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HomeMy WebLinkAbout11-15-10y S SWARTZ CAMPBELL, LLC By: Leah M. Lewis, Esquire PA Attorney I.D. No. 207045 275 Grandview Avenue Suite 104 Camp Hill, PA 17011 (717) 303-1580 Attorneys for Petiti Nationwide Mutual w 0 0 0 c :~, ss Z IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNT ORPHANS' COURT DIVISION IN RE: THE ESTATE OF Michael Alan Clifford, II, No.: ~ / - /b _Q deceased * * * * * * * * * * * * * PETITION TO APPROVE SETTLEMENT OF WRONGFUL DEATH AND SURVIVAL CLAIMS AND NOW COMES, the Petitioner, Nationwide Mutual -Insurance Company ("Nationwide"), by and through its attorneys, Swartz Campbell LLC, and hereby files this Petition to Settle Wrongful Death and Survival Claims, and avers as follows: 1. Michael A. Clifford, Sr. and Misty Clifford, the parents and natural guardians of the decedent, Michael A. Clifford, II, are the Administrators of the Estate of Michael A. Clifford, II, having been granted powers to administer the Estate of Michael A. Clifford, II, by duly issued Letters of Administration (File No. 2010-00703) by the Cumberland County Register of Wills on July 14, 2010. A true and correct copy of the Short Certificate (Intestate) is attached hereto as Exhibit "A." 2. The decedent, Michael A. Clifford, II (DOB: October 31,1988; SSN xxx-xx- 0456), died on January 19, 2010, following injuries sustained in a motor vehicle- m %-'~ ::::~ ~-~ _r~ ~~,',' -7~.:" c- , c;-', -- ~~ i .~ -_' :-,-, ~_~ ~~i pedestrian accident on Trindle Road (Route 0641) in Hampden Township, Cumberland County. A true and correct copy of the police report is attached hereto as Exhibit "B." A true and correct copy of the death certificate is attached hereto as Exhibit "C." 3. At the time of the accident, the decedent, Michael A. Clifford, II, resided at 113 Hummel Avenue, Lemoyne, Cumberland County, Pennsylvania 17043. 4. At the time of the accident and his death, the decedent, Michael A. Clifford, II, did not leave a valid last will and testament. His only intestate heirs are his parents and natural guardians, Michael A. Clifford, Sr. and Misty Clifford. 5. At the time of this Petition, Michael A. Clifford, Sr., has passed away as of October 22, 2010. A true and correct copy of his Death Certificate is attached hereto as Exhibit "D." 6. At the time of the accident, the decedent, Michael A. Clifford, II, was walking along Trindle Road. Simultaneously, Kathy E. Dick was driving her vehicle down Trindle Road with two passengers, Dennis L. Dick, Jr. and Gerald F. Rohrer, Jr. See Exhibit "B." 7. The accident occurred when Michael A. Clifford, II, was crossing the street at night while wearing dark clothing and was hit by the vehicle driven by Kathy E. Dick. See Exhibit "B." 8. The decedent, Michael A. Clifford, II, sustained fatal injuries as a result of the accident. The driver, Kathy E. Dick, and her passengers did not sustain any injuries. See Exhibit "B." 2 } ~ 9. At the time of the accident in question, the Petitioner, Nationwide, had issued a policy of insurance to Kathy E. Dick providing liability coverage in the amount of $100,000.00. A true and correct copy of the Declarations Pages of the policy in effect at the time of the accident is attached hereto and marked Exhibit "E." 10. Following the January 19, 2010 accident, Michael A. Clifford, Sr. and Misty Clifford, parents of Michael A. Clifford, II, presented a claim to Nationwide for damages arising from the death of the decedent, Michael A. Clifford, II. 11. Thereafter, Misty Clifford, in her capacity as parent and intestate beneficiary of the decedent, Michael A. Clifford, II, negotiated settlement of the claims of the Estate of Michael A. Clifford, II. 12. Pursuant to the settlement, Nationwide has agreed to pay the sum of $100,000.00 to the Estate of Michael A. Clifford, II, in settlement of all potential claims against Kathy E. Dick (as the policyholder) and Nationwide. 13. The $100,000.00 settlement represents the liability limits of coverage and the full amount recoverable under the policy of insurance in question. 