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01-23-09 (2)
15056041125 REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number Poeoxzaosol INHERITANCE TAX RETURN 2 1 0 8 0 3 4 2 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 1 0 2 4 2 0 0 7 0 3 2 0 1 9 3 8 Decedent's Last Name Suffix Decedent's First Name MI S w a u g e r E a r l L (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number N ~~ T h e r e s a L S h a d e W i x ~ o _ ~ .o ~_~ ~ r c Firm Name (If Applicable) ___ __ =.,77 , , REGISTER ~F':~CyS US~LY r_' , i W i x W e n g e r & W e i d n e r ,rr, Iv r~i -~'~ t, First line of address n ~ W ~ i ; 4 7 0 5 D u k e S t r e e t II '~" ~ I "~ Second line of address '~ ...~ ~--t •• I y. ._ i City or Post Office H a r r i s b u r g State ZIP Code L---. P A 1 7 1 0 9 DATE FILED ' Correspondent's a-mail address: tl5w2000(cilaOl.COm Under penalties of perju , I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief it is true, correct and~plete. D ion o parer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA/T P_ ONR SPONS F TURN ~/ _..,-L~ Cif`/~. >!`i'>~ /7/~~ DATE / LZ-Uy /'~-V S~1E S/f7azlS OF /7v"~~> DATE '~d _L{ ZOS ~w,~.P- ~`f-6-2e,`{' (•1517 r-trq P/-t ~ ~ ~~C[ PLEASE USE ORI AL FORM ONLY Side 1 15056041125 15056041125 J ~,~r~ ~\ 15056042126 REV-1500 EX Decedent's Social Security Number Decedent's Name: Earl L. Swau er RECAPITULATION 1. Real estate (Schedule A) ........................................ 1. • 2. Stocks and Bonds (Schedule B) .................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages 8 Notes Receivable (Schedule D) ........................ 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5. 1 0 0 0 0 0 , 0 0 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. • 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. 8. Total Gross Assets (total Lines 1-7) ........................... S. 1 0 0 0 0 0• 0 0 9. Funeral Ex enses & Administrative Costs Schedule H) 9. 8 7 4 7 6 9 P ( ................ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ 10. 6 1 5 2 • 8 8 11. Total Deductions (total Lines 9 & 10) ........................... 11. 1 4 9 0 0 , 5 7 12. Net Value of Estate (Line 8 minus Line 11) ......................... 12. 8 5 0 9 9 • 4 3 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) .................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14. 8 5 0 9 9 , 4 3 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .0 _ 0 0 0 i 6 0, 0 0 17. Amount of Line 14 taxable at sibling rate X .12 8 5 0 9 9, 4 3 17 1 0 2 1 1, 9 3 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 16 0, 0 0 19. Tax Due ................................................ 19. 1 0 2 1 1. 9 3 20. FILL IN THE OVAIL~IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 7 \) ~~~~ ~~ ~ «~ ~~',~ ~~"~ \ Side 2 15056042126 15056042126 REV-150o EX Page3 Decedent's Complete Address: File Number 21 08 0342 DECEDENT'S NAME Earl L. Swauger STREET ADDRESS West Main Street -__ _ - -- CITY STATE ~, ZIP Mechanicsburg PA i 17055 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 10,211.93 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A +g +C) (2) 3. InterestlPenally if applicable D. Interest E. Penalty Total InlerestlPenalty (D+E ) 4. If Line 2 is greater than Line 1 +Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 +Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due, 0.00 (3) 83.16 (4) (5) 10,295.09 (5A) 8. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5B) 10,295.09 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred : ................................................................. ..... ^ b. retain the right to designate who shall use the property transferred or its income : .......................... ..... ^ c. retain a reversionary interest; or ........................................................................................... ..... ^ d. receive the promise for life of either payments, benefits or care? .................................................. ..... ^ ^Q 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ................................................................................. ...... ^ ^sC 3. Did decedent own an 'In trust for" or payable upon death bank account or security at his or her death? ... ...... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................................................................ ...... ^ Q IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the lax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent (72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (O) percent [72 P.S. §9116 (a) (1.1) (ii)J The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefciary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger al death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (O) percent (72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) (72 P.S. §9176(a)(111~ The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent (72 P.S. §9116(a)(1.3)]. Asibling isdefined, under Section 9102, as an individual who has al least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Earl L Swauger 21 08 0342 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointlyowned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t. Proceeds of settlement of claim asserted under the Pennsylvania Wrongful Death 100,000.00 Survival Act. (See Schedule E, Exhibit 1) "The decedent died on October 24, 2007, at the age of 69 years as a result of of injuries sustained in an autombile accident that occurred that same day when when he was a pedestrian and was struck by a vehicle owned and operated by Wendell Ritchie, who was insured under a Pennsylvania Automobile Insurance Policy issued by State Farm Insurance Company. The following documents have been attached to this Exhibit regarding the settlement proceeds. 