAGE8 Page 4 of 1.0 COMMONWEALTH OF LICE CRASH REPORTING FORM PENNSYLVANIA J PO Pegs AA 500 3 Crash Number A0000075 fm= rype: A 1-0river 2 Pxt D A Passenger/Occupant l E OD-None tlaed ! Na i?ppxcable ?__. . G7 0 liable = Senger 7=Pedestrian 01-DrKw • a l vehicles 02-front Seat Middle Position 01-6ho<,Ider belt Used G2-Lap Belt Used I-Not Erected 2=Tntally Ejected Soother 03=Front Seat RigM Side 03+d.ap And Shoulder Bak used 3=Partially Ejected 9--Unknown 04=5econd Raw - I eh Side Or 04.Ch%d Safety Seat Used 9=Unknown Motorcycle Passenger 05=Motorcycle Helmet Used OS=5etond Row - Middle fbsition d R i 06 S 06=Bicycle Helmet Used H F.f PPff3 SW F =Female ow - R - econ ght Side 07-Third Row Or Greater - 10-Srfuty Wt lied Improperly IIsChild Safety Seat Used knpropcrly D -Not Ejected / Not Applicable `o a+ M =Male U =Unknown Side Left OS _ Row Or Greater - 12- 90=Restnt UsdAdmt yl, Unknown 1=T1VOug11 Side Door Opening 2=Throe Side Window N Middle pwion 09eThkd Kew Or Greater - 99=Unknown 3aThrough Nftndshield 44hrough Back Door Right Side 5=Through Back Ow Tail to Oaening 6=Throu h Root O eninn SWtroof/ 10-SWper Sartion of Trvckcab F 010-nbne ! Non Applicable g p gg Comertr'ble Top DoiiA. C 1 1=Kililed I 1=let t]Iher Enclosed Passenger Or Cargo Area 011 -Front Arc Beg neployed (For This Seat) 02=Side Air Beg Dep" (For Thi1 Seat) 7.Through Roof Opening (Convertible 2"or Injury 3.Moderate 12*In en Area (9 Of Pickup. Etc,) o.3=Other Type Air erg Deployed 04=Multiple Air Bags De pkiyed Top Up) 9=Unknown Injury 13-Trailing Unit ' 05-Momrcyde Eye NoWt 4aminor Injury B I U k 14oflid ing On Vehicle Exterior er 15--Bus Passen 06-8i yclist wearing Elbow/Knee/Fads it N t D l d S h O *=Air B n . njury, g eg w c o ep oye . n 0=Not Appliabk 51mrtty 98-Other 11=Wr Bq Not Deployed, Wich Off 1=Not Extricated 9.Unknown if injury 99--Unknown 12.Air 8 Not Deployed. Settkil; 2=ExtrK.lted By MettWnical Mears F : 13=Air B g Removed Prior To Crash} . - reed My Non - Mechanical Mearo 8=Other 19=Unknown if Air Rag vcployed - ---•-.- 9=1LInknown t EMS Agency- I WEST SHORE EMS Medical Feci ty PENN STATE HERSHEY MEDICAI. CF.NTE Unit No Perw No tMinte? Data of Birth (MM-00-YYYY) A B C D E F G 14 1 r 01 01 p 06 - 26 - 1943 IJ D El 0I 99 00 0? Nom / Address / IlMne El opera or RITCHIE, WENDELL F 6228 LOCUST STREET i.ING1,13STOWN PA 171 CD Ys Transport Unit No Person No Delate7 onto of Birth (MM-0D-YYYY) A B C D E F G H I 02 O 1 p 03 - 2Q - 193 $ FLI H1 a OQ 00 00 6? 15,115"1 Name / Address / Phone ERAS Transport ?amr SWAUGER, EARL I. 125 WEST MAIN STREET MEC HANICSF3UKti PA 17 M Yes CD No -...y . _.___. ?_ ..... _.. _ _ Unit No Person No Delete? Data of (MM-DD-YYYY) A B C D E F G -1 C) LJ01:1C?OC?Ellf Name / Address / Ptrone EMS Transport [I Sam. as Operator CD Yes CD No Unit No Person N Rio of slr11h (MM-DO YY A B D E F G H I Name 1 Address / Phone EMS Transport ? Same Uperrtor (] Yes Q No (U?nlt NO Person No Onto of Birth (MM4MIiY(YY)) ( AA B C E F G H I Belem? Name /Address /Phone EMS Transport _ ? Operator O Yes Na Link No Person No Date of Birth (MM-DD-YYYY) A @ C D E F O G ti I D e7 -? 00Fl=F]0LJ Nome / Address / Phone EMS Transport ? Same as Operator Yes C] No rotlst0AA-sso ftmq PENNDOT COPY http-//www.dot6.slate.pa.us/icons/PriniTmage"miFi les/200710533 71DLMBDR752007... 10/28/2007 State Farm Ins. 2/4/2008 3:18 PM PAGE 11-14-2007 09:19 KOCH FAX Print CRS A0000075 COIi MONWFALTH OF PENNSYLVANIA , Poua CRASH REPORT NG Fmm raw AA 500 4 "a°" 1ean't" - ( Q"' O-Nonleaubn P=Head On 4=Mgis 141ear End 3-11W )w 5•$?d -..;%wbo ) Reb!"n to Real dwav ? 