14. Misty Clifford, administratrix of the Estate of Michael A. Clifford, II, has executed a release in favor of Nationwide Mutual Insurance Company and Kathy E. Dick, as the policyholder affording coverage for this accident. A true and correct copy of the General Release Agreement memorializing the settlement is attached hereto and marked Exhibit "F." 3 s s 15. Misty Clifford, administratrix of the Estate of Michael A. Clifford, II, has not been made aware of any unpaid or outstanding claims or liens which are raised against the estate of the decedent, Michael A. Clifford, II. 16. Misty Clifford, administratrix of the Estate of Michael A. Clifford, II, has signed an Affidavit stating same. A true and correct copy of the Affidavit it attached hereto as Exhibit "G." 17. Misty Clifford, administratrix of the Estate of Michael A. Clifford, II, is of the opinion that the proposed settlement is fair, reasonable, and in the best interests of the Estate of Michael A. Clifford, II. See Exhibit "G." 18. Since the Estate of Michael A. Clifford, II, has not retained counsel in the filing of this petition, no attorney has incurred expenses in connection with the settlement of this claim for which reimbursement is sought. See Exhibit "G." 19. The petitioner, Nationwide, retained the services of Swartz Campbell, LLC to prepare this instant Petition. However, Swartz Campbell, LLC has neither acted as legal counsel nor given legal advice to Michael A. Clifford, Sr. (deceased) and Misty Clifford, administrators of the Estate of Michael A. Clifford, II, in preparing the paperwork. She Exhibit "G." 20. Michael A. Clifford, Sr. and Misty Clifford, administrators of the Estate of Michael A. Clifford, II, paid the funeral expenses and are not seeking specific reimbursement from the settlement proceeds. See Exhibit "G." 21. The decedent, Michael A. Clifford, II, did not owe any child support arrears at the time of his death, according to the Pennsylvania Child Support Enforcement 4 ~ i System ("PACSES") website (www.childsupport.state.pa.us). A true and correct copy of the PACSES lien report is attached hereto as Exhibit "H." See also Exhibit "G." 22. Michael A. Clifford, Sr. (deceased) and Misty Clifford, the wrongful death beneficiaries of Michael A. Clifford, II, who are over the age of twelve (12), do not owe any child support arrears according to the Pennsylvania Child Support Enforcement System ("PACSES") website (www.childsupport.state.pa.us). See Exhibits "I" and "J." 23. The petitioner, Nationwide, upon the request of and with the consent of Misty Clifford, administratrix of the Estate of Michael A. Clifford, II, respectfully requests allocation One Hundred Per Cent (100%) of the net proceeds of the settlement to be paid to the wrongful death action as follows: a. Wrongful Death Action $ 100.000.00 b. 24. Survival Action $- - -0.00 The reasons for the request allocation are as follows: to minimize possible taxes, paperwork, and checks. 25. Pursuant to the Wrongful Death Statute (42 Pa.C.S.A. § 8301), the beneficiaries of the Wrongful Death Claim and their respective proportions are as follows: To: Misty Clifford (mother of decedent) $50.000.00 To: Estate of Michael A. Clifford, Sr. (father of decedent) $50,000.00 Total: $100.000.00 5 1 Wrongful Death Action To: Misty Clifford (mother of decedent) $50,000.00 To: Estate of Michael A. Clifford, Sr. (father of decedent) $50.000.00 Total: $100.000.00 Respectfully Submitted, WHEREFORE, the Petitioner requests that the parties be permitted to enter into the settlement recited above, and that the Court enter an Order of Distribution as follows: Date Leah M. Lewis, Esquire Attorney for the Petitioner, Nationwide Mutual Insurance Company 6 i ~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SHORT CERTIFICATE I, GLENDA EARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 14th day of July, Two Thousand and Ten, Letters of ,^DMIN/STRATTON in common form were granted by the Register of said County, on the estate of M/CHAFE ALAN CL/FFORD // late of UPPER FRANKFORD TOWNSH/P (first, Middle, LesU a/k/a M/CKEY in said county, deceased, to M/CHAFE A CLIFFORD SR and IFirst, Middle, Lastl MISTY CLIFFORD !First, Midd/e, Lest) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 22nd day of September Two Thousand and Ten. File No. 2010-00703 PA Fi 1 e No . 