1. Petition for Approval of the settlement proceeds and amendment to the Petition 2. A release for the settlement proceeds of $100,000.00 executed by Martin Fuhrman as Administrator of the Estate of Earl Swauger 3. Court Order dated November 14, 2008 and executed by the Honorable Judge Hess regarding the payment of the settlement proceeds of $100,000.00 4. Correspondence dated December 5, 2008 from Attorney Ethan Stone, counsel for State Farm Insurance Company, forwarding the settlement check to Attorney Theresa L. Shade Wix, counsel for the Estate of Earl L. Swauger 5. Correspondence dated November 4, 2008 from Bryan Rondon from the PA Department of Revenue, Bureau of Individual Taxes, regarding the Department's position on the aforementioned Petition. The Department as per the correspondence had no objection to the Petition Note: Interest was not calculated on the tax due until December 6, 2008, which was the date the Estate received the settlement proceeds. TOTAL (Also enter on line 5, Recapitulation) ~ S (If more space is needed, insert addifional sheets of the same size) ~? ~ o C. ~ ~~ -n ~_, r(~ ('7 --+ i l - ' l f ,- , ~ _ r~J C. Tl J ^' GJ ~ ~ :, _-_~ i.. - ~Jl "] l:7 ~ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: NO. 08- 1~a41 ~~v~lTern~ 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: 1. 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. Schedule E, Exhibit 1 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 $5,152.88 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: 9-/7- n6 _~ ~ ~~' artin N. Fuhrm , Administrator of The Estate of Earl L Swauger, deceased WIX, WENGER & WEIDNER r Q~ ~ 11I Date: ~' ~ C~'~00~' ~~J ~ ~~u-bLe~ W~-tG 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 ba(~e•de ±.J he trL',^,. I understand that false statements herein are made subject to the penalties of 18 PA. C.S. Section 4904, relating to unsworn falsification to authorities, which provides that if I knowingly made false averments, I may be subject to criminal penalties. Date: /` G,~%~ ~' RTIN N. FUF~ ,III 9-/7-cg 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 ~~ ~~~ Gaye Cri State Farm Ins 2/4/2008 3:18 Pbf PACE 3/012 Fax Server 11-14-2©87 tj9: 19 KOCH FAY. ,Print CRS A0000075 t s COR/lPoi0~3tNE.gLTi-0 OF A=P:R:SYLV>•1~JIA J POLIC~c CRASid REPORT3T:G PORUI ~ ppQe Case Oosed Reportable Crash F--I 'Q Q'Fnn ~ n ,... .. a:,, r. yes f~1 No ~ t F•AGE2 Page 1 of 10 IIIIIII~IIII I~~I~~~h1 Gash NUmbor A0000075 v ~- - ~ ~ - ~~ - ~ .,,.... Pollee A •nry Potrol Zono Incid ant Number 21404 404 , MBG-?007-10-0472 sti ation Date (M.LhOC YYW) I ° nve A en Mamo Prednct URC 10 - 24 ~ 2007 '' Mechanicsburg Baamgh MF.CHANICSB ~, DIS aun Time (cop Arrival Tlme (mill Ireestl etor Badge Numher RY 2210 GOMF y . 0654 0655 FTLM. DEVIN L. htONT o Reviewer Eadge Humber Approval Datt (HIM-0O-YYYY) l4veek v o Mumcr all Munici all (dame Qg Court Court. Haae ~ P LY chanicsburg Borough O $dn O IDu n 4 c 21 CumUerland 40 O Aten O Fe I ®I [rash Date (Mb1-np.YYYY) Crash Tlmo (miD No of Unlo Pao H In ur!d KIPed' 'If > 00 Tre complete O O Sa' i ~ ) ~ - 24 - 2007 0650 2 2 0 I Fortn F O sued Q vnk /f Yes C.emple2 N School Bw y No School Zane O yes ~ No Natlfy PEHN00T0 yez ~ No Secien 29) O V!s ® n Related O tt ~ Related hvalntenance Wprkxona Form M ~ . 1 t rseMon Noe Magi-L°9 O Rallrcad Oo+sfnq r~,,,,'~~ 0 4 Way Intere P<{i0n O 'Y' ImerSPCtlnn O In I!6eQ~Cn O 011 Remp ~^~`~` nn Traffic C'vde/ LLll•' O OlhPr ~ O MldblrKk O 'T' Int!r5ectlon O RoenA Ahnut O On Ramp O Gasiever .gyp pvarlay _ , use Numher (If appfcahie) H Route Number Segment (Optional) Travel Lanes Speed LI It Q North o t ~~ ° c u114 oz zs .ry! O so~m ~~ u AB'' Street Endng O tasf far hlld-hlxk eraNH Only Usx ~ Street Namp I \V l ® pc;tsl Nw;e :VUmte• and rata sue TAI S f •- ~ ~ e l ~ PMaba Macfrva $uezt Name I5 MAlrt ° L/ UnknC'/. it IJlcd In it uJng 1.t is ePt?:n P.OV1= uneuute ~ Axnpike O TUfllPlke O 'ld!e O t-rasn;y O LOCdI RW+ O PfIV3t@ O De12'l Ra)d Or Strtzl Road Unkr+>wn h ~ -J Ni O O .. rr a _ $r^mr^ IEL^1P/6t) Spur (Hol 1'umpiEc) vl ~ Route Number Se meat (OpTionaq Travel lanes $pttd Llmlt ~ B No-tn 1 ~ L I .__ $troet Ending ~ fast c ~ SVC<t Hame O Wsrt. ' ~ ._ ST ° Yr y HIGH O Un<ncwn ~ [ £ ,~~^^^ O hlfenta:e O Turr,prie O Turnpike O State O Count' ~ Lxal P.o.ad O Pirvate O Other/ un H.yhway Road er 5tre-a Ruod U:rkno^n :/vl tl E :p a es (NOt TVmplrl I / F(et Intersecting Rt Hum Or Mlle Post Or Segment htarker J y O 5outn ~_ ~! ! I` '~ , 8 St Ending ~ I ~ ~ Or Intenectinq Street Name O East Or Mila 000 P:aase '- - E ~ ~ O Wesf En;!r ~ ~ (I ^ • ~ IntgrmaFnn C ¢ ~ for BO7H p landmar'es ~ 11 Using Inbrrw<tlnq ftt Num Or Avila Post Or Segment Rla rker ~ f' ~~ ~~ ~ o 4 O t'IORh O :outs piaan[e From GaSS 5[!nP LO L3r1d013f~( 1 Tnq Option ] X i s (FOf Crash between y ng E $t End OrlnterseRin Street Name O Fall LBndmY'k 7 and .~ 0 9 ~ ~ O wut LanCmark 21 ,Degrees Mlntrtes Seconds Degreer Pdlnutes Seconds latitude: ~ ~-~.0 Lp ng nude: - ~ ~ •~ >~ (~ Ydd Si O Po!ica O4i<er or Mr en'r^! Dev2a S^ Flagman ` Tfn Fn tinnlnn Er..ergenry Dcact Funniorin9 Pmem fire No Controls O O P O hs efly Si nal ro ® O Not AppfiCahle O Tra HiC Signal O Active RY CrV 5510g ~ U[her Type TCU Controh p g p i i r• nasldng ValfC O O Stop Sign Passive RA Unkno•un i l O O 0r n9 0 UnL•novrn Device Nat D. iCC WnCl O Fun<ton:ng ~ Propcdy _, gna S Cro:9ng Contols__ - -_ , ~ _ ,. _ -_"---~ ~ pll l n ra..e n^^'^- O North O E.nl O North and $eu \^q E a. a.,,e Oeo-rl (M R'or App7icaNe', skip rest 01 the Lane Clovre aecs/oN . (N,S. rs O Not APGlitabl< O Pmvally a Folly O Unknown ~~'~ O Sculh O Yyc^;t I~ Eaa and Wea ILilllC Yes O .NU ~ Unknown O < 30 Min, a 30-60 htin. O 7-3 hrs O 3L hrs O 60 hu O > 9 hwrs O i 9 ~',~, ~ Unknow^ O _- -Jam..:~=s== _ IIASSf I roar r'ua°°(vv'J FCMNDOT COPY - Exhibit "A" hl f ta•//u'urev.Ant6.cTatc.na.us/iconx/Printima2es/XntlFiles/2007103371 DLMBDR752007... 10/28/2007 State Farm Ins. 2/4/2008 3:18 PM PAGE 11-14-2097 69:26 KOk'}1 FRX Print CRS AOUQOU7~ u r r J lrUYk~n'9LAfit:L~7F~e17 a0'1 m~ pa~w>3sble,aF~s~~ [''r2('_B=Pa ~:2A5P@ PdE~d3l8S7PfG FC1C15y7 Page: AA 500 2 P'0~ `"` o"y l ~ l 8/012 Fax Server F'R6E7 Paoc 2 of 1 ~ ~I I~IIIW I~I IWI/II~ Crash Nurssber A0000075 E MoWt Vehicle in O Hit E Run Venide O Illegally Parked O Legally PmF.ed Q Nun ~ Mu!or¢zd .- ~- • Commerrral Vehfrle ~~~ - ~ -~- Tv~ Transport O Y!s ~ NO m Belt FeUe;trian un Sku le,. OisaSlzd From O Phantom Vet Yrein O Pedestrian O O - O ~[le in Wheelrhalr, c:c Previous Crash (11 Yrg Compfare form C) _ ' (!/'PedeRrlen' or 'Pedearian on Skates. m Wheelchair, etC', COmple, to Farm M, 5?Rion 13) Unit No Flrst Name Nll pets OF Rlnh (R1~b1-GO~YfYY) Ol WENDtLL ~ 06 26 1943 last Name Tele hone Number OtleteT O RITCHIE 717)909701 Address I CI 1 state __ 21 ~ 6228 LOCUST STREET LR.'GLESTUWN PA ~ 17112 Driver Li®ns0 NumLar StPA Clas~ f 15 699 700 5 AlcohoVDruas $uspeRed prlver Or PedetMl+n PRVSIaf Condition ~ ~ No O Illeoal Dr.gs O Medication ~ 'lpo~r~nttf O IUSe a• D r 9 O Fatigue O M?dicaCon O Alcohol O AlcnhJ and Jrogs O Unknown O Nae !teen O Srk O As'eep O UnZnewn ndnkin0 I l a Alcoh lTrst 7Vpe h O Oth PdmarY Vehicle Code Vo/a flora r a hatged. p er ® lest NCt Given O Brrat ~ O Ytt O NC u i = Unkncwn if O eluud Q Urine ~ Test Given r ~ ~-_~~. Almhof Test Results (~Te:I Ra(uzad OUnkncwn RC!u IU" prlver Presence 1=Dri:er Opua!ed 8=Orvu Fled S<¢ne f Vahida S-Hit and Aun I O Test Gwen, ^ ~ O ~~ll~~.. Unknown 9 O i ~ Cou laninalrJ ArdL , r - 2-No .er Owner/Driver 00=Net PpP;lcaSle 02=?rivets VdtiCIC Hot Om5late Police Vehicle OT=Municipal PnSR Vah 09=Federal Gov Veh O1.Prlva le Vehlae O.vneL Ov.ne!