1--On Travel Lanes 9=1Nadien 2-Shoup er ,=Roadside 5=0utW6 7fiffieway 7151301,41 (FttUrp korseclfat) 5=m Pa"g I.Ane 9.Unknom to ? ? RlnNnaf! fi? ?' Waatlrey CondlNons Read [onditians s` I F S a° E 2> No Ugms PraFbatlwO?vk • Unr vn _lghnn 1•No A ve?nM 3--81s0 (HA 5=FO9 74%et do Foy 9wtJnkrnwn 2-Rain 4-8now S.fHin & Poo B_Odw - 0=Dry 2=&A Mud. Did, 4?lush - oWhed a-mar 6-loa P 1=wat 3=5now Covered 5=les r or Ftalnp Harts Event L Most? Utility Pole Number Unk No 1 02 LJ s 1 01 2 ? O PWu ry`n 3 ? 0 Events in "Ztw SegEl ° Harm Event L/R Meat? UtiEty Pale Nunther 1 II Unit No El a 02 2 Q Meese put 0 1 OWE ovens In SCq rt/EllderrraJ 4 ? Q G Unit No Nsrm want sbt Unk No [farm Event F O1 02 ern 02 11 06 ro" span an nxmwn an "%am prm Envhonalllrgl/ RtudweY 103 2 3 P0e011W FecMr3 (PAP) OOaNone 11=Siippery Road Conditions ke/SnDw) 01= Windy Conditions !2=Substance On Roadway 02=Sudden Zthe Conditions '3=Potholes 03-Otlur Weather Conditions '4=Broken Or Cracked Pavement Dusan In Roadway ' 5_TCD Obstructed OS=Obstacle On RoadNa•r 16=Soft Shoulder Or Shoulder Drop Off 06=0ther Animal in Roadway 28•Other Roadway Factor 07=Glare 23=Other Erwiromnental Factor ' 0"belt Zone Related 99-Unknown IC A rr r1u NJ u.wipers glfa r pine Q6=Exhaust 13=Driver Seatirg/Conrd 01=Tires n7_Head R`L 14Doors. Hood. Etc 02-asks System 08=Signal Trdr Hitch 03=Steering System 09--Other is 16=VV#.6Wds ' S 04-Suspension r Trai rn 18 17=-TA railer Overioaded 05=Power Train I I =Mirrors 19=Unseture/Shifted T Not O 1 t ()Q 2 2 Trager e Load O?rrtpraper T 21-Obstr%d Wi Meld unit 09-Unkrwwn indicated Prime factor nvrupcp?iq ?1°?ramabnto E/R V 0 P CD C7 99 0 troRar a ,usoo fts>ni1 Unit No Oeemr Cede 01 10 M FIR is the Prime Factor Type, leave trnir No blank N J Eventr (Nana Event 01sNk Unit t 02=Hit Unit 1 O=HR Unit 3 04=Hit Unit 4 05_mk Unit 5 Ofi=rrt Other Traffic Unit 01--.Hit Deer 08-Aft Other Animal D9=C0#Ww With Other Nan Fend Object 11=Struck By Unit 1 12=5tnxk ey Unit 1 13=Struck By Unit 3 14=Struck By Unit 4 15=SMrdc By Unil 5 161115Uutk By Ocher Traffic UnIT 21 . t Tree Or 5ttrubb?ry 22m®r Emt?Bnkment Z3wHk Util!?'?ty Pole 24=Hk 7,A Sign 25=HR Guard Rail 26=1# Guard Rib End 27=Hi1 Curb 28-W Gonerete Of sal Uamer 29=1 it Itch 00-M Contributing Action 01=Driver Was DlsCacted 0?=Driving Using And Held Phone 03*Driving Using •Iends rive Phone 04=Making Ilio.7al U-1 urn OS--Imp opeainmless Tuming 06=Tum om Wrong Lane 07aPrOCr?mg W/0 tleaiance After Stop End TO e"MI Device 14=Ceps Pzsing Or lane Change t S=Passing In No Pasiing Zack 16=Driving The wrong Way On 1-way Street 30aHk Fence Or Wa8 31 Hit Bu"vV 32-Hit Cullen 3304 Bridge Pier Or Abutment 34=HR Parapet End 35-Hit midge Rail 36-Hit Bguldw YOr Obstacle 37--Nh krytact Attenvator )M•Hit Fire Hydrant 39411t Roa my Equipment 40=Hk Mai 8= 41=Hit Traffic Island 42=Hit Snow bank 43a HR Tempo ary Construction 48-Hk Other FBMd Obtect 49aHA Unknown F 0*,ct W-OveRWrrAol Over 51-Struck By Thrown Or Fa" 52-PPoonks Or Other Pavement kregularibes 53-Jacks h Sarre In Vehicle SB=Otter Non-Cdlhbn 99--Vr*nown Harmful Event 17=Car0ess Or Illegal - Backing On Roadway iB:INNyg On The Wrong side 6r Road 19-Making kspraper Entrance To Higt 20--Makrlg Improper 2idareem Pa?rkrx 4;iading 22-Over/Under Compensation At Curve 13=Speed 24?(ivhy i00 fast For Conditions 25-Faili,re ro Maintain °rnper Speed 26-Driver Fleeing Police (Pd Chase) 2%Ddw I ertced 2JJ-Falt,re T Specialized Equip 91?Ufected By Physical Condition g8-Other Improper Driving Actions 94=Unknown No ck 1 10 2 3 ?.4? Not 02 1 00 2 3 1? ° F Pedesbfan Action (P) 0.