21- 10- 0703 Date of Death 1/19/201 D S . 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AM dente ,ck0u~ sp. Eec) p 9=Unknown ~dtipkai o e ~ ,.M'wcr ~Y iMlnjsey, Unk Savedry 1~T 1~On VeNde 6Uabr r t 5.1us /acserger 98=ODier ~ 0 06aBiCycHfte~Yk ~ EboMdlGtedP,ds t0a/ur B~ Not fi t t Air a N t ~ ~ 9=tAskrgwn i1 '~ 99=tMikrgwn O . o t 12~oir Bag Not Deployed. 2.Extrirated ly MectwYal Mem l3-Jut RemosN~Hriar To Cash) 3~frled By Non -Mechanical Means d ~ ~ °e~~ ~ known 1 ~ 99~Jn kn dNSS darts Agengr. HAMPDEN EMS ~ AAedlnl FaaBty: NIA ~~ he,aa ~ Ol Ol ~~ ~~ (MM-0D-YYr1~ A 8 C D E F G H I O T 06 - 03 - 1972 l~ F~~ 01 03 10 ln~ 1~ Naarre / Addno / PMorte Same ~ EMS Transport ^ ot~a~r DICK, KATHY E 50 FAIRVIEW STREET CARLISLE PA 17013 71724 Ores O No QtNo ~ O T ~~~19 -X19174 2~Mn® 03D 03E IOf 1~0~ 1^ N,Ilte / Aeldrea / Plrene tiMK TranapoR ^ c~~r DEMdIS L. DICK JR SO FAIRVIEW STREET CARLISLE PA 17013 Ore: O ~ unk Pb Parsers teo OI 03 De1d~T Oats O OS -~ rYYY1 g G - 1972 2~aa OS 03 99 ~~ !^ Name / addrea /Phone ^a~e, a GERALD F ROHRER JR. 501 WMDY HILL ROAD SHERMANSDALE PA EMS Transport O res ONO unA NO ~O" ~ 02 01 Date o ~~+ ~•~-~ A C D E f G H 1 p T 10 - 3I - 1988 aoaooooafl Narsw / Addnsa / t'hwN EMS Tnnsport ^ ~~ CLIFFORD, MICHAEL A 113 HUMMEL AVE LEMOYNE PA 17043 7172 Ores O No tMN No Persen No c~c~ MMte7 Date of Bktlr p~M.l-OD•YYYYI A B C 0 E F G H a r~-c~-c~aoac~oooaa Name / Addnsa r wprK a Si111e as EMS TraanpoR Operator O Yes O No UAh Ne tkraon No c~c~ Oeletrt Date of Birds (MM-0D•YYYY) A B C D E f G H I ~ c~-o-c~aaooc ~oaoa None / 4ddress f Phone . I -'_- _ -_ sue r.Y.~.. 7174125179 natlonwlde Natlonwldelnsurance ,< m Print CRS W0142462 J CONINAONYIIEALTH OF PEWNSYLVAMW PaLICE CRASH REPORflN6 PORNA ~ M 500 4 '°'° t'~D'r+' 08:56:41 a.m. 07-26-2010 16/22 Page S of 9 W0142462 a.rlrr Pwerb« Crxh t7erobtlen 1 ti t t~ ~ g ~~~ D ~) ~ ~ ~) 7~ 4t Ob pd 9 O tl AJ~ = er nown a 1=Ort TrwM lane ~Madlan b=OFFaide tallowy 7~Gora (Rump inNgactla+d I!=SlrorAdRr 4xlWadllde trrta vrldep Ltae Y.U Maawn ~ ~ s,aa,Mt t1=D dsw - -- 4.Oaek ~ 11NeNrer Conduear Q s'~,° 3.64N B1wf z_=_ S.ka 7.BFN1 a ~a 9etlnWrewe f ~ ><=Reh 4_$rtaw B.Rain i top tkO Bar - ~ g - ~----~ -~~~.____.__- --- Red Srrfaee Cmrdtlae ® ~ ~~ Mod. Dirt, ~ B=be PaOr:Ma 8=Olwr I=VVN 3=8nOrr l.oven tl 6.lOe 7=a - SanWnp •'~ ~'- 1 02 ~ p a=esus wane i9,ard 01 INiI l 30.11is tenor a Wales -- 31:1iI BulOing IIRk No Olasl IJti1 J 32~tn Culrat ^ p I ~ 0 ( 2 D3•Hq Uro! 3 Os U N S 3]=Kt &Idge Pier 0+ ALrmnent 35 19 ~ ~ ~ n ~tit 1 M d . 1 PNate Put Es v+t I 3 Q ^ C] 0 ~I ~ TrMfic Ih1it tNtFM A l OB tii i 3 ~ Bo~nder~yOr Otnade 31 Ff1 M ~ e s n Seouenlia+ r = t Are D9,Cd6ion Vdth Other Non . rp9C! tlenuator 3B=H1 fim Nydanl Order 4 ~ ^ p e t,.p'edwar eo~uas 1 ago-a~'it +r1. ~ t2.5wak ry t1r:t 2 a.1at rrafG[ Mena 13.St+udc h Unit 3 42altit Snow Bank won Event u+t 1lfoet7 uttlgr tbN Number 1 11 ~ p is•SUtdr ~ tM t 5 t6.stnrd; h oUFe rabic udt 43:~~rxy Consinrdion atl.sNt thhe fhea 06~c1 Untt No 21.111 Toe Or SMrtlre 49=Hit Urdrnersct Feed Otyett 02 ! ~ ^ p p 22411 frnYerirntera 2mH~'a k r5ale SorquplrarVpol Oran S1 ~ M Thrown Or Laing ~ E~ r tr k~i t ~ a p zs.lk euerd B i1~.NIt G~ laB &re sz~a Holes a o;net S~~ t 4regdarnes SeRUrnBa+ 29.F1tF Cowete Dr S~dire M VNpde ~r 4 Q a p 29dIR itdi lame 9~9=Urlk~nowtr~NUm4! Event tine tb w+m Event tlnlt No won Evarrl ~ 01 02 ~ 01 02 Delver Action f0) °~-+~ corarLullfrp Acion Driver Was Dislt kd 17=Cereless a Regal Bedmrg On w°a°""y 1tt~ ~ On tae Wron ~ irr Dr llSi Ft dsNldPh g Sloe It >d o.