/1-eased by Driver OS=PEI:NDOT V=hide 08=G.har Muniii,al 9Il=Uth¢r U] Leased by Criver U3=RCnted Vehicle 06=Other Statz Gov V>^. Gevem¢eet Vahide 9y=Unknown Owner Gin; Neme Owner Ust Neme or easiness Namc U( Pcdcs fria.n, rkfp this Section) ' ' Same as Driver O I:IUSTINE I fi WL' RITCHIE Addref> / U !State ! P Vehlcla Mako 'Make Cod< 09 $577 BAN6RIL)GG llR HARRI,SDLIRG PA 171127112 Plymnulh Model Yaar Vehicle Modal (.ze uvedayl VIN ]994 SLN lY3AY28U3KN132976 I Ucense Pla<a 0.eg, State Est Spaad VeFld+Tewrd Towed by GTK3972 PA 035 O Ye; a No lnrunnrt Insurance Company ~ '~ .' Pollry No __T__~- $ 1 dyes O Na O known UNKNOWN n Ta Ta N i T T r ~ ag ag ~ rmi-Tra l<r r lIn ~ p I=Towing Cats Vrh d=lvl0hilt°lMOdutar Home 7= ~ 2=TOVring Track S=Cam[.Kr B•Uther n No. cf ~ ^ ^ Trolling 0 3 r 6-Full TIai1Fr 9r110kI ~OWD Tr Utili d T n Sl tvJ ty a e OV = units a Direction of a 'Vehicle Position 01 'h2ovement UI 'See Ovarle SPenal UsaOe y revs merrial OlT 7 C Vehicle Cnlar Vehicle TvPe OS=large Truck 20=UricyJe. E~gde, nm 2= Passenger i 06=VellO.v OI 07=Silver pl=Aulemoblta Oo=SUV Triryde O1 02=MPIDrCyCIe OT=Van 2I=Other Pedalyde & B p7-1101 APplicatic Carrier 01=Fro Vah 13=Tad na=GOId ujgY pt=Bus t4=SnownnbYe 22=HUrse p2=dn•.polance 2t=TraRCrTra9er of=ewe o9.BrVwn pw=9mall Truck t t=farm Eqelp 23aHOre [, R~ e? pg_,FOPCa 22=Tetra Trailer U!=Aed 10=Orange pf '01', Comp/et<Ferm 12danrtrvaion Equip 2d:Train 09=C:nar Emergency 23=Triple IIader pJ=SVItiIC 17=PurpL h1. Section l6) 13=ATV 25=Trolls/ yehks 31=Modi(ed Veh OJ=Green 12=Other (!f -10' or -Z1 S ComPleta 18-0ther Type Spec. Val 9d=Other ec Veh 99=llnknnwn 19=Unk T 6 I1=Pupil Transport 99=Unknown OJ=BIeck 99=Unknown . ype p Form N. Section 171 lnlt/al fmuact POfnl Damage lndlnter Gradient 3=Downhill Road ANonment ht 1=Strai 01 pO=NoroCOllisian tA=Undercartage in 19=Towed Unit I dl k P 2 0=NOre 7•FpnttiOnal ~ I=Mina 3=Di5ab6ng Q1-Level '•PO(IOm 01 Nitl S=Tpp of Hell MI U g ~ 2=Cursed known V -12 oc p ts O 13-TOV 99=Ulkravm 9=UDknOwn p 2= g=Unknovm n 9= toper • Maur Its=1 PENNDUI VVYT .dot6. state.pa.u s/icons/PrintIm~taes/Xn1lFiles/200710 i33 71 DLMBDR752007... 10/28/: State Farm Ins CtD4Afr1F.'1.T5M57i1EA16.4P0 F~F ~I:LUv'l"?;VLbaAWEtA R~^_B=E CRH561 RE17'i.6YYBPlU F4o-TM Page: ar, soo 2 PaFCe Uv Prly ~~ 11-14-2007 09:19 KO(7-I FRX Print (_'RS AODUUU75 is n s 4/012 Fax PAGES Rage s or 1 u ul l~~'I~I~I~IIIIIU~~ Crash NUmbu A0000075 EAOtnr Vehicle in O O Hit & Run Vehicle O Iliegal'y Parked O Legally Parked O Nan -Motorised Commercial Vehlde Transport Tvpt O Yes S No .v+ UnJ{ Pedezvlan on skates, Disahled ken O Tram ' ~ PedeAd~n O O O PhanlPm Vv`Fiic,e in WheckWrt, etc frcviws Clmh p( yes, Complete farm C) . (ff 'Ped st ' 'P d st ' Tk te; In Wheelchair etc' Comp/e!e form M, $ecflon 2B),~_ Unit Na Flrst Name MI Date of t3irth (b1M11.70.YY1'Y) 03 F.ARf_ L~ 03 20 1938 lest Name Tele hcne Number -_ Delxte? 7176084926 ~ O SWAUGEK Address / CI / St+te 2i -° 17055 125 WEST MAIN STRF.F.T MECHANICSBl1KG PA e Driver LkCnse Numher 3tat~ CI+s s U~- a •~ AI[ohd7Drvps TUSpeRed Drlv ror PedesWan Ph vsica/[ondir/on I~ Ille 1 Dru s Medicmion ~ No O 9a 9 O ACUei~npy Illegal Um9 O Fatigue O MCd.a lion e Nprma O U;O x O Alcohol O AIcOMI and Drugs O Unhcovm O Had BCen O Sick O Asleep O Uikrov:n Drinking y _ Akohd Tesf Tvpo _~ pd Bry V hkle Code t/iolaGon Charmd7 p ~ Tee[ NG Given O Rreath O Other O Yrs O No c O Plncd [] L'rlne ~ ies~ G.enil u y un own Almhof Fert Aeru/a O Tesl Fe(usad O Results Driver Prcsmao I=p,iva Optm^.ed Je~ri~.er Fled Scene ~ Teti Given, ^ O O ^ Vehicle d'alt and ken n k o 9 U - Contaminated Fesulu w n n - 2~No Dri+Cr I I Owncr/Ddver OO~NOI Applicable 01=Private Vend=_ Nut OiRate Pd!ce Vehlde U/_Mwticipa: Felice Veh 09=Federal Gov Veh 01=Private Vehidr Om1eCr Ownedtieased 6/ Driver O$=PCNNUOT Vehkk 03=other Alurio~'s11 9E=Ulher 06-0ther State Gw Vch GOVCrnrtnl vehicle 99=Unknown Q~ Leazed by Odrer U3=P,ented Vehicle O"v^°r Firs[ Namn ~ O~.vner Lart N+me or 9u siness Hame (/f Peoesfrian, fki th%s $eR~on) Same az r Driver O I Vehlde MaSn •Ma'<e Codel I /Stele! ZIP Address / CI !r ~~ /' Riodel Year Yahkle Model (zee wzi:ayll VIN ~ ~ ~ Yo~ U<enso Plau Rap. State Est Speed Vehl o 000 o ye+ ea Ne InmrancO ~~ Insurance Company Policy Ne `o Oyes O No U"' O ktown a o ' TrarFn T e 1=Towing Pasz. Wh G=MohileP.lodvlar Hun`.e 7 ieali•Trai'ef TagTag N~ Ta~ Tao Truck S=Camper B=Ulher o! )=Towin No ni ~ g . n t ^ U t ^ Trailing 9~Vnknmw i: ll T l 6 F x u ra er }-Towing VUlity Trai er = Unrtz. Y i T Dircntion of o •Vehlele Petition o 'Movement o 'See $ptt7a1 Urege Overlay ` r ve l i a 11-Commerc Veh/de Color Vehlde Npa 05=Large Truck ZO=Uniptile, HiCy;le, Faziengu Tdc;de GO.NOI Appl'.c. t 05=Yellow (''~ 01=Automobile 05=5'JV abl Carrier D7=SiHor I IU2-MPrortyck DT=Van ZI=Uihrf C?dal[ycfe 01=Fre Veh t3=lad fer Tr 8 9 T )?w orse ractor a u99Y OZ=?mhvl+nce )1= 08=Gold ILLL---...~rrJJJ 03=9us lOw$nOwmObilt ~ i U1=Blue 09.Brown 04c5mall Truk 11 =Fdnn Equip Z3=hP152 •°. Rltler 03=POlire 72=Twin Trailer 02=RCd f O=UrdixJa (II 'OI', Complete Form II=GPOSVUC:IRI E:y_ip 2J=train OB=Other Emergency 23=Triple Trailer 03=Wh'te 11=Purple AT. Settion 761 13=AN - ZS=Troli?Y Vchirlc 31=1dadifr-d Yeh 18wCihcr Type TPee Veh 9A=Other 11 =Puce Lansport 99=lJnknpwn th 1 G ' reen 04= Z=O ZI ; Complete er (J('IO' or Tettion Z7) 19=lksk. Type Tpec V:h 994 nknOVm U5=91acY- 99=Unknovm farm M , JotNe(~ pamavo indicator Gr dlen Road Allpnmtnf _£-.1 3=DOws+hll 1=SL'ai `hl 0=1JOne )=Funzional J=EOttartl OI Hill L rved l C d i age ~ u emrr o Opw(JOn•Collisipn 14=Un 5-TO of sa71 2= 1=Nhmr 9=Disabling O 1=Leve 9=UnkAOwn 01-12~i luik PointT 15=Towed Unh Z=Uphill l ntN.n D=Un ., _.,~ 9=Unlnown - . _ •.,",~ 13=TOP 99=Unknown FPWa a MacU (ILUE) 2/4/2008 3:18 PM PAGE HtNNUV1 I:VIY lTttp://www.dotE.state.pa.us/ieons/Printlmages/XEnll~ iles/20071053371 DLMBDR752007... 