=Working 00=Norte 04=PMng vehicle Dl peciirtg cation rg At s pedfin! Location 05??p mach Or teavin9 Vehicle OB-NJorking Omit Vehicle d' S 7 01-Walking, Running k'49r^9. tan 0 . 9 Or Playing 9 99=Unknown Unit Me O i 00 Unit No 02 01 PERWDOT COPV . 5/012 Fax Server PAGE4 Pale 5 of 10 II Mpl?ll Crash .,*e 1 A0000075 OlrxHen) S.H# Pedestrian 7= Nit fted Oblad 9sOMer/Unktown httlD://Nvww.dot6.state.t)a.tt:/icons/PrintlmaL,es/XmlFiles/20071053371 DLMBDR752007... 10/28/2007 . State Farm Ins. 2/4/2008 3:18 PM PAGE 10/012 Fax Server 11-14-200' 09:20 KDCH FAX Print CRS A0000075 i J COMMONWEALTH OF PENNSYLVANIA POLICE CRASH REPORTING FORM Page AA 500 5 P*2 uu cry PAGE9 Page 6 of 1 113111111 Crash Number A0000075 ..._,,. ?....,.....I._.........._. ;..... , .,..... ; r r ! I ? I I I 1 i I ! ...... ! i 1 I ..__...i...._....a..........e... ,.. .v.................. .. a...._ _..r.........r.......... ....._..:..,_._..I ....... .._ _ .. _. _«. { i ! € i ! . . -=........?._.__S.__._.C._....!-'-_- _ ! , ! ? ' i i 1 ( ' j I i 1 1 { r e , , ) i : r r , I ! ! I i ; I I I I .._....!................... ...._..?...._... ... ' ._ ' ... ' _.. _. .............. ... ... ................. - ... .... ! i ! .....y......... i..._...7.. ._ __ _ _. ._ ... _- _. _._ .. _ .._ - _ _ _.. i i ...._....i..... .....i...........i.._....._..i......._.i.......__i ..... ... ... ... ... .. .. . .... .. ... .. I i I ? I } i i I ._._.?._ .. i ...i _ i .. I........_f ... `.. __.1 _ _..i ?..; _.I .. ..i " _..?_ . ? ...t«. ...I. t I , i r ! I I I I_......__.i... . .._i. _ .i. ..i . , i. . . . .. . ir.. . i . i. .I. i + i . : . . i _ .. ... ._._ . . ._ . ...... . . . ..... ...... _ ......._ . .... ....... . -..._- . .......... . . .._....y....__... ..._.... .. _ ... _.. .. Witness Name Address Phone 1 t LEON BYRD 1010 COUNTRY CLUB RD CAMP HILL PA 17 7178291408 21F,AN MACKE.Y 7073 CARLISE P1Kl /iii CARLISLE PA 1 7177660316 Narrative and additional witnesses: Accident Investigation Notifica ion Mucci? O Property Damage O ON 10/24/2007 AT APPROX. 0654 HRS., THE MECHANICSBURG POLICE DEPT. WAS DISPATCHED TO THE INTERSECTION OF W. MAIN ST. AND HIGH ST. FOR A PEDESTRIAN STRUCK. ARRIVED ON SCENE AND FOUND A MALE LAYING IN THE MIDDLE OF THE ROAD GASPING FOR AIR AND YELLING. PLENTY OF EMS PERSONNEL WERE ALREADY ON SCENE, NO ASSISTANCE WAS NEEDED. WAS ADVISED THE STRIKING VEHICLE HAD a FLED THE SCENE. BOLO WAS PUT OUT ON DESCRIP TION OF VEHICLE, A DARK IN COLOR EITHER DODGE OR CHRYSLER SEDAN WITH POSSIBLE FRONT END DAMAGE, LAST SEEN 9 f HEADING WR ON W. MAIN ST. NO FILE 2 WAS OBTAINED. SPOKE WITH WITNESS #1, A LEON BYRD, WHO ADVISED HE WAS TRAVELING WB IN THE 100 BLK. OF W. MAIN ST. BEHIND THE STRIKING VEHICLE, APPROX. 3-4 CAR LENGTHS BEHIND STRIKING VEHICLE. THERE WERE NO VEHICLES IN BETWEEN BYRD AND THE STRIKING VEHICLE. BYRD REPORTED THAT AS HE WAS TRAVELING BEHIND THE STRIKING VEHICLE, HE SAW THE VICTIM STANDING ON THE N. SIDE OF W. MAIN ST. BY CLAY'S EXXON STATION HOLDING AN UMBRELLA. BYRD REPORTED THINKING TO HIMSELF THAT IF THE VEHICLE IN FRONT OF HIM DOESN'T SLOW DOWN, THAT HE'S GOING TO HIT THE PEDESTRIAN. BYRD THEN REPORTED THAT HE SAW THE MALE START TO CROSS THE ROAD THROUGH THE STRIKING VEHICLES WINDSHIELD AND THE S TRIKING VEHICLE DID NOT HIT HIS BRAKES BUT KEPT GOING AND STRUCK THE PEDESTRIAN. BYRD THEN REPORTED THAT THE STRIK ING VEHICLE PULLED OFF TO THE SIDE OF THE ROAD, THEN PULLED AHEAD A LITTLE MORE, THEN FLED THE Pam 0 ",Am t12" PENN NOT COPY http://www.dot6.state.pa.us/icons/PxintImages/XmIFiles/20071053371 DLMBDR752007... 