~.,.,eKM,..,rw. p r g ar one D 3•Driv!rp lkirg Fterrds free Pose 0 19=Makerg knwoper _ 9 ~ l~TUn Enu~ n oe To M9Moa ' 1~1A_naArlsartef ~Raedtvav /olandal /near (6RJ 1 29 2 ~ 3 a ~ ~ T~~~ l a g ~~ fxA ~ ~ ' o0dbro 1 tr5l+pppptevryy Road conditions 4ca6navl O = ty ie 07=Procaedig WA t:ksranoe alter sto R om H gP 2 t ~erekss P+r~n9'UroerdrF9 22 t^1Nudy Condniae 12+nu On Roadway 02.Sudden tMtatlFe CondGorrs i].PMhda p ~ =OvedUrFde ~arnp gation Al carve R3.Odw Welber Carrdliorrs ta.erotretr or Cacted revenant Oe=Dee In Rwdway 1 S.TCD Obstructed to=Feiw o to ORRr Taffic~omal Device rt ~ ~ OS.ObAade On 16.Soh Shorlder a 9rwlder Drop Oft ~ arinal>'r Ro vay Ztl=OMer laedwap Fatter I 1 ~1 12=Suddas 9owi 25~aBr ra T Meinwn Raper Speed 26=prlve PdiR {Pal Ctatd w ~ 07 29=other Enviiorrner'W facer OBslMbrk Zone Related 99.Urdurown t3.Regely ~ 14-~ Pastin Or U 2):Drive 6 e edenceA 28::ieiNre To Use Spewliad ~ g na 92=AffMed B tl i A C dtl hasRAr tAtMda iakiwea (q 12-wipers 13=Dri ODeN s i e I S=r»g In No Pmirg Zane rys c an ir , o Y ~n ~ImPraptr Drivrrg Actions ~ ve eat ny orrr D6ofidnufl arad of=nrn oT.Neadlyncs t4,ioat, odors, Hood, Est 02 1 ' 15=Trail 1 Fli S 08 h 16.Giw+p Toe vvronp Yvry qn 1•Way sweet : a ee ystem s tc aS9tse1 l ~S~ Sysoern 019~4Ter lig~hK 17 w 01 s~ 2 T~ 1 1 3~. R ~ 05=iowerTgin 1ldlirras IB=TailNOverladtd I9=UrnacureShihed ~ O I 1 00 2 ~ dm a nd l I 2 N~o 02 1 ~~j 3 1 N o tO pop i np ~ . ..._. J t 21+AbstnKtaa V A rdslvdd ~ 02 1 00 2 ~ ~nk"o'vn f10~NOne ANon ~ DOA.Nrvetride 01#rtteritg Or Crossing At O~PW~4 a reeving Vehicle o6 W Spebfitd louGon . atirrg on vends braP~iMd Misr factor Un~ l~ ,°o+an"w e~ ~ Mornitlpi °" 02 02 02 O ak9 arvwrg, lagging, 98.Oth~ 99 U k e/R V 0 / _ _ - r---~ UahNo 0~ I 1 = n nown ume rb n~ ~ ~ a~-1 7174125179 natlonwlde Nationwide Insurance Print CRS W01424ti2 COMMOIYtiYEAL7H OP PENNSYLVANUI POLICE CRASH RO~ORTIN6 DORM ~ AA 500 5 atsu^a~r f e __ ,1 ~ Nsrratlve and additions) wltrwsso: Aaklskkt Investlystion NoWlatiort iswsdt ~ hapsktir l)amaas O 08:57:22 a.m. 07-26-2010 17122 Page 6 of 9 ~I~~l~l ~~. ~ W0142462 Unit-1 was Westbamd on Trindle Road. Pedestrian(Unit-2) crossed the Eastbound lane into the path of Unit-1. Unft-1 struck Pedestrian (Unit-~ knocking him back aaosc the Eastbound lane. Unit-1 stopped on the shoulder of the Westbound lane. The drnker of Ur1it-1 got out to check on Pedostrian (Unit 2}and remained at the some. 7174125179 nationwide Nationwide Insurance 08:57:47 a.m. 07-26-2010 18 /22 eaa Print CRS W0142462 Page 7 of 9 Foo ~~ ~IIII~I~~II~IHI~ a.al -+B• o Nrw AA 500 ~ ~~~ -~ ~ o ~, woiazasz Gsrrtlrwatloe Mad Sufis hne O 4idt or oioAt O Okt fmnW Arit/IrAse O MlNtary O Olhar Federal Sites ~aaN a O se~ O Othn O 1t~rYdla~°dka O kdgn Besavedan O t>ther O Ibdcmp see O unknown O NaManal hrk O ~~ "' O UnNrown PNeae mniplele Unit kaforenaMolt for eed- unit inrsMd In a filMaalh. [b e » ngat die htBorntalian ha the Nelda aboae on ~~ O1 ^ ~~ ONon{oliiaion O Ott lz o0 0 O Reeericdore O fbt a Fannrylwnra ~~ O Tep 10 02 O s~ Neltiictlarn ~ O No Newiaiarf O tasrrpie0 WIIh O WmrP ~e O wag' O 09 03 O Not AppBlubN O p rowed unN 0 c ~ gao O ~ ' i i6i H~feanaylrania O O tMkrlouar 0 O t ,asr p d wIm O O O U Awdaaee paannrr O None ~~ ience O PUanea unknown Compl O ~1Ne~ O Evken~ae ouur O Olha AvWdrrce Maneuw- 3 O ~ ~ i f ~ O ml R ~ « O Ma b ~vfd~eM 0 wwirer sta O mcondu:rK Ida t]r p idn d O ~ ~ ~`d11 O ~~"~'°~'~ O ~ oli~Wr~ Q stewing and Bracing O Unlmown O Not Uanned O ~ tiaaKe ~ O Unkno n ENdaice a Stated w ~~ 0^ne 11at 1Yee O good O t]Iha O ~ °r Underddr, qo O rtm.M O vd° aye' 0~ ~"' P C7 N0"' O Urine O ~ If Test h,t na wn tk'dar'b u N u k l t>tra. ra>trwia . nk, r a.. w>rd-cs ~ '~ ~nt O ~ n nown nden dt O C ~ O urde ~e or 0 . pp TeC Ghear S . elamind a ~„~ ~ ~ ~~ 1 . alo Dny Baparnd i . KY S • B a OUnr TeA 4 . ~ ~ D ^ ^ ~= in Enw rt O tlBhtc Hadfing ~ tiotl~ tlyhh and Sinen ~~ g ry O ~ O sken Soun ~B O unknown urdt ye l f J d d t r rr a e rreee lkefnt O Narrcdkslon O ~ 1 tz o O O O co d Y O o ate O Tv t oz O. e VNh Ir p O No BuVktlorrl O ~~ at'^r O CU ~ B O Undernniage O 09 03 O Not Appgrabk O cnetpganaa o m P S O Towed unit O ~ 0 of °i ~~ O O trenrashrr+ia p unknown ~ o O O ~,,,wB.d vwd, Nequired O none Oe~ ~ O~aitra~wr e A+ad,~r.aBan.ww Na Avoklrrce O O ~ipBance Unknown Marwewar Q Ervide Ke Otl~er O Oth~ A~ ante Not Requkad far O Ve~ide Ong O Unk if CDL a araklnq Skld O Marks ErideM laeerirrg - Eridena Oar prirN Sgttd O