10/26/2007 State Farm Ins. 2/4/2008 3:18 PM PAGE 9/012 11-14-2007 69:20 I:OCH FRX Print CRS AOOU0075 J CONIMOPltdtJEAEY7-I OF pEPd;~SYIYANIR pOUCB' CRASPI REPpRTIMG FOftNi Pags AA 500 3 rou. ore u~p ^ plsoa type: Srar M•.R,M~ K~ $Efy..Nur~ p'r!rM Onn' A tAuvn D W=Not A P35sengrr/D000CMI E w=None. used? not a 9=Unknovrn 0.1=Second Row - I eh Side Or 04•Criild $a(e Matcrcyde Pznenoer 05=Matoryd OS_',econd Row -Middle PosRion 06=9icyde Nx l ~; OG=Second Row -Right Side 10=ialaly ee B F =Ferrate 07=Third Rcw Or Greatar - 11 =Cold Seh M =Md~2 u =unknorrn L[II S,de Da=rnim now Dr Grva ter - 12=Hekner tl: ro=RaRrsnt I Midd4 Posdion g9=UnknPVn 09<lhird Kcw Ur Greater - Right Side $ f T t I t~ L)f N ERJUpL F OU=NOOe USe 1n LN SP~e'~N MIOn p NC±Ca =+ eiFer l C bloat mj,.red 11=1n OC.er Enclosed U1=Franl Air I=Killed Passenyer Or Cargo Arve 0?=Side Air B 2•N'aja• Ir;ury t2-In Upen area 03=0Ner Ty; 3+Mod<rate (Bx UI Pickup. Etc.) Oa=htult¢le! In)t,ry t3=Trailing Unit OS-MCmrcyd 4.Mmor Irjury 14=Ridi,v7 6n Vehicle Cr[trior O6=B:pdist V B•IniUry, Unk 16=Bus Fazsen9er 10=Air Bag N Se+enry ?6=Other 11=Air Bag N 9•Unkr¢,wn if o9=Un4ncwn 12.4,1 Bag N Inlury Un'< Sw,(r Fax Server FRiaE2 Page 4 (tf ] ~ ~~~UI~~~I~n~~~~B9i~l~~ EreshNpm'xr ^ A0000075 Belt Used Used t U:etl r ~j D~=Nat f•pplcaole 1 •Nat Ercl:d ~=?nt3lly Eie6ed 3=Partia'ly Ejected 9=Unknmvn H EjeCr%or Park D-IJoi Eedad /Not 339 Tznbye0 6or i!. Sea') ag DeplcyeA (Por This 5<zt) y<;hwugh ftoc(~Opznirg (Convertihle s! A.r Bd Deployed S T:,p U ) n=Unma.vn epuyed ~r BdsS e Eye PrOlcrl~0~ lear,ng Ei6cw/KneerPads Er;,-IcpNut: of Deployed, Switch On ~ O=NO! WCLCable it Deployed, Switch Off (=No: E.torated of Deployed. 7=ExV,Cdted By Ma.harccal Maars h $eD.inS 4-FreFA Py Non - Mt<hmti<al Med.v ~ ~meved (Prior Te Cra;h) I( Air flag UCp'oYed B=Other S=UnkncWrl evs Agency: \VEST SHORE EMS -~ MWkel Pa<IBty. PENN STATE HERSHF,Y MFDICAI. CENTF. Unit No Pcrcon M° Delata7 Date at Birth (MIS-0D-YY1'YJ A B C D E F G H I OI OI O ob - 26 - 1943 I^O^ fit 99 00 ~ 0^^ Nerve !Address / Phona EM$ Transport ~ Same as R1TCH[E WENDELL F G?28 LOCUST STREET T.iNGLESTOWN PA 171 O ves 4 Nn Opemtar _~.~-T- - -~__.. .,___._,---._._-.,-. Unit Na Pcnon No Dab cE U:rth (Nlht-DO-YY1'19 A B C D E F G N I 02 Ol DeOa7 03 - 20 - 1938 7^ M^O 00 00 00 a^^ Nerve /Address /Phone E,Vt$ Transport ~5ame as SWAUGER,F,ARLL125 WEST MAIN STREET MECHANICSkdUKG PA I7 ®Yes ONo Opantor Unit Nc Person No Delata7 Date of BirtlTi fMhI-DO-YV'M A 8 C U E F G 4~- ~I [^ ~ C^-^-~T^^^^^^^^^^ $ame as Operator Oelete7 O ~ Same es Operator Unit No Penon No ~ DekteT ^ ^ ~ Same as Operator oalat.7 0 :_.. ~oaaoo~ ENI$ Transport O Yes O No Name (Address /Phone • -Px fkAS Trasnsport ^ Same as O Yes O No Operator roeat / aaaw pxrmr pENNDOT COPY , http:/lH~~~.dot6state.pa.us/icnns/Prinlimages(TmlFiles/z0071053371DLMBDR752007... lOiZK/Z~i[i7 - ENI$ Treroport O Yf•s O No =~^o^^^^^^^^ ETAS Transport Q Yes O No State Farm Ins. 2/4/2008 3:18 PM PAGE 11-14-2007 G5~19 KOrH FAX Print CR5 A0000075 COfVi'dA0`NNIIcALTHOPP'tWT)SYLV60i~112 r ~If IIII~I~III~~I~~~ [rashNumSer J PQ41CE CR.@SY kEPIIRTI7JG F01iTA Pag• AA 500 4 '"""""" ' ~ A0000075 C=Pbn-Codison :=Haas Ong- Crash OeMiOfion a ear d p-Re a R E 1=Mgle 5deawi ~ 6-Sldaavr?e --- ~~B~Ha POdesMan (Opposis Otatllon) r(Unknovm Oh B d ~rog ) I-Rear n (Sarre Q3iraetion) - e = 7=Hit Fiaed Oged ._. .eO. 3 E E ^ ReladOn to Roadsray 1 7=On TRVBI Lpne9 1-Median ~~1 2-ShOUldar 1=ft0edaitle _ _ ._ __ InlarsacLOn 5=0ulaitla 7Rf0Cway 7.Oor¢ (RUnp ) E=1n Parking Lane -9•Vnknorm - I/Nmina:lOn ~ t~aylighl p=0ark - No Etreel Ugtda_ ~Qi hts tee 9 /=0uek O=Dark' I PTOadw: :1 Woa!her Condltlons 1-No A:Nerea CandiOom y_Slcet (Haig FOB • ~ 2-Pain a-Sno-.. fs=pains _...._ -_ _.-_- I' d5 rf [onddions ~ ~ o-07 L-Wet j=Sand, Mud, Dirt, Oil 3=Snow Covered a=sluan _ S.ke 7 02 ~ ®~ I od-tI 02=H unn No 03=H OI 1 ~ O ~ Da=H us-~ H OE = 7 H Please Prat 3 =rte in E Ir-~1I ^ ~ ~ ~ = p 08-r 09=C v Seeuenrie! L-.-I F Orch! / q ~ ^ O 17 5 13=E o Harm Ev<nt I/A Mart7 Utifrty Pole Number I4=: lc=g 7 ° 1 1 ^ ~ ~ " Untt Na 22= w 0'? 2 O ~ O 2a=; 2E=1 ... b1 Pfease Pvr Elrntr 7n J ~ ^ ~ 2 27=t 25-! Eecucntial Order / ~ ^ O ~~ I 29-1 Fiat ~mlul ve Vnit Na O1 Henn Event rNer Uni; No armlu 02 van m 02 Hartn Event II Odw OC-1 pt=1 y tt~th n_ nsN O7=I Olal o.,ni ,.our mrnuna is a.,nerww t u0nmenrar r nmv..v. 7 03 = , E/ +) C • Pobntlal FactorF ( C pC•NanP 1liippery Paid COOdiiiGnS ((C!$nOW) pt='Mndy COnditinns 12=9ubsWnce On Roadway C E 0'_=Euddan WaalMr COrdil9nd 03+Orhrr N'earha Condrtiom :3=Pnrholas 'a.Brcken a Cm<ked Pa•4nMni 1 W=Doer In Rnadw<y p9=Opsude On Poaolva// 'S=TCU OESpucted dFxgoh Shoulder lk Shauider DrnP Otl 1 06-01her Anmal H ROaC•way 29=00ar EovitlGnmenpl Factor ~ 1 07=Glare DE-vr'ak Zm1c Rciald 99-Unincwn P n3fa VehiLle Failures (l7 12aW pets 13=0nver 3eatinylConlrol UC=N90E p6=Exhaust O'r.Hwdlphe la-Bud , DWrs. MOrx!, ~ 01=71st erl Harh 02.9rake Synem 00=Signaf Lighe 16•T1~ 03=Steering :ynem 09=Other Lights 17=AVbegs 10•HOrn O~Su;pan:on 13•Triller Ovedoeded 0;=?ewer Lam 11=Mirro r. 19=Unsecure/9N1;x1 Unit ~ ~ O 1 7 OO 2 TraOer Load 2C=M^rcQer Towing9 Na 2I.OtitnJ(itd Wrtl;hiald ) Unlt 00 = 02 99=Unknown i i No 'sbalaye Pagn.l:r nrrwrubrtn OI 10 E!R Y D P 0 ~ ~ Q X E/R 6 Me Prime Forty Typq /east Unit No blank / AASan (rttrel 5/012 Fax Server Traf is Unlt 7=Bleat it Fop a.ar>:r 3=01het Animal nrtth Ctther Nor act Unit 1 Unit 2 Um13 Unit ~ Unit 5 Other Tra..ie Uni; II Erd 9 Ur 5 pottier ~ O 1 ling Acinn 1 iutrm tad I land Held Pha'4 d •Iands hee Rrone I il U-two retest Turning ) 7 Wrung Lane IterJS;op 7 E ga PLignt :s ord io Control Devica , tarter Or Wa!I Building Culvert Bnr'ye Pier Or AacGnent Parapet End Bndq< Rail Bou der Or Gossade Poadwa m(.NCt ~renuatgr rite Hydrant Bnadway Egr:ipment IAaO 0ox iraHk Island Snuv Dank iemco~aa Con:mrcian :k 0Y Thrown Or F:11ing ,n Holes Or Other amenl kreyularlTH mte In VeNde er NonCdIL'on '.noxn Hannlvl Evan[ Irrpreper To Highway Irtgnaper Ewt JI Bhway ParkingNrrparl.ing der lidlipn Al CVrve god fait Pot Candrtiors fo klamlain ?roper SPe_M teeing DNire (PCI Chase) 14=Carden Pa:zing Or una gi=ARecsed Ay P~ryscal W~.dl Change Sg.Other Improper pridng Ar 15=Pas;'ng In No Paiilnu Zone .n=llnV,nown tE=Driving The Wrorg Way On - 1-Way Street kot ~~ 1 10 2~ g~.4 Nail 02 7 OO 2 ~ s ~ e (~~lone 1=Enteing Or Usrssing AI Spcdfrcd LxM~On 2-Walkirsp, Punning ingq'ng, Or Piayfng unli Ne 01 UO PENItiDOT COPV ' v-=~ao,a,y ....... OS~ltproaihky Ur l<anny Vsh:de OE+Ymrtmg On Veh[Ie Ui-9tandirtq 9E--0ther 9?