10/28/2007 State Farm ins. 2/4/2008 3:18 PM PAGE 6/012 Fax Server 11-14-2007 09:19 KOCH FAX PAGES Print CRS AD000075 Page 7 of 10 OF PENNSYLVANIA ?INif?fh?lilf? Crashwe„ksr -1 KtCZ CRASH GIItI"6 OOG ram Age C? New A0000075 AA 5WN l hi- x ? ?o c) ca?flnuatlsA n 9 wmldve and additional witnesses: SCENE. BYRD ADVSISED THAT IN HIS ESTIMATION, THE STRIKING VEHICLE WAS TRAVELING APPROX. 35-440 MPH. SPEED ON W. MAIN ST. IS 25 MPH. BYR D THEN WENT TO THE AID OF THE PEDESTRIAN. 2ND WITNESS, A JEAN MACKEY REPORTED THAT.SHE WAS TRAVELING EB IN THE 100 B LK. OF W. MAIN ST. MACKEY REPORTED SEEING THE PEDESTRIAN STANDING BY THE EXXON GAS STATION HOLDING AN UMBRELLA MACKEY ADVISED THAT SHE ALSO SAW THE PEDESTRIAN CROSSWALK SIGN. MACKEY ADVISED THAT SHE OBSERVED TWO VEHICLES WITH THEIR HEADLIGHTS ON HEADED WB. MACKEY THEN THOUGHT TO HERSELF THAT THE VEHICLE IN FRONT BETTER SLOW DOWN BEFORE HE HITS THE PEDESTRIAN. MACKEY OBSERVED THE PEDESTRIAN START IN TO THE CROSSWALK. AT THE INTERSECTION OF W. MAIN AND HIGH ST., THE PEDESTRIAN, LATER INOENTIFIED AS EARL L. SWAUGER WAS STRUCK BY THE ONCOMING VEHICLE. MACKEY REPORTED SEEING THE PEDESTRIAN BEING STRUCK, EJECTED IN TO THE AIR APPROX. 15-20 FT. IN TO THE AIR AND THEN LANDING ON THE PAVEMENT. MACKEY THEN WENT TO THE AID OF THE PEDESTRIAN. SWAUGER WAS TAKEN TO HERSHEY MEDICAL CENTER BY WEST SHORE EMS. SWAUGER SUSTAINED INTERNAL INJURIES, AS WELL AS HEAD TRAUMA AND LEG TRAUMA. SWAUGER DIED THAT NIGHT AT APPROX. 1937 HRS. AT HERSHEY MEDICAL CENTER. SUSPEECT VEHICLE WAS FOUND, DRIVER IDENTIFIED AS WENDELL RITCHIE. DRIVER WAS INTERVIEWED AND CONFESSED TO HITTING SWAUGER. RITCHIE ADVISED HE DID NOT SEE SWAUGER UNTIL THE LAST SECOND AND THEN PANICKED WHEN HE SAW HIM LAYING IN THE ROAD NOT MOVING. 1R VEHICLE WAS IMPOUNDED AND A SEARCH WARRANT WAS OBTAINED TQ SEA RCH THE VEHICLE FOR EVIDENCE. CHARGES PENDING ow FOAM f &*4 FMMq PENNDOT COPY httn:/Iwww.dotb_sfate.na.us/icons/PrintTmas:;es/XmlFiles/2007105337 f. DLMBDR752007... 10/28/2007 State Farm Ins. 2/4/2008 3:18 PM PAGE 11/012 Fax Server 11-14-2007 09:21 KOCH FAX Print CRS A0000075 i E PAGE10 Page 8of1.9 FOLOmi rowa O New M 500 F ft-Ziao'" Q -3 0 CM W A0000075 I wntIflu" n load S 1Yar 0 Bridr or Blodt O DIR Special /orfsdkdan O Military - O Other Federal Sites Conaele o Gravel nr Q other M nO?SKda^ Q Ilan Reservation O Dow Batlctap ©Unknown Q Natlerlal Park Q CC, niversrty O Unknown Please complete Unit Informatbn for ends unit involved in a final Crash. Do not repeat the Information in the fields above on multiple pages vo U I Pdnd It O 0 I Nonntollislom O -toRlsion 11 12 0 O O c 5 O Restrictions Co li d w O Not a Pennsylvania O Top 10 02 r a Cor mp e ? Or? (? 09 03 0 No Ratrktionsl Cam. O red VWfrth Q Unknown C li O Undercarriage 0 4 NotApplkaOle O Compliance omp ance C:) Towed Untt O 07 O 05 C O6 O 1$5 0=- With Pennsylvania O Driver Q unknown O (D to Q Required - Non Compliance Q Unknown Compliance AyoMaaa AfarseZW 0 Move Required O ?? im, No Avoidance Manawsr Braldn Other Hance O 9 ? Evtden t'! Maneuver VdvW dred for 4u O M 4M C? If CPL or O 11 llfty dkerldrt O or [Mvveir Stated O Imm?ckaive ? 