Mcondusive p ~ ~ ~~ ~Dl Itequked O Not a hrMrgdwnia Orirer O yadaMh Drirw~ O Sinrirg and waking O unknown O Not Liaaraed Vepd lkeree for O O a O Unkntnm stmd Evidence or stated r undr Ede Irdaa Sara -aA lYee O load O~ O No Urrderrida ar O eosin nbe, No O Overtide, other ~nt O None Q Urine ~ if Test O G Orerti/e Vehkte IMnlSlen iwn INderrWe Utrderride Unknown N Orayt Tat Itawfb - Nib r /our /~earlart © ^ . O CamPar4nelrt InVtuion , 0 fnmpertment O Ufldenide or InGuslon Unknovm t3venade 0 . Na Tat Ghen 5 =Amphetamines Y ~ ~~~ t D aarrpy 2 a py 3 • foralne ~ ~ 9:Unknown Ten ^ ^ E~ena Ua N i E O Uglys prh~ O Botli L1gMs and Ares a.oaiara Rewfts oL n awgenq O ~,,. O Sr.. se.~fM (~IIrJrMWl1 7174125179 nationwide Nationwide Insurance 08:58:21 a.m. 07-26-2010 19/22 Print CRS W0142462 Page 8 of 9 ~1M1~1~1~ F01 W~ ~ O Nwn d~N/I~I~ aaMh Nu~e.r AA ~ M `~ ~ O ~~,,, W©142462 Haft No fae A^sws Y h ~eMw IeaaOt Fa inRinO Siu arld FMmM lyp~ w dre tolRrwiny codes: Y . Yw N . Me U = Uelaawn ~^~ 9~ QC 1 I1dm~tlyitl tt~dcdlRU.i tll~.~ 1191~!!at Ihl ~CWBT a Eyc Protacdars ^ T a ~ ~ ^ Eye MotacWn ^ = a ~ Pissevs4a ^ MC Ediatbn I l lacy Sleeves 3 . Halt Ndmet Style Style 3 . IIeR helmet ^ long Skrves Style BBaagq ~ LL..••~~ 9 • Unlmown 9 • Uticnawn a TrW ik Q long Paras ^ Fidrrrit Stry Onl ~ long Pants ^ Nelmet Stay Ont Trakr ~~ ~ Over Ardde Hoots ^ OOa SneNSneN tklenl has ^ Qver Mtle Book ~ ~ netion _ ' Yi i~t N0 ylbf.y~K4 ~ N= No l ^ POavenBtv7 ^ HtMiet7 ~ Ne Yl~tyS~ Q N: Ho S ~ Pasaengat ^ Hekrret7 U ~ ~*~ ~ l1Bbri7 ~ liefleROnl U r Ihdmowr ~ ~ 7 ^ Relkttas7 ® ~ © ~ 01= Mrpd Cr b ai Ol rt M~avsectipn 02: AL IMersecdorl - No Crossvrllet 02 = At lnbxdiar - No Cromrralks 03 s NoMMersectloe Craawelks tl~~tooifi 03 . tbninersectlon Croswvslla OYes W x Odrevwy llatess Q Yes 04 = OmRwiy ACOefs i 06b 06. Not Rmdvay O No 06 ~ Not Roidwry ONA it MaSAAIan 07 ~ f~k~i~ O N M ti lllf an O I fl d 07 a MldHp ~ t19 s StroJdQ . y, ~ ~ ~ ~ y y y ~ { 09 a Sliarlder O ~ght 10= 5derwlt O Ught 10 a 9dlMNBC O OaAc i I . < 10 Felt OFF Raid li : > IO Feet OFf Road O ~ 11 a < 10 leaf Od Road i 2 : > lO Fee 0Q Rod O fleAecihe 13 a 0utlde TriRicwiy O PeReco~e 13. 0ulslde uitpcway O Untnowil 14. Shared PiOWtrah O Urdtnortn 14 a Sfurtd PrthyTriys 9g = IAiclrown Y . Uricwrlm ~~ ~~ ^ laoe Ckeue) O Cartshaclioa aorq Teen? O t1eFOre Isl Work Zane ~^'9 59^ ~ Road Clostd aitli ^ p1aa7 O Wintenaue t T ) t3h ~ O admrae Wan' Ares ~ 6 7~~ t ^ M ( ~p ~ ar erm O yK e in ip ~no t ~r ~ ~ O Ue~q Company O Acliviq Ares O O No ~n~ag lraro ^ 1i~ a O o0ra O TMriination Area O No O ~'~" ^ Ftigga Canod7 O 0tlra O unknown ^ Odra Addid.nN Ynga lrstaeesratiers 7174125179 nationwide Print CRS W0142462 Crash Nurrrber. Wt)142462 Inddent Number. HAM201110100522 Page 9 of 9 1LC7T TC! ~+4L~~ -~-- --~- Street li hting 86Q feat Sssa Mud track E. TRINDLE ROAD Street lighting 790 feet ~ c W o rn 0 0 Nationwide Insurance 08:58:48 a.m. 07-26-2010 20 /22 d N O 7174125179 nationwide Natlonwidelnsurance 08:58:57a.m. 07-26-2010 21 /22 f Crash Repotting System Synopsis i~.i tlustiiy Assurenca Synopcis ~ RepoA Page 1 of 2 Print CjoseWindow Creak Synopsis created 02N 9!2010 for Crash Number W0142482 WsbGroup: KEPT Pdice Agency Data; The crash report was recorded by pollc9 agerwy 21103+1ampden Township, paVol sane -100, under incident number HAM20100100522. The dMpatch data was Otli 9/2010, Ms dispatch Mme was 0112 hours, the investigatlon date was 01!182010, the arrival Time was 0115 hous. The uwsstigatorwaa CPI. THOMAS A. SPECK badge number 198. The report was approved on 02/042010. Cresh beta: This is hit pedestrian crash occurred h Cumberland in the munidpalNy of Hampden Township, an Tuesday, 011192010 at 0109 hours. The illurrkralion at the time o/ the crash was dark wdh no sheet NghN. Ths 2 -und crash Involved 4 people wRh no injuries. There was 1 fatality as a rasuk of this sash. Thb b a reportable cash. Highway mairrtenance was not nolifisd. The Bosh was not schod bus related. The crash was not adaol zone related. The cash did not acgx in a work zone. The Bbdtbp roadway suAace was dry. Weather conditions included No