=Unktavm unft No 02 O1 71053371 DLMIi11R7~2007... EIC PRi'oE4 Page 5 of 10 10/2S/2007, . _. State Farm Ins COMMONVIEALTH OF PENNSYLVANIA PO! 1CE CRASH REPORTING FORM page AA 500 5 ror._Ue aM 11-14-2607 09:2t~ KOCH FAIL Print CRS A0000075 T PR6E5 Page G of 1 U III uIIIW II III~I~II~ Cash Numher A0000076 I I 1 , l l l l I l l l l ~! I !~ l 1 I I I _ I . ~ - I I y i I I .. , . I( .I I ' V I I I ' ~ I . l o I I , I ._..I ._ . __ I L.. ,. .1 ..j. ---r r I I __ .. ' _. , _ , _.., L.._ L._.:_._ I , - - --- ' i ! . , I j , I : ;.. I I , I i - - ... _ _..-1 1. ~ I i L. I I i. i l l ...i...l ~ .L..~ i ~, ~ i .. I I ' ' - ... .......I , , ~ 1 '~ _ ..:.. ._...~_.. . - : ® . .. ... .. ~ .-.: .. .I.. .... ~'~ j I 1 I I I I 1 I - 1 I 1 I I 1 I I 1 I I I i : i I . I I I. . : ~ _ __ i ~i i , L. . . _. I I I _ ._. . _._ .. - ... _ I - ~ ;~ I l l i i l' I I i l" 1I- _, I _._ , ... _... 1. ' , - - - . : WiN~ess Name (Address Phone LEUN B YRll 1010 COUNTRY CLUB kD CAMP HILL PA 17 7175291403 t S 1F;AN MACKF.Y 7013 CARLiSG Y]KF/N?ZB,CAkLISLG YA ] 7177660316 Narrative and addldonal vritnesses: Accident Investigation Natilication Izzued7 C) Property Damage Q ON 1024/2007 AT APPROX. 0654 HRS., THE MECHANICSBURG POLICE DEPT. WAS DISPATCHED TO THE INTERSECTION OF W. MAIN ST. AND HIGH ST. FOR A PEDESTRIP.N 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 ~ FLED THE SCENE. ' g BOLO W.4S PUT OUT ON DESCRIP 710N OF VEHICLE, A DARK IN COLOR EITHER LAST SEEN RONT END DAMAGE E Y , F DODGE OR CHRYSLER SEDAN WITH POSSIBL c HEADING WB ON W. MAIN ST. NO FILE 2 WAS OBTAINED. F SPOKE WITH WITNESS #1, A LEON BYRD, WHO ADVISED HE WAS TRAVELING \^B IN THE MAIN ST. BEHIND THE STRIKING VEHICLE, APPROX. 3-4 CAR OF W 100 BLK . . LENGTHS BEHIND STRIKING VEHICLE. THERE'NERE NO VEHICLES IN BETWEEN 6YP,D 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. PaAIN ELF THAT IOF THE VEH CLE N IFRONT OF HIM DOESNT S OW OWN, THATING TO HIIvIS HE'S GOING TO HIT THE PEDESTRIAN. BYRD THEN REPORTED THAT HE SAW THE MALE ND THE S E I O E O NG AND STRUCK THE EPT GO BRAKES BUT K NOT HIT H S V CHICLE D D TRIKING BYRD THEN REPORTED THAT THE STRIK LNG VEHICLE PULLED OFF TO PEDESTRIAN . THE SIDE OF THE ROAD, THEN PULLED AHEAp A LITTLE MORE, THEN FLED THE aonu r u.rm team) 2/4/2008 3:18 PM PAGE 10/012 Fax Server PENNOOT (:VYT http://www.dot6state.pa.us/icons/Prindntages/XmlFiles/20071053371 ULM13llR752007.. ~v,i`' .. 2g3' 10/28/2007 `+~~" . YC.. State Farm Ins. 2/4/2008 3:18 PM PAGE 6/012 Fax. Server 11-14-2667 69:19 4:DCH FPY. Print CRS A0000075 ~ff4`AGA~7't^Si1dSY40 mF L°~P7VtlatlM1Y61~iL°OGl tPCD61eE ~h9 ~(hIDOCnRiSn FeY~.%J AA 500 N br ux a,n -'1 Plarrativa and additional witness¢s: Pnge Q New IIIIOIillllllllllllllll~.I A0000075 7 ~ ChenpU CnntlnuMlon FYaGES Page 7 0l' 10 Crah NumNr SCENE. BYRD ADVSISED THAT IN HIS ESTIMATION, THE STRIKING VEHICLE NJAS TRAVELING APPROX. 35-40 MPH. SPEED ON W. MAIN 5T. IS 25 MPH. BYR D THEN WENT TO THE AID OF THE PEDESTRIAN. 2ND WITNESS, A JEAN MACKEY REPORTED THAT.S HE WAS TRAVELING EB IN THE 100 6 LK. OF W. MAIN ST. MACKEY REPORTED SEEIIJG THE PEDESTRIAN STANDING EY THE EXXpN GAS STATION HOLDING AIJ UMBRELLA. MACKEY ADVISED THAT SH=ALSO SAW THE PEDESTRIAN CROSSWALK SIGN. MACKEY ADVISED THAT SHE OBSERVED TWO VEHICLES WITH THEIR HEADLIGHTS ON HEADED W0. 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 INDENTIFIED AS EARL L SWAUGER WAS STRUCK BY THE ONCOMING VEHICLE. h1ACKEY REPORTED SEEING THE PEDESTRIAN BEING STRUCK, EJECTED INTO THE A!R APPROX. 15-20 FT. IN TO THE AIR AND THEN LANDING ON THE PAVEMENT. MACKEY THEtd WENT TO THE AID OF THE PEDESTRIAN. SWAUGER WAS TAKEN TD HERSHEY MEDICAL CENTER BY WEST SHORE Ef.1S. SWAUGER SUSTAINED INTERNAL INJURIES, AS WELL AS HEAD TRAUMA AND LEG TRAUMA. SWAUGER DIED THAT NIGHT AT APPROX. 1937 HRS. AT HERSHEl' MEDICAL CENTER. SU5PEEGT 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. VEHICLE WAS IMPOUNDED AND A SEARCH WARRANT WAS OBTAINED 70 SEA RCH THE VEHICLE FOR EVIDENCE. CHARGES PEND{NG G~p~_ ~, fond f ALl00.V (~J PCNNDOT COPY . httn://wtvw.dotCstate.na.us/icons/PrintTmaueJXmlFilcs/2007105.i371 DLMI3DR752007... 10/2S/2007 State Farm Ins. 2/4/2008 3:18 PM PAGE 11/012 Fax Server i1-14-2667 G9: 21 K6CH FRX Print CRS AOU0007.5 pAr,Ei6 Yage R of 1.? ~nu~r~~r;:rcda2v~a~G~~~a9ti~kra~sta, ~~~~IY~~~II~~~ll~i'I~II~II 4"t"iU'f~.'Tc QWdt.°.,rA Q@ir~'JL°!4'il'f~Pi FC~6Lr1 Pa e O Naw aaah w~maar g A000007~ AA 500 F ro"¢ "" ° ry ~ ~ changel Contlnuatfon pmdSuMec llrnc O BdcY Or elort O Dirt goeciaf lodsdicrion N ~ MllUar' O Y O Other Federal Siies 4 w Convete Sta .Gravel or O 9 O Other No S cial ~ ¢ Indan Resemtion O O Dther O 8tahtop Stone O Unknown lurisn ian O National Park Collegetlniversity Unknown ' O 0 Gmvut _ _ Pku complete Unlt Information for asarl unit involved in o fat<I crash. Do not repeat the Information in the (idds above on muhiple pages ~ UD PrfndD111mDact Po!nr -~ - -^'~ OI ~ ONao-ColBalc^ 0 (= 0 11 0 O d l 17 D20 Dr}ve,•Res4i[tio1 T Ratt n ¢na OCnmplied Vfrth Nola Pennrylwnu ODrlva OTOp Co<nol O Remictlons Nat Unknown O O Unda¢arda e D 09 W O O ® Mo RcstrtAiansl Complied With Compliance 0 174 Not ApplKAble Compliance O OTowed Uni[ 0 0 Unknown 07 0a Bs ~ Re uir d - O O Pnrrr fndorstrnmr q e O Canpticd Vldh O Not a Penmylvanla Drlvcr Q Unknown O Com once i N R d A id M equ re ~ on O Unknowm O vv antt aneuver c Compliance 8 None Required O ~ Compliance No Avoldaru ~ Maneuver Brakin -Other Cdae A oidance O O 9 ~ nce Unknown Canplla N z e Ev!Cen e Driver LiMnft O Not Regained ler ~ Unk If COL or O BtaklnoQ•Skld Marks Evident OSteering-Evdence (, Imm~dsaive or Driver Staled Compflonm Vehlda Class CDL Required No Valid Llcerue O for Class Not a Pennryivania O Drives Braking - No Skid O A1uks Dnvet Steerin and Gratin O g D O Vnknown O Nat lJcensed O Valid Licerue for k O U Stated Evldena or Sated ~~ n nown UndK R!d¢ lndiulW /a..~ OrvQ Tett Tune O Blrrod O Other ND Underrde or ~ Undardde, he O+errid Other O Compartment O 4 Vehid< B Nor O Urine O Unknown it Tett Override invasion Given Undarrlde UnknOWn I( Und¢rnde Jyl+3 Test Rr•saltt - (Op m Faur pesu/ts1 O ^ , (, Compartment In'ruaion , O Compartment O Undemide or knrvsion Unknown Overtide 0 = No Test Given 5 =Amphetamines 1 . 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Wam/na Sbna fn Nana-UrC additional Maya Infer anarlioss PENNDOT COPY http:/hvww-dol6state.pa.us/icons/PrintLnsses/X1nlPiles/20071053371DLMBDF7S2007:.. !0/2S/2007 State Farm Ins 2/4/2008 3:18 PM PAGE 12/012 Fax Server 11-14-2607 6'3:21 K0~7i FAX Print CKS /10000075 Crash Number: A0000076 Incident Number: MBG-2007-10-D472 ~~. ~_ ..: _~ . /~v~' rp ~~-'PLC I G~1 U ti N PA9E11 }'age ]U of tti http://wwtiv.dot6. state.pa.us/icons/Pri ntImagesl?Cmll'ilzs/7007 t 053371llL bfBI)R 752007... 