1 Ide ired Requ 0 No Valid Liceree for Criss O Not a Pennsylvania Driver Braking - No Skid Q Mar Driver Steering and Braking 0 Unknown O Evidence or Stated O Not Licensed O "*d Ueerue for S Class O Unknown Under ardrratar ursderrida No thou Test Tme C] Blood O Other ? No underride or C ? ment [] V?? Other O d None Q Urine O Unknown if Test i Overrldd In G ven Undarrlda Unknown If Underrrde L? Tint Aas.trrr - fw to ror? Iten,fn/ F1 , O Irttrusion t , or O mUenkt O U ride Override 0 = No Test Given 5 = Amphetamines I . No Drug Reported 6 s ea 2 = 8 Oth D EfRemert0! Both Lights and C7 Lights Flashing © 3 . Caalne 4 = Oplates = er 9 ¦ Unknown Test Results (? !_ J ? Not In Emergency Use Siren O Siren Sounding O Unknown unit No 02 E PdnaWk1IInn a Point O Non-Collision O - Olt 12 0 Q O ' R t i t 1 2 Resokybru; es r c ions a Compiled VArh Not a Pennsylvania O Driver O Tap No Restrlttlonsl O Resaktlons Not coffloled with Q Unknown compliance CD Undwarri ge 0 09 03(_0 Not Applicable O Compliance O Towed Unit ©08 07 O n b O ?? O Required • Complied with O Note Pennsylvania iknret O unknown 0 0 Regnked - Non O Unknown Avoldenot MMuver W None Required Compliance O Required - Compliance No Avoidance O Maneuver Other O Other Avoidance CD M Compliance Unknown i fvlde e Zam? Nor Required for O Velsirk Class O Link if CDL or Brak ng Mid c) Morin Evident G Steering Evidence 0 Immnehalve car Driver Stated No Valid License O for Class Cot Required 0 DNot ri arPennsywenia Braking No Skid 0 MarluDriver edeq O Unknown O delneqce an SttaBraki M Not Litmed O V alid License for U Stated V Q nknown 'Under ft Indicator Dorian Test ? O Blood Other O No Underrida or Q d O Underride, Na Override Other O Compartment Vehicle None urine d CD UnkrKmon if Test Given verri e Mtruaon Urderride, Undrrrlde, Unknown if Dnnj rest Resaft - ft to Four Reaultr) (} Q O Compartment Intrusion O Compartment O Undwide or Intrusion Unknown Override 0 s No Test given S s Amphetamines 2 = 1NAoariDrug. aportod 6 = F(F a a . Coo he 0 = Unknown Test D e,Vem Use Not in Emergency CD Lights F4shing O Si?? Lights AM 4 = Opiates Results O Use O Siren SowWtng O Unknown VUM a Awaovfaaeq PEA NEW COPY t T 11ttp://wwvv.dot6.state.pa.us/icons/Printtmages/Xm1Files/20071053371 DLM13DR752007... 10/28/2007 StAte Farm Ins. 2/4/2008 3:18 PM PAGE 7/012 Fax Server 11-14-2C?0' Q9:20 KOCH FAX PAGED Print CRS A0000075 , Page 9 of 10 J COWNROGINMEALT H OF G °A New Q Page 111(1111111 Crash Number AA 500 M u° C:) OMW A0000075 I I r Unit No For Anwrars to tiro bellow (.=W f . ingine Size rand Helmet Type) use the following codes Y = Yee N = No U . Unknown E"g im LID&= Delver Protection 7 Helmet Two* Passenger Proton 7 Naknet Tvee Motorfytle Ham? 7RAAdzV-klae2 ? Eye Protection 0 - No I141mst ? t - Full Helmet 0 = fu Helmet F? Eye Protecrion 1 = No Helmet 11 Passenger ? MC Education Z - 3/4 Style 3 lm Half H t 2 . 3/4 Style lf H l t 3 H c Saddle Long Sleeves - e e style e me = a ? Lang Sleeves Style ? Sip arid/ 9 = Unknown 9 = Unknown or Trunk ? Trailer ? Long Pants ? Helmet Stay On? ? Long Pants ? Helnnet Stay On? Helmet has ? Over Ankle soots Q DOT or Snell Helmet has Over Ankle Boon ? DOT or Snell Designation Designation • r Unit He Passenger? Heknet7 N n No ? ? Urdt No Use eode5 Passenger? Helmet? ? N= No g i U Unk Head nown Rear Lights? eeileelors? U = Unk nown Head Rear Li ht ? R fl ? g s e ector O We lhealesmae etie.. 01 = Marked Crosswalks at Intersection 01 = Marked Crosswalks at Intersection 02 = At int 4mcdon - No Crosswalks 02 . At Intersection - No Crosswalks Amhdrjiw Myth* 03 = Non-Intersection Crosswalks MeStdian SkM 03 ¦ Non•Intetseclion Crosswalks Yes 04 = Driveway Access O Yes 04m Driveway Access r to ND _ 06 In Roadway 6 ¦ Not in Roadway O No 06 05 • In ay ©"at kolm-cliolt C7 = Mecbn O Not at Intersection 07 s Median 08 = Ward 08- Island MOWN cmum 09 = Shoulder Pedestrian !