adverse rmrtddions. A notdintion of an atxideM invesligalion was rtot barmd. Other ertvironrrteMel J roadway potential I~lors hduded another erwtronrtrental factor. The Indicated prime factor for this assh was a pedeslrlan9 eclbn (Walkirrg, running.1o99in9. DlaYin9 or cydmg) for unN 02. The fast and most harmfW event (or fhb sash was that and 1 Fld unit 02. Type location: This was amid-bock (non knersedion) sash, which occurred at no special location, Prhdpal Roadway: Cumbertand County, route 0641, the orientation of the roadway was East, Mere were 02 travel lane(s), the speed IimN was 40 Mph, with a stale highway mute signing_ GPS: The police-entered Lelitude was 40 i 3:12.000 end rho police-entered L.ongkude was 78 59:07.000 TCD: TreRc CoMrd Device: no traAk control device, No controls. Work Zone: Type of Work Zone: not a work zone. lane Cloacae: FuNycbsed. Lyle cloture direction East and Weal. Traific detoured yea. Estimated hours closed 1-3 hours. UNiT INFORMATION: 1 Und Number 1 was a motor vehicle h transport. The and was owned by DICK KATHY. Address: 50 FAIRVIEW STREET CARLISLE PA 17013. Thb 2002 Dodge identified by VIN: 1t34GP253728503098wesregistered is PA wRh licerue EWD5624. Travel speed: 036. Und maured: vehicle has insurance, Msurenee Company: NATIONtMDE, The lhrd was towed by ROADSIDE AUTO RESCUE. This was not a oaronereial vehieb. This Unit was a van, Vehicle color: 81ue, Spedel Ledge: Not applicabb. The iralial impact point was at 11 o'cbek, Oamaga Indkaior. Minor (able to be driven), Veldde role: Hit unk 02. Vehicle poakion: h 11te curb lane right. Direttron or travel: West, Movement: Trying to avoid animal, ped, object, vah, etc, Gradient on s level roadway, AlignmaN: Straight. Driver Infarmatbn: The driver of this unh was KATHY E DICK Atltlress: 50 FAIRVIEW STREET CARLISLE PA 17013. Telephone: 717.245.9738, Drivero 7174125179 nationwide Nationwide Insurance 08:59:22 a.m. 07-26-2010 22 122 Crash Reporting System Page 2 of 2 apparently normal. Vehicb code NONE was vfolaled. No citation was writlen. Paaaanger IMomralion: a passenger 02: DENN18 L. DICK ,fft., Address: 50 fAIRVIEW STREET CARLISLE PA 17013. Telephone: 717-245.9738, D09: 1 011 9/1 9 71. Aye: 3S. Sox: Mak. Sect poa4ion: front seat rlpM aide. Primary selety equipment: lap and shoulder beq were used. Secondary safety equipment: A'r bay not deployed, swkch on_ Injury aeverify: Not Injured. Ejection: Nd ejected. Passarger Iniormalion: a passenger 03: GERALO F ROtiRER JR., Address: 501 WINDY HILL ROAD SHERMANSDALE PA 17090. Tebptione: 717-713-8457. 008: 052911972. Aye: 37.5ex: Male. Seat posNion: Saca+d -ow - middle poskion. Primary sakty equipment: lap and shoulderbNt vrere used. Secondary aatety equipment: Unkrawn. trytlry severity: Not iryured. Ejection: Not ejected. UNIT INFORMATION: 2 Unit Number 2 was a pedestrian. PedestriantMonnatan: MICHAEL A CLIFFORD. Address: t t3 HUMMEL AVE LEMOYNE PA 17043. TeNphone:I17-249.9823, DOB: 10/3111988. Age: 21. Sex; Mab. primary safety equipment: None used ! NW appliabb. Secadary safety egryrmera: Nark used / Not appUcebb. In~1ry severity: Killed. AkgIWUDrugs Suspected: Alcotx>t, Alcohol Teat Type: a bbod, Ak>ohol Tart Results: ResuN = 0.98. The indwiduata condition had been drirdcing. The pedesvisn's sdion vws Walking, running, jogging, pieying of oyelir>fl. The pedestrfm's cblhing was DaAc. PriI1< CloseWi- ndow^~ 7174125179 nationwide Natlonwldelnsurance 08: 52:47a.m. 07-26-2010 9/22 04/22/2010 14:34 7172493344 ABOM8ICUTULAKIS PAGE 03/03 LOCAL R~GiSTRAR'S CERTI~iCATiON Q~ DEATH WARNINQ: N is illegal to duplicate this copy by photostat nr phatogrAph. Frr 11rr :hie cerrif'it~;rtr. SR.lH1 This i< ro crrtify thvt the infnrroatinn hcrc given i. Correctly corint] from an orieirurl C.trriFieatt ol'lltati • del}• tiled with me ac local Registrar. Tllp origins edrtiticulc will t*: forwardnl lq the State Vita RecorYls Otficr fi:rr ~enn9nent filrng. P 16053717 ' JAF~ ~ 1 Ot0 (:crtitic;tiinn Numh~r Laical Royialrar ~ Tate Jssucd M~raw~r. no:e. Ca1MOMWlALTIt OR M-1Nl1Yt,1MMA • D~Ar17~MAT OF IlEAL71t - IMfY1l 11lCOn03 ~~ - rnr..,...r,.e .. r i n P1 N aco aODCaL RQ_ Nawilla, Aa 17241 IrirrrN =,.