10/2 S/2007 COMAIONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE OVREAU OF FINANCIAL OPERATIONS DMSION OF THIRD PARTY LIABILRY ESTATE RECOVERY PROGRAhI PO EOX 8486 HARRISBURG, PA 77105-848fi May 14, 2008 WIX WENGER & WEIDNER THERESA L SHADE WIX ESQUIRE 4705 DUKE ST HARRISBURG PA 17109-3041 Re: EARL SWAUGER CIS k: 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 reimbursethe 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 $6,152.88, is to be entered as a priority Class 6 claim against the estate. Please acknowledge ,receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Since^r'ely, Susan E. Naylor TPL Program Investigator 717-772-6265 717-772-6553 FAX Enclosure Exhibit "B" ~ ~ i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT Of PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION .CASUALTY UNIT PO 60% 8486 HARRISBURG PA 17105-8496 May 14, 2008 STATEMENT OF CLAIM SUMMARY NAME . "' Estate of SWAUGER, EARL ID -` 002 537 506 MEDICAL ~ CLASS$ CLASS6 ~ 'TOTAL " INPATIENT .00 5,711.12 6,711,12 OUTPATIENT .00 441.76 441.76 LONG TERM CARE .00 .00 .00 DRUG .00 .00 .00 REIMBURSEMENT TO DPW .00 6,162.88 6,162.88 COMMONWEALTH OF PENNSYLVANIA Ct..~.4 ,; .,,~~„ -r„ ,;: _ r DEPARTMENTOF,PUBUC WELFARE,y ``'~ry,«~`_ '`,3 „r,,t^ May 14, 2008 STATEMENT OF CLAIM NAME' SWAUGER, EARL ID--..;j. 002 537 508 PINNACLE HEALTH HOSPITALS 111 S FRONT ST ARRISBURG PA 17101 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN '. USUAL CHARGES AMOUNT APPROVED 12/10/99 - 12/16/99 04/10100 40000753122170001 40000753122170001 3n,550.70 5,711,12 DIAGNOSIS 1 : 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2 : 5781 MELENA PROC CODE : 000000 PROVIDER SUB TOTAL - PINNACLE HEALTH HOSPITALS 36,550.70 5,711,12 O1 100002563 0043 t s ~ COMMONWEALTH OF PENNSYLVANIA F w[~.e.~:: C' Y ' ~- x t ~a';..~"`.,~DEPARTMENT OF~PUBLIC WELFARE, ~,:~-, y* May 14, 2008 STATEMENT OF CLAIM NAME-~ SWAUGER, EARL ID'„~~::-~1, 002 5J7 508 GROSSMAN ALLAN B 2200 DOVER RD ARRISBURG PA 17112 DATEOF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN .USUAL CHARGES AMOUNT APPROVED 12115!99 12/15199 07/31/00 40001956790770001 40001956790770001 185.00 45,00 DIAGNOSIS 1 : 1101 DERMATOPHYTOSIS OF NAIL PROC CODE : 99254 INITIAL INPATIENT CONSULTATION FOR A NEW PROVIDER SUB TOTAL - GROSSMAN ALLAN 8 185.00 45.00 14 001559467 0004 i - ~ z~ - A ~ y COMMONWEALTH OF PENNSYLVANIA : b..S~`~., ~ ~ r. ";, ~ , z.. ~'?>~^ae ~, „n r~ ;" DEPARTMENT,OF,PUBLIC WELFARE #~ y,.,i, s ~?,.,.-;_ May 14, 2006 STATEMENT OF CLAIM NAME+ SWAUGER, EARL ID `~4~^ 002 537 508 MANDAK JEFFREY S 1000 N FRONT ST IORMLEYSBURG PA 17043 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN ~. USUALCHARGES. AMOUNT APPROVED 12/12/99 - 12/12/99 09/04/00 40002306617520001 40002306617520001 30.00 7.50 DIAGNOSIS 1 : 41401 CORONARY ATHEROSLEROSIS N DIAGNOSIS 2 : 41071 SUBENDOCARDIAL INFAR INIT PROC CODE : 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT L PROVIDER SUB TOTAL', MANDAK JEFFREY S 30.00 7.50 31 001473101 0003 ~ -' COMMONWEALTH OF PENNSYLVANIA -" ~: a t ,.,}~ ~ p DEPARTMENT OF,PUBUC WELFARE ~ >,, .' ~, ,. .~-~ ~, ,, ,,-.j. 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 CRN USUAL CHARGES AMOUNT APPROVED 12/10/99 - 12/10199 04124100 40000886139810001 40000886139810001 220.75 36.00 DIAGNOSIS 1 : 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2 : 5781 MELENA PROC CODE : 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE 12!11/99 - 12/11199 04/24!00 40000886139620001 40000886139620001 206.50 145.63 DIAGNOSIS 1 : 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2 : 5781 MELENA PROC CODE : 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT 12/12/99 - 12!12199 04/24/00 40000886139830001 40000886139830001 206.50 145.63 DIAGNOSIS 1 : 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT 12/13/99 - 12/13/99 04/24/00 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 12/14!99 - 12/14199 04/24/00 40000886139850001 40000686139850001 92.00 15.00 DIAGNOSIS 1 : 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 5781 MELENA PROC CODE : 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR 12!15!99 - 12/15199 04/24100 40000886139860001 40000686139860001 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 - 12/16/99 04!24/00 40000886139870001 40000686139870001 122.75 15.00 DIAGNOSIS 1 : 41071 SUBENDOCARDIAL INFAR INIT DIAGNOSIS 2: 6781 MELENA PROC CODE: 99238 HOSPITAL r,: PROVIDER SUB TOTAL ` SAFAEE MASOOD S 1 032.50 369.26 ,~~ ~ Ty.- ~'!~ ~~~p^,x,~ 31 001714180 0001 , ~ n .ib'Yec'w jyiyPrc ~+',>"rpr~! I3lexne, Inc. (7l7) 7GG-3421 rnday, may z's, zuua Nlrs. Sara t. Funrman 4bu rcoio court Nlecnanlcsourg, F'q 1 /uSS uear Sara, Lloyd L. Nlyen Jr., Supervisor 37 East btain Street Niecuanic5burg, Pennsylvania IYUJS A s[anaard of excellence m Central Pennsylvania since 191i) Fay (7171 TJ?-7291 Thank you for selecting our funeral home to provide services for your family during your bereavement. I hope that you fot.~nd our services to be of the highest standards and that they met your needs and those Cf yOUf family 2nd friends. The fDll D'alny IS a SUmma~°~! Gf ilic 52re iCc Ctla f~c5 05 piaVIOU Siy cxpialneiJ anU provided in written foml on the sen'ices for: Earl L Swauder SUMtutARY OF EXPENSES TOTAL OF SERVICE RENDERED $8,842.67 LESS: Credits granted 1,595 00 LESS: Total Payments 3.1 BO 09 CURRENT BALANCE $4.057.58 Cr¢dils Granted' 51,5?5 ^0 PacY,age Prce Dlscau•.' Interest at the rate of 1.5 % per month (1 B % per annum) will be added to balance after 30 days. If there are any questions or concerns that remain unan_wered, elease call me. Sincerely, /i- /~ .~ .~ ~ % ~. , ..r ` 11 yam ' r,1 Exhibit rr~rr __ . ,, COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 FIARRISBURG, PA 17128-0601 Telephone 9/4/2003 717-733-5825 717-783-3467 (fax) brondomiPState.pn.