^ 09 . Shoulder O Light to a S clewaat Q Light 10 = Sidewalk Dark 11 - < 10 Feet ON Road 12 . > 10 Feet 01 Read O D#rk 11 = < 10 Feet Oft Road 12 = > 10 Feet OH Road Q Rellective 13 = Outside Trafflway O Reflective 13 . Outside Tu f CAVY O Unknown 14 ¦ Shared Paths fraf 99 = Unknown O Unknown 14- Shared PathslTralY 99 = Vnknown Wad Zone True z6ftle In whfk Zone ? Work I SDeed g rAd vft*Liar (( 0 taneClowrc) Construction (Long TORN _ . , Before 1st work Zone Warning Sign ta>r Fn?ooolmtat Road Cued with ? Dame? O Maintenance Q Advance Warning Area O r ene (Mark ally that Work on ShWrler (Snort Tenn) 0 Transition Area lv t r O Utility Co"" m ers 0 Act" Area Q Yes O No t?raw, leave ? Intermittent Work? s Q Other Q No O termination Area 0 unknown Q flogger Cornualt Q Other d Unknown Other List a# lbaft Stunt In AWr.]pir? A ddifiona11M4•ap Ink matian PENNDOT COPY http:lhvww.dot6.state.pa.L slicons/PrintImageslXmIFilesl2007l 053371 DLMBDR752O07... 10/28/2007 State Farm Ins. 2/4/2008 3:18 PM PAGE 12/012 Fax Server 11-14-2007 09:21 KOCH FAX Print CRS X10000075 Crash Number. A0000075 Incident Number: MBG-2007-10-0472 ?.? a?r?,x?Yiacr ?r 7G? ?tc? N PAGEli Page 10 01 t i p 0 httpJ/www.dot6.state.pa.us/icoins/PrintImages/Xmi iles/2007105337IDLMBDR752007... 10/28/2007 F"k;b, f 7? COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 May 14, 2008 WIX WENGER & WEIDNER THERESA L SHADE WIX ESQUIRE 4705 DUKE ST HARRISBURG PA 17109-3041 Re: EARL SWAUGER CIS #: 002537508 SSN: 195-28-0294 Date of Death: 10/24/2007 Dear Ms. Wix: Please be advised that the Department of Public Welfare maintains a claim in the amount of $6,152.88 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $.00, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $6,152.88, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. if the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, 4 1404-1 Susan E. Naylor TPL Program Investigator 717-772-6265 717-772-6553 FAX Enclosure Exhibit "B" I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION - CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 May 14, 2008 STATEMENT OF CLAIM SUMMARY NAME Estate of SWAUGER, EARL ID 002 637 508 MEDICAL - CLASS 3 CLASS 6 TOTAL INPATIENT .00 5,711.12 5,711.12 OUTPATIENT .00 441.76 441.76 LONG TERM CARE .00 .00 .00 DRUG .00 .00 .00 REIMBURSEMENT TO DPW " .00 6,152.88 6,152.88 <0 f YLVANIA v,-, r W QP yWELFAY U?fi. .. k 7Sd4 y 'k = v ?. o(pf ? ? hCt. COMMONWEALTH OF-PENNSYLVANIA DEPARTMENT OFPUBLIG WELFARE, May 14, 2008 STATEMENT OF CLAIM NAME SWAUGER, EARL ID 002 537 508 PINNACLE HEALTH HOSPITALS 111 S FRONT ST ARRISSURG PA 17101 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN 12!10199 - 12116199 04110100 40000753122170001 DIAGNOSIS 1: 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 000000 ADJUSTED CRN I USUAL CHARGES I AMOUNT APPROVED 40000753122170001 36,550.70 5,711.12 PROVIDER SUBTOTAL PINNACLE HEALTH HOSPITALS 36,550.70 5,711.12 01 100002563 0043 ` COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE May 14, 2008 STATEMENT OF CLAIM NAME SWAUGER, EARL ID 002 537508 GROSSMAN ALLAN B 2200 DOVER RD ARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINALCRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 12115/99 - 12115/99 07131100 40001956790770001 40001956790770001 185.00 45.00 DIAGNOSIS 1: 1101 DERMATOPHYTOSIS OF NAIL PROC CODE : 99254 INITIAL INPATIENT CONSULTATION FOR A NEW PROVIDER SUBTOTAL GROSSMAN