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RECEIPT OF DISTRIBUTION. RELEASE AND INDEMNITY AGREEMENT
This receipt, release, and indemnity agreement (hereinafter called the "RELEASE") is
given this oZ8'' day of Scp~-tn~-. 2009, by:
Neurology Center, P.C.
(hereinafter aalled the "CLAIMANT") to and in favor of KEYSTONE
GUARDIANSHIP S)Q~RVICES, (ADMINISTRATOR) of the CYNTHIA N. STAGER
ESTATE (hereinafter called "ADMINISTRATOR").
For the purpose of inducing the ADMINISTRATOR to make the distribution described
herein, and intending to be legally bound, the Claimant hereby represents, warrants, convenants
and agrees as follows:
1. Acknowledgment of Receipt -The Claimant acknowledges that he will receive of and from
the Fiduciary the following securities upon returning this Receipt & Release document
properly signed, witnessed and notarized to the department.
Cash - In the form of a check in the amount of $44.29
2. Release -AND TI~EREFORE, the Claimant hereby does by these presents remise, release,
quit-claim, and forever discharge the said Administrator, their heirs, successors and assigns of
and from the said payments to me and of and from all actions, suits, payments, accounts,
reckonings, claims and demands whatsoever, for or by reason thereof, or of any other act,
matter, cause or thing whatsoever.
3. Indemnity Agreement -The Administrator has indicated a willingness to make a distribution
without the adjudication by the Court. Accordingly, the Claimant agrees to indemnify the
Administrator and hold them harmless, to the extent of any funds or assets received by the
Claimant from the Administrator hereunder, from 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 Administrator may be subjected by reason of its administration of the account. In
connection with this Agreement, the Claimant agrees to:
a) Refund or return, promptly upon the Administrator written demand, any funds or assets
distributed by tlhe Administrator to the Claimant, if the distribution thereof is determined
at any time to lyave been an erroneous or negligent distribution to the Claimant, wheth r
such error or negligence was or was claimed to have been premised upon mistake
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b) Modify and displace any otherwise applicable period limiting the time within which the
Administrator Faction to collect an erroneous or negligent distribution must be
commenced, so as to provide that the Administrator need not commence an action to
collect an erroneous or negligent distribution to the Claimant until two (2) years after
such time as the Administrator shall have obtained actual knowledge of such error or
negligence.
4. Miscellaneous -The construction, effect, validity and performance of this Release shall be
governed in all respects by the laws of the Commonwealth of Pennsylvania.
The provisions of this Release shall be deemed severable in the event that one or more
thereof shall be deemed invalid or unenforceable, with the effect that the remaining
provisions shall persist as if such invalid or unenforceable provision had never been a part
hereof.
This Release shall' bind the Claimant his heirs, representatives, successors, and assigns
together with any clhildren with respect to whom the Claimant is a natural guardian.
IN WITNESS WHEREOF, the Claimant has executed and sealed this Release on the date
first above inscribed and the presence of at least two (2) witnesses.
BY:
Neurology Center, P.C.
uth rized epresentati of Claimant
WITNESSES:
v
( ITNESS I E)
( SS TWO)
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