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 [ax purposes only, this Department has no objection to the proposed allocation of the net proceeds of this action,'S 0.00 to the wrongful death claim and S 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. §3302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as [he proceeds are allocated. In re Estate of ~terrvman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I tmst that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections [o 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 dishibution of proceeds of a wrongful death /survival action. Sincere~~ ryan Rondon usiness L'alcation Specialist Inheritance Tax Division Bureau of Individual Taxes Exhibit "D" v IN RE: NO. 08-6291 Civil Term ESTATE OF EARL L. SWAUGER, Deceased AMENDMENT TO PETITION FOR APPROVAL OF ALLOCATION OF PROCEEDS OF SETTLEMENT OF CLAIMS ASSERTED UNDER THE 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, WnENGER & WEIDNE/JR n Date: ~ b ~ ~iJ~Q~tuJ ~ ~~1tu6C~, ~~ ~, -~-- 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 i•~/~~ Gaye Crr t RELEASE For the Sole Consideration of One Hundred Thousand ($100,000.00) Dollars the receipt and sufficiency whereof is hereby acknowledged, the undersigned, Martin Fuhrman, as Administrator of the estate of Earl Swauger, hereby releases and forever discharges Wendell Ritchie, his executors, administrators, agents and assigns, and all other persons, firms or corporations liable or, who might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the future develop from an accident which occurred on or about the 24th day of October, 2007, at the intersection of Main Street and High Street, in Mechanicsburg, Cumberland County, Pennsylvania. This release expressly reserves all rights of the parties released to pursue their legal remedies, if any, against the undersigned, their heirs, executors, agents and assigns. Undersigned hereby declares that the terms of this settlement have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of precluding forever any further or additional claims arising out of the aforesaid accident. Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Witness Whereof, I have hereunto set my hand and seal this 20 day of ~j0~"~/ , 2008. In presence of: ~/~~utiv ~~/~-~- Signed Witness artin of Earl Swauger ~' IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: ESTATE OF EARL L. SWAUGER, Deceased G1~ 9'/ ORDER AND NOW, this ~~' day of 1~~'r'"'° , 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. 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 SUMMERS, MCDONNELL, GUTHRIE & SKEEL, ATTORNEYS AT LAW sre=~._.~ J. s~~.lueRs T no.++AS A. McoovNEu JOSEP4 A Huoocn Jrs Geeee A Gurneie PErEa B $rcEE~ PAr EicM M GOVNELLY' JeEEe Er C CArAmzAeire KEVIN D. RiuCX 'ALSO Ao.nrreo IN W V "AL30 Aorvurreo IN OH "'A~_so Aorvnrreo w NJ HARRISBURG OFFICE: Ion MUMMA Roao LEMOVNE. PA nOd3 PHONE. 71 ~-90 L 5916 FAX JIB-920.9129 December 5, 2008 Theresa Wix, Esquire Wix, Wenger & Weidner, P.C. 4705 Duke Street Harrisburg, PA 17109 RE: Earl Swauoer Claim No. Insured D/Loss Our File No. Dear Ms. Wix: 38-L330-618 Wendell Ritchie October 24, 2007 16071 J>soe, A. Haves Eew M. BRAUN Guv E. Buss M.rgrc J. GocErv R oaerxr J. F:snE~ Ja Kinee9w L. Gauuccr JesscA M. JuaA V.o Ea:crc V V:OLAGO JonN A. Lucr ServT B~ACn~~~ ErrAU K. Srone M>rrncvi RrOLEr Pursuant to the Judge's Order, enclosed please find settlement checks in the following amounts: 1. $89,537.94 - Martin Furman as Executor of Estate of Earl Swauger; 2. $6,152.88 -Department of Public Welfare; 3. $4,067.50 -Myers Funeral Home; and 4. $241.60 -Wix, Wenger & Weidner, P.C. Kindly disburse these checks in accordance with the Judge's Order. It was a pleasure dealing with you in this matter. Should you have any questions or concerns regarding the above, please feel free to contact me. Thank you. Very tr ly-Yo~~ Ethan K~toT e EKS:kan HUDOCK, L.L.P. PITTSBURGH OFFICE: GULF Towea. Scare zaoo. vm GeANr SraeEr P:rrseuaon. PA Iszls PHONE a~2261.3232 FA% a12361.3239 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES PO Box 280601 HARRISBURG, PA 17128-0601 Telephone 9/4/2003 717-733-5325 717-783-3467 (fax) brondomi`st~te ua us (e-mail) Theresa L Shade Wix Nix Wenger R Weidner 4705 Duke St Harrisburg,PA ]7]09-0341 Re: Estate of Earl L Swauger. File Number: 2103-0342 Court Number. CCP -Cumberland Co Dear Ms Shade: The Deparhnent 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 fornarded to this Bureau for the Commonwealth's approval of the allocation of the proceed; paid to settle the actions. Pursuant to the letter, the 69 -year-old-decedent died as a result of being shuck 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 [he net proceeds of this action,'S 0.00 to the se-rongful death claim and S 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. §3302; 7Z P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of \ferrvman, 669 A.2d 1059 (Pa. Cmwlth. ]995). I Intst 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 an}thing 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 wTOngful death / sun~ival action. Sincere~y~ f~(~ /Gcvt c-tti ryan Rondon usiness L'alt:ation Specialist Inheritance Tax Division Buzeau of Individual Taxes Exhibit "D" REV-1511 EX+(12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Earl L. Swauger 21 08 0342 Debts of decedent must he reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t. Myers Funeral Home, Inc., 37 E. Main St., Mechanicsburg, PA 17055 4,067.50 (See Schedule H, Exhibit 1) 2 B. 1 Brachendort Memorials, Inc. 2131 Herr Street, Harrisburg, PA 17103 Cemetery Marker (See Schedule H, Exhibit 2) ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Social Security Number(s)IEIN Number of Personal Representative(s) Street Atldress City Slate Zip 1,600.00 WAIVED Year(s) Commission Paid: 2, Attorney Fees Theresa L. Shade Wix, Esquire 2,625.00 3. Family Exemption. (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 59.00 5 Accountant's Fees 6, Tax Return Preparefs Fees 7. The Sentinel, P.O. Box 130, Carlisle, PA 17013 166.60 Estate Advertising (See Schedule H, Exhibit 3) 8. Cumberland Law Journal, 32 S. Bedford St., Carlisle, PA 17013 75.00 Estate Advertising (See Schedule H, Exhibit 4) 9. Cumberland Co. Prothonotary, One Courthouse Square, Carlisle, PA 17013 78.50 Petition for settlement of proceeds under Wrongful Death & Survival Act (See Schedule H, Exhibit 5) TOTAL (Also enter on line 9, Recapitulation) $ g 747.69 (If more space is needed, insert additional sheets of the same size) Continuation of REV-1500 Inheritance Tax Return Resident Decedent Earl L. Swauger Decedent's Name Schedule H -Funeral Expenses & Administrative Costs - B7. ITEM DESCRIPTION 10. Cumberland Co. Register of Wills, One Courthouse Square, Carlisle, PA 17013 Short Certificate (See Schedule H, Exhibit 6) 11. Cumberland Co. Register of Wills, One Courthouse Square, Carlisle, PA 17013 Filing Fee for Inheritance Tax Return 12. Wix, Wenger & Weidner, 4705 Duke St., Harrisburg, PA 17109 Copy and Postage 21 08 0342 File Number AMOUNT 4.00 15.00 57.09 SUBTOTAL SCHEDULE H-B7 ~ 76.09 IV~yPrc F+'n~tPr~l ~C~I1le TI1C. V 1 H lyd l ' (7t',)7G6-3431 r nOay, IVlay ZJ, ZUUtl Mrs. Sara t. runrman 4aZ/ KOIO LOUR IVlecnanlc50urg, PH 1 /Ubb uear aara, tsoyd t,. Myers Jr., Jupervuor 37 Easl Main Street ;vtecnan;csburg, Pennsylvania I'/U» ,v standard of exce hence m Central Nennsylvania since 1910 Fos 1717) 79?