~ p,rt•wN~IrINYWY/ r01r~rNMnrFlM ~ ra~r•rMwi(NANS rrWI•..rrlry :ra urr,py N.r '~+ :a.r~.r N w Nolllager Crematory Mt.HOl rs.y~raW u.n.rN:r rn:..rar~ '-""" 1: D0 A. r. JanWly I9, 20I0 °`",p ~~""r fns rNr N. ~ W.:r I t' ~~ """""'^"~ ~.. Hsad inturiss ~iri-NV ~ -•' ~j -- : ~~"'r""+~ a Hotor~ihic],a Craab ; Wr, l ~ e, ~ rM..,~ 6 r fta Ml. w.y,~ i4M.,,gr,~ ~I. WiwYMOM l goei.m ..r+r i.. err,w, 1a Morry.vPba etrn1 ~11uM.Mw4wON:r r b..rarr dMrr Cyr Jaa. 19,2010 >radaseriA.a, attack by a,ini-van ~w ~[W ^1b ~~ y~111YYw ^I.rr.Yr}N d~prX. ~4:IM'raV1 Mry (J.r.r ~rwrMtl:IbNr1N :Y IY r::.amW.y+.NN.w,.y :00 A.K Da 1711ti t]o.r rau.. dM,,,a ~..,.,, S. Mn~ .~ r~"`~"Jn~*1~wer~iNi.~.+«Nair•~ree+prN~rr~NwrNri~r.n~Mrrai a .~wrr4rw:M1/rWrLh~MnW ~NhMrrvrry,y...." .......................... 0 ~ sNw.r r•r•.ir~:ru:rrawra~rr,q ' rallrlbMJ1~ MF~.:Ir.~IM~1~.wIM\iNIM iNM.y~M MiN~MIrYL......... ~ a\LMs O.M:,q:IrWMrN,wrlr WNy.r~,.'N N1W, Nr ~~wArNtlN. Y~„1,rANY11N4 __••••_• a ry~(~~ ~y ~y ~FlrM nrr.Nr.r~~ x -~lF~ :- .~S~A-YH i.i /1 _ ~a..- _S. 1 n w r.r.a~u.a i.... 3Y-. _. CC[ ~ ON Ohm __ I N l] ur.w .n.+. ^ .r M~r.IrhMM /f*wlrrwrNr j~ VIrT.~Mwllln Rd.. Hechadcaburg,RA ~~1 CaranaC ~L7r.~~~lWi :Weary 19, 20].0 .rwNwtrwll si~ttsb IWlnieriiaiarniiw~~ ••w••r• r:r•ra.rsrr rat :rvanrl ~mcraswuumn MAehsal A Clifford Jr. ale a~..r~,~4 _0456 ~• Jini~iary 1..'2010 aNyt t ~ r 21 rr 4. M.. rr. rrr „. r Oct. 31, 1988 Yorkr FA ~ w '~" .. raw wrrr~r.. irr++r.M+N.w w rrN pn,,.., ! Cuabsrlaad Han su g ""'"r aw.wrwr:wwraaiw+ a. r r.re~:.r.nrrnN4rNU.a Pd 296 East Triadls Road P~•~'~ q}y, w+w..w. rr,.•.:: Nn7~ to WMMII .~r .wa6 +:•wriN7arMr4MNenr~l Laborer Da~'~ pw l~rr I~rn naa "w.+.Me`N`iwq"`""~r,~` uo.r:r.w.~r.Nawta~ n+.+raNra ver xarr 326 a'lobcat RA. ,,..°~"~ , n.r. pennavlvania Pi"r. ~`I+Mre„ru~wr yp¢er PrankL`ord ieswille, PA t 7241 r* o-ay CuwbarlaAd ,:N::R. rm.^ raw. ru...h a rwsw rr. ~. HI05.805 REV [01/07) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 I P 16855071 Certification Number This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. ~~ S~~t'~.c'~> `Ds~rct~' oC.1~' 2 6/2010 Local Registrar Date Issued 1~ rL ~wi ~t~ae COMMONWEALTH OF PENN8YLVANIA • DEVAA71AENr OF NEAL7H • VRAL RECOR0.S 1111'"' s CERTIFlCATE OF DEATH (Sb• InbVactlm• entl unmpNE on nwrw) srATe wE ruNtaen tr.wrotwe.N~rran br.btlN x Nw a Noeb 7mtM rnew N. brt a Nttb Ntur~. aw. wtA A. G f M 160 - 38 - 7592 10 2 2010 :tOtB•r NMWIt urT Irlr1 e.arrsb t. rtltrbw Nn l'ewr0•rN •.+• oy. nta. Hwpa: ONbr. 60 va 9/18/1950 Weshninstex, MD [BeNtrr ^mratttN.t ^oa ^ law ^wrat. ^aa~7prt •. crgrorb tGt7l. Nbq TtP rOttb a.Mpprwp nollMbTdwrwlrbiuiEr) 0.1Na owta7rl~.r Oaph9 N• Yw 10. btm NSbn bra Nbx YNib, ra Clmberland Fast Pennsbom 7Wp Select Specialty Hospital ~s ~.bi White 1i. btwartt rw•t r r. inter 1x wr ntlan twr r h u utTtlNNe ¢rda Idrrt aiM rtlrr Im awNlllw) 1n ntrW 7Nne Ynb4 lbtr llbb4 a suwNq 7Nr a p rr d1• nrrw iwn4 Mlrr WrN wrr bnMt ~ U8 Nnra Mw7 l 7•NOnhr/ pt~ CaN•p• (11 a &) rNNwr, DirTr (Spwpf Owner for M. A. S ^rw ®Ib Married Misty A. Rhoads a.brvabnWbpNm•rl7wKrgrnrn rr~,gl orrrH Pp obueaN Tw oesn ueb URper Frankford Tp kNr nra.•. mart L 17n OD r. 326 Bobcat Rd. T ~ , u..a.w1 Cumberlar7d 7m^ Newville7 PA 17241 ~~r 7Tacrrp ayrm• t0.Fiw'•tbwliitknYalnYr, Wd 10. WNrh rwb lFNxnidlt, rdbtrnwnr Carl - Clifford Ton nNTrwr• 7ww Ir7wrNaq xm N+o•.r• ~etro.w leNwL eb rb.s r. tv.a) Misty A. Clifford 326 Bobcat Rd., Necwille, PA 17241 2la rrmroepwrs i ^mitNa sln orrupTrw PLan.M~wA rnlwrgtprrw abnranrT,aanrrtarrprep 7la tarNa N7ylra,rr, aynrry p^,,,°rr ^ "r°rNnn9Yb ~ b"rw°~ie.~r:"~'o...~n~'°C~Yvw^ 10 28 2010 Evans Cranation Services Leola, PA iSM~nr is ZD.lls lnrdw 7ffi lbw bd Nm..rN.NNt - FA 012633 L ENrinq Brothers Funeral Home, Inc., Carlisle, PA 17013 Crtl7lll Nrw ahrwlwNtl7nN T•MNrrq amNrEt/bdR bbrrgtwtYYa R4rMntlNU1 79n lbrb•bnb 79e br 97rNMMl d,. Twa ~rnllw Y M •rblb r btt r arb b abTevr616 r.]ra srbaMrNMNt~ xAibdOtrh 97.pb Mwtd 7etd llbAM.fwA i0. Ww YRim~b lriktl Fanbr/Caa•rb•ibrm OMrMCm/ma0brlmt rbp•abtw arN. 10:25 P M ^rw +F i+ Ot OIbTM pr brnarrb rtl wwwpw) ~ •tn Px obw• b Na7T. MkFArbNNl~rl~-rwtw4 eYtbearw•abbb~lY abrt•ba0lbar.bo rOTwemirl wwbad~wwdw trawl, ~ p•rb OtrN rN nrialrgbtb rrryigata yob ML ^rw Niabrl, X1•••4 arwbY6Yb11w4r rrrgNirq.lY Myaw riwmdir. ~ ~ ^ R ^ Urlbr ; ~~ ~ i/u ~ l /T/~~G 7 c S 'r ~ » ya ~ ~ y . ~,/ e~ .