ALLAN B 185.00 45.00 '' 14 001559467 0004 -- ` COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUB'LIC WELFARE May 14, 2008 STATEMENT OF CLAIM NAME SWAUGER, EARL ID 002 537 508 MANDAK JEFFREY S 1000 N FRONT ST ORMLEYSBURG PA 17043 'DATE OF SERVICE PAYMENT PATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 12112199 - 12112199 09104100 40002306617520001 40002306617620001 30.00 7.50 DIAGNOSIS 1: 41401 CORONARY ATHEROSLEROSIS N DIAGNOSIS 2: 41071 SUBENDOCARDIAL INFAR [NIT PROC CODE : 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT L PR SIJ6jgTAL , MANDAK JEFFREY S 30.00 7.50 31 001473101 0003 I' I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE May 14, 2008 STATEMENT OF CLAIM NAME SWAUGER, EARL ID', 002 537 508 SAFAEE MASOOD S 2601 N 3RD ST ARRISBURG PA 17110 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED URN USUAL CHARGES. AMOUNT APPROVED 12110199 - 12110199 04124100 40000886139810001 40000886139810001 220.75 38.00 DIAGNOSIS 1: 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE 12/11199 - 12111199 04124100 40000886139820001 40000886139820001 206.50 145.63 DIAGNOSIS 1: 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT 12112199 - 12/12199 04124100 40000886139830001 40000886139830001 206.50 145.63 DIAGNOSIS 1: 41071 SUBENDOCARDIAL INFAR [NIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT 12113199 - 12113/99 04124/00 40000886139840001 40000886139840001 92.00 15.00 DIAGNOSIS 1: 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR 12/14199 - 12/14199 04124100 40000886139850001 40000886139850001 92.00 15.00 DIAGNOSIS 1: 41071 SUBENDOCARDIAL INFAR [NIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR 12115/99 - 12115199 04124100 40000886139860001 40000886139860001 92.00 15.00 DIAGNOSIS 1: 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR 12/16199 - 12116199 04124100 40000886139870001 40000886139870001 122.75 15.00 DIAGNOSIS 1: 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99238 HOSPITAL PROVIDER SUB TOTAL : SAFAEE MASOOD S 31 001714180 0001 1,032.50 389.26 rx-k; C-, • Y !Ayers Funeral Home, Inc. ttoyo L. Myers Jr., bupervisor 37 East Main Street mecnanicsburg, Pennsylvania 17055 (717) 766-3421 A stannaro of excellence to Central Pennsylvania since 1910 rnoay, may 2'3, Luus Mrs. Jara t. Funrman 4521 KOIO C:OUrt MecnanlCSburg, NA 1 /Ubb Fax(717)795-7291 uear Sara, Thank you for selecting our funeral home to provide services for your family during your bereavement. I hope that you found our services to be of the highest standards and that they met your needs and those of your family and friends. The following is a summary of the service charges as previously explained and provided in written form on the services for: Earl L. Swauger SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED $8,842.67 LESS: Credits granted 1,595.00 LESS: Total Payments 3.180.09 CURRENT BALANCE $4.067.58 Credits Granted- $1,595.00 Package Price Discourt Interest at the rate of 1.5 % per month ( 18 % per annum) will be added to balance after 30 days. If there are any questions or concerns that remain unanswered, please call me. Sincerely, 3 Exhibit "C" ?,cf?? b",t ? COMMONWEALTH OF PENNSYLVANIA DEPARTMENT'OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG, PA 17128-0601 Telephone 9/4/2008 717-783-5825 717-783-3467 (fax) brondon distate.pa.us (e-mail) Theresa L Shade Wix Wix Wenger & Weidner 4705 Duke St Harrisburg, PA 17109-0341 Re: Estate of Earl L Swauger. File Number: 2108-0342 Court Number: CCP - Cumberland Co Dear Ms Shade: The Department of Revenue has received a letter concerning the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the letter, the 69 -year-old-decedent died as a result of being struck by a car. Decedent is survived by two (2) siblings. Please be advised that,, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the net proceeds of this action,'$ 0.00 to the wrongful death claim and $ 89,537.94 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death / survival action. Sincerel , Te ftv- n Rondon ness Valuation Specialist ritance Tax Division Bureau of Individual Taxes Exhibit "D" :TR CJ Q - E o ?. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY PENNSYLVANIA IN RE: NO. 08-6291 Civil Term ESTATE OF EARL L. SWAUGER, Deceased PENNSYLVANIA WRONGFUL DEATH AND SURVIVAL ACT 18. No Judge has ruled upon any issue in this matter or any issue regarding the Estate of Earl L. Swauger. 19. On November 3, 2004, Ethan K. Stone, Esquire, counsel for State Farm Insurance Company, spoke to Attorney Theresa L. Shade Wix, counsel for Petitioner, and indicated that he concurs with the allegations set forth in the aforementioned Petition. WHEREFORE, Petitioner prays your Honorable Court to enter an Order approving the proposed allocation of the proceeds of settlement in accordance with the Petition. WIX, WENGER & WEIDNER Date: b J?? Theresa L. Shade Wix, Esq., ID #43089 4705 Duke Street Harrisburg, PA 17109-3041 (717) 652-8455 Attorneys for Petitioner CERTIFICATE OF SERVICE AND NOW, this 5th day of November, 2008, I, Gaye Crist, an employee of the firm of Wix, Wenger & Weidner, attorneys for Petitioner, Martin N. Fuhrman, III, hereby certify that I served the within Amendment to Petition for Approval of Allocation of Proceeds of Settlement of Claims Asserted Under the Pennsylvania Wrongful Death and Survival Act this date by depositing a copy of same in the United States mail, postage prepaid, in Harrisburg, Pennsylvania, addressed as follows: Mr. Bryan Rondon Pennsylvania Department of Revenue Inheritance Tax Division P.O. Box 280601 Harrisburg, PA 17128-0601 Ethan K. Stone, Esq. Summers, McDonnell, Hudock, Guthrie & Skeel 1017 Mumma Road Lemoyne, PA 17043 WIX, WENGER & WEIDNER Gaye Cr t It IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF EARL L. SWAUGER, Deceased AND NOW this /q1A day of NO. 08- Civ+t bent, GJA9/ ORDER 0 , 2008, upon consideration of the Petition for Approval of Wrongful Death and Survival Settlement, and finding that the proposed settlement is adequate to protect the interests of the estate and beneficiaries, IT IS THEREFORE ORDERED AND DECREED that payment of One Hundred Thousand Dollars ($100,000.00) in settlement of the Survival Action is APPROVED. The settlement proceeds shall be distributed as follows: TO: Wix, Wenger & Weidner, Attorneys at Law, $241.60 for reimbursement of costs; TO: Department of Public Welfare, $6,152.88 for restitution of medical assistance; TO: Myers Funeral Home, $4,067.50, for funeral expenses; and TO: Estate of Earl L. Swauger, deceased, $89,537,94 for payment of any claims, debts, inheritance taxes, and attorneys fees of the Estate, with the balance to be distributed to the beneficiaries of Decedent's Estate. J. VI NVAIASN 3d AiNno O Z :Z1 Wd I 1 AON OOOZ 3O, L4.40-OM Distribution: Theresa L. Shade Wix, Esq., 4705 Duke Street, Harrisburg, PA 17109-3041 Ethan K. Stone, Esq., 1017 Mumma Road, Lemoyne, PA 17043 Bryan Rondon, PA Dept. of Revenue, Inheritance Tax Division, P.O. Box 280601, Harrisburg, PA 17128-0601