-7291 Thank you for selecting our funeral home to provide services for your family during your bereavement. hope that you found our services to be cf the highest standards and that they met your needs and those of your family ar,d friends. The following is a summary cf tta sa;vice charges as previously explained and provided ir. written Porn; oo the services for: Earl L Swaugsr SUMMARY OF EXPENSES TOTAL OF SERVICE RENDERED 58.642.67 LESS: Credits branted 1.595 00 LESS: Total Payments 3.180 09 CURRENT BALANCE 54A67.SB Credits Granted' 61.696 PO PacY,age Pnc= ~isceurt Interest at the rate of 7.5 % per month (18 % per annum) will be added to balance offer 30 days. If there are any questions or concerns that remain unan6wer~d. please ca!! me. Sincerely, ;!~ ~ / / i i c' jG' Schedule H, Exhibit 1 BRACHENDORF MEMORIALS, INC. BUILDERS OF FINE MONUMENTS SINCE 1920 2131 Herr Street Harrisburg, PA 17103 (717) 234-7909 JANUARY 20, 2009 MR. MARTIN FUHRMAN, EXEC. ESTATE OF EARL L. SWAUGER 540 MOUNTAIN VIEW ROAD SHERMANSDALE, PA 17090 DEAR MR. FUHRMAN I HAVE PRICED THE MEMORIAL FOR MR. SWAUGER AT THE CEMETERY IN DAUPHIN . FOR A GRAY GRANTI'E MARKER: $1,600.00 THIS INCLUDES THE DESIGN AS YOUR FAMII.Y CHOOSES, THE UNDER- GROUND CONCRETE FOUNDATION, AND THE INSTALLATION ON HIS GRAVE. THERE ARE NO OTHER FEES OR TAXES UNLESS YOUR FAMILY CHOOSES SOME SPECIAL DRAWING OR ARTWORK, SUCH AS LASER SKETCHES. WE APPRECIATE YOUR CONSIDERATION. THANKS, GARY W. ALLISON Schedule H, Exhibit 2 RETAIN THIS PORTION FOR YOUR RECORDS REMITTANCE ADDRESS 81LL TO THE SENTINEL - LEGAL WIX WENGER & WEIDNER ATTY P.O. BOX 130, CARLISLE, PA 17013 AD NVMBER CLASS SALESPERSON BILLING DATE LINES 348865 10 PUBLIC NOTICES shoet 05/27/08 40 * 2 AD DESCRIPTION START DATE STOP DATE NOTICE LETTERS OF ADMINISTRATION O 05/10/08 05/24/08 PVBLICATION INSERTIONS RATE NET AMOUNT GROSS AMOUNT 3 THE SENTINEL - LEGAL 3 LGL 159.60 TOTAL AD CHARGE 159.60 3 PROOF OF PUBLICATION OlPRF 7.00 Earl L. swauger PAY THIS AMOUNT I 166.60 199.92* MESSAGE: Thank you for advertising with The Sentinel. Deadlines for in-column legal advertisements: Monday is Friday at it a.m.; Tuesday is Friday at 4 p.m.; Wednesday is Monday at 12 Noon; Thursday is Tuesday at 12 Noon; Friday is Wednesday at 12 Noon; Sunday is Thursday at 12 Noon. If you have any questions regarding your Legal bill please call Tammy Shoemaker 717-240-7176 Fax your legals to 717-243-3754 attention Tammy Shoemaker You can also EMAIL your legal to Classified ads: classified@cumberlink.com Please send a cover letter including your name and address as an attachment Schedule H, Exhibit 3 CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 May 30, 2008 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Theresa L. Shade Wix, Esquire RE: Eazl L. Swauger Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: May 16, May 23, and May 30, 2008 Advertising Cost $ 75.00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 75.00 Total Amount Due 3 0.00 Becky H. Morgenthal, Executive Director Schedule H, Exhibit 4 RECEIPT FOR PAYMENT ------------------- ------------------- Cumberland Countyy Prothonotary's Office Carlisle, Pa 17013 SWAUGER EARL L ESTATE OF (VS) Case Number 2008-06291 Received of PD ATTY WIX DKB Total Non-Cash..... + Total Cash......... + Change ............. - Receipt total...... _ 78.50 Check# .00 .00 $78.50 Distribution Of Payment Receipt Date 10~23~2~=, .;' Receipt Time 13:00:1 Receipt No. 216=~- 3360 Transaction Description Payment Amount PETITION 55. 00 CUMBERLAND CO GENERAL FUND TAX ON PETITION . 50 BUREAU OF RECEIPTS AND CO\`TP OL SETTLEMENT 8. 00 CUMBERLAND CO GENERAL . FUND AUTOMATION FEE 5. 00 CUMBERLAND CO AUTOMATI ON Fu:: JCP FEE 10. 00 BUREAU OF RECEIPTS AND CONTROL $78.50 Schedule H, Exhibit 5 RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17613 SWAUGER EARL L Estate File No.: 2008-00342 Paid By Remarks: WIX WENGER & WEIDNER WZ Receipt Distributicn Receipt Date: 12/11/2008 Receipt Time: 15:16:27 Receipt No.: 1055049 Fee/Tax Description Payment Amount Payee Name SHORT CERTIFICATE 4.00 CUMBERLAND COUNTY GENERAL FUN ---------------- Check# 3415 $4.00 Total Received......... $4.00 Schedule H, Exhibit 6 REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE/ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Earl L. Swauqer 21 08 0342 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Commonwealth of PA, Depart. of Public Welfare, P.O. Box 8486, Harrisburg, PA 17105 6,152.88 Lien from the Department of Public Welfare (See Schedule I, Exhibit 1) TOTAL (Also enter on line 10, Recapitulation) I $ (If more space is needed, insen additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA DEPARTMENL OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 11105-8486 December 31, 2008 WIX WENGER & WEIDNER THERESA L SHADE WIX ESQUIRE 4705 DUKE ST HARRISBURG PA 17109-3041 Re: EARL SWAUGER CIS #: 002537509 SSN: 195-28-0294 Date of Death: 10/24/2007 Dear Ms. Wix: This is to acknowledge receipt of payment in the amount of $6,152.89 regarding the above-referenced estate. The Estate Recovery Program's claim is satisfied. Your cooperation in resolving this matter is appreciated. Sincerely, ~.-~ ~ Susan E. Naylor TPL Investigator Supervisor 717-772-6265 717-772-6553 FAX Schedule I, Exhibit 1 REV-1513EXt(9-OO) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER __ _ 21 08 0342 r=an ~. ow au ci RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE TAXABLE DISTRIBUTIONS [include outright spousal distributions, and t2nsfers under I Sec. 9116 (a) (1.2)1 1. Sara E. Fuhrman Sibling 42,549.71 4527 Rolo Court, Mechanicsburg, PA 17055 2. Claire M. Swauger, 264 E. Cherry Rd., Lot 11, Quakertown, Sibling 42,549.72 PA 18951 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, O N REV-1500 COVER SHEET j], NON-TAXABLE DISTRIBUTIONS: 1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size)