~,.rr, r ~. M b (r w • wwb]wA 071: ~ ~ ,~ , ^LY•plrrrwrstn g ~ ~ y ~ Y arb4tr/, n ~ ^ y ~ ~ ~ ~ '8ir6 ~YN~6CMNE0. Oubla M•.•rP+•w rl: ~ Iblpyw, mpnyiwNNe lP hp warn ~~1~~N~rEp 4 b1rI~I 3tp LMT ^ N . ~ O. b lu w • mw4+rw aQ: . nblNrPwN•rNggwin747•bl wr bb• dM a i ^ Uio a n / rr MNn Nb pr~r P bV ~M~ ~ ~ S1 IfbnrrO•bn 9b_b,Ya MHIb•i4M~Mr) 9A bwsb lM l}ry0contl Y ¢ ry 1 W n ~c q~Nw gry r Itb+oN 9g•M•F•~Y~ l•iibb Rbrb Npn d Cbrtr Dwbt ~ }P NY•I ^bentla~ c. NL l ^Yw ~x• ^rw ^NO ^'~• ^Pbt0.y n••rPN^• 77a tbbrHul 7b. Y}iryr Wb7T 7b.NTirtpbWwnNq l$'riy) lO ^ P ^ M l ^ Oa 770. Lwrmdklul (&r, dylbr4 rrN //" ^ bas ^ Orw r4 r o~anebt M ^ rw ^ w lr prW spi we w . Olnr-~ 7N•CwM•Wraitr/r•1 7b.egrr•bb 0.rwlblMw•r•PnNk'aioN7b7a,u,a7awb Nr~noblr PnlMa. nb7b•0.w~aW~NaalObba bm7]) T•btlwlrgbbrtNN4rlrll••rrr bNbaanLyNwrwratYYa_________________ _______________ - • _ r~irNrr'N°wLawr`~°b•wwr~rn ~rh. ~.e'~m.rbi7b~.~."a):a'•.....aa ^ ~~_ ^~ ~(/.t~/G ------------ • NbNrO~birTL>tr•nr ------ p q o dIbWYMerYrWwalwrwtNplb~bq•ynNTn,Y attwbarNbw,iY,rtl pltw,rtlawbhmwtlgrtl wwwrw rrr. ^ 7/.nbw.a~aa~l Pb•m blb Ibm~1 Tt7•/RM/~ ~ _ rrdr (1/rnb ~~ ~( l07 ~ l ~ b ~ 7aarFbanb•n.aT.wta ~ /, oltpwrsMrrn~_, (iSL511,~ 71 741 2 51 79 nationwide Natlonwidelnsurance 08:51:30 a.m. 07-26-2010 6122 ~ " NATIONWIDE AUTO POLICY DECLARATIONS Page Ot of 02 These Declarations are a part of the polcy named above and fdent(fled by policy number below. They supersede any Dedaratlons Issued earlier. Your policy rovides the coverages and limits shown In the schedule of coverages. They apply to each Insured veh~le as Indicated. Your policy complies with the motorists' financial responalhNlty laws of your state only for vehldes for which Property Damage and Bodily Injury LlabAfty coverages are provided. Policy Number: Policyholder: (Named Insured) 58 37 C 757416 KATHY E DICK 50 FAIRVIEW STREET Issued: CARLISLE, PA 17015 DEC 31, 2009 Policy Period From: DEC 29, 2009 to F® 27, 2010 but only ff the required premium for this~erlod has been paid and only for s1x month renewal periods ff renewal premiums have bean paid as required. This poly Is Inftlatly effective at (1) the time the applicatbn for Insurance Is completed, or (2) 12:01 a.m. on the first day of the policy period, whichever is later. Each renewal period begins and ends at 12:01 a.m. standard time at the address of the named Insured stated herein. This policy cancels at 12:01 a.m. at the address of the named Insured stated herein. IMPORTANT MESSAGES: IF THIS DECLARATIONS PAGE SHOWS THAT COLLISION COVERAGE APPLIES TO YOUR AUTO, THERE IS ALSO COLLISION COVERAGE FOR DAMAGE TO A RENTED AUTO. COVERAGE IS SUBJECT TO CONDITIONS AND LIMITATIONS LISTED IN THE POLICY OR ATTACHED ENDORSEMENTS. THE FOLLOWING CHANGE(S) HAVE BEEN MARE TO YOUR POLICY: EFFECTIVE DEC 29, 2009 2002 DODG CARAVAN -CHANGED LIENHOLDER INTEREST SEE ENCLOSED NOTICE FOR PREMfUM DETAIL INSURED VEHICLE(S) & SCHEDULE OF COVERAGES 1. 2002 D006 CARAVAN I D ;l~184tiP253721i503098 Covers es 9 Limits Of Liability Slx Month Premium $$ COMPREHENSIVENACUS?OMIZATION ACTUAL CASH VALUE LESS $ 100 $ 41.20 COLLISION AND $ 1 500 TION C ~ ACTUAL CASH VALUE LE55 $ 250 $ 120.50 PROPERTY DAMAGE Ty L~ABILI BODILY INJURY LIABILITY 50,000 EACH OCCURRENCE $ 60.40 100,000 EACH PERSON UNINSURED MOTORISTS-BODILY INJURY 300,000 (S CK00~ EACH OCCURRENCE $ 84.20 ~ 100 EACH PERSON UNDERINSURED MOTORISTS-BODILY INJURY 300 000 (S 1 ® ~ EACH OCCURRENCE $ 11.80 00 t EACH PERSON TOWING AND LABOR 300,000 50 EACH OCCURRENCE EACH DISABLEMENT 81.20 FIRST PARTY BENEFITS $ 1.40 OPTION 1-MEDICAL BENEFIT OPTION 2-INCOME LOSS BENEFIT .100,000 10,000 TOTAL $ 49.70 OPTION 3-ACCIDENTAL DEATH BENEFIT 10,000 MONTHLY $ 9.70 OPTION 4-FUNERAL BENEFIT 1 500 $ 2 0 FULL TORT , $ .3 .TOTAL $ 462.50 LIENHOLDER-CORNERSTONE FEDERAL LIEN EXPIRES