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This receipt, re se ~ and indemnity agreement (hereinafter called the "RELEASE") is
given this _~ day of 2009, by:
Cumberland-Goodwill Fire Rescue
(hereinafter a led the `CLAIMANT") to and in favor of KEYSTONE
GUARDIANSHIP S VICES, (ADMINISTRATOR) of the CYNTHIA N. STAGER
ESTATE (hereinafter ~Iled "ADMINISTRATOR").
For the purpose of inducing the ADMINISTRATOR to make the distribution described
herein, and intending toj l~e legally bound, the Claimant hereby represents, warrants, convenants
and agrees as follows: i
1. Acknowledgment o eceipt -The Claimant acknowledges that he will receive of and from
the Fiduciary the lowing securities upon returning this Receipt & Release document
properly signed, wi ssed and notarized to the department.
- In the form of a check in the amount of $78.67
2. Release - AND T FORE, the Claimant hereby does by these presents remise, release,
quit-claim, and fore discharge the said Administrator, their heirs, successors and assigns of
and from the said a ents to me and of and from all actions, suits, payments, accounts,
reckonings, claims d demands whatsoever, for or by reason thereof, or of any other act,
matter, cause or thin whatsoever.
3. Indemnity Agreeme t -The Administrator has indicated a willingness to make a distribution
without the adjudic t on by the Court. Accordingly, the Claimant agrees to indemnify the
Administrator and ` d them harmless, to the extent of any funds or assets received by the
Claimant from the d inistrator hereunder, frq~ and against the Claimant's pro rata share of
any and all liability including attorney's fees and other costs or expenses of defense) to
which the Administ~a or may be subjected by reason of its administration of the account. In
connection with this greement, the Claimant agrees to:
a) Refund or retur~, promptly upon the Administrator written demand, any funds or assets
distributed by th~ Administrator to the Claimant, if the distribution thereof is determined
at any time to ha 'e been an erroneous or negligent distribution to the Claimant, whetheN
such error or ne~ igence was or was claimed to have been premised upon istake o>d -
,
law or of fact. ~ ~ ~
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b) Modify and d.
Administrator
commenced,
collect an ern
such time as
negligence.
4. Miscellaneous -
governed in all r~
The provisions of
thereof _~hallw~be
provisions shall pe
hereof.
This Release shall
together with any cl
IN WITNESS
first above insi
tce any otherwise applicable period limiting the time within which the
tion to collect an erroneous or negligent distribution must be
s to provide that the Administrator need not commence an action to
>us or negligent distribution to the Claimant until two (2) years after
Administrator shall have obtained actual knowledge of such error or
construction, effect, validity and performance of this Release shall be
is by the laws of the Commonwealth of Pennsylvania.
Release shall be deemed severable in the event that one or more
~d+ invalid or 'unenforceable, with the effect that the remain{ng
as if such invalid or unenforceable provision had never been a part
the Claimant his heirs, representatives, successors, and assigns
with respect to whom the Claimant is a natural guardian.
)F, the Claimant has executed and sealed this Release on the date
the presence of at least two (2) witnesses.
BY:
Cumberland-Goodwill Fire Rescue
Authorize epresentative of Claimant
WITNESSES:
~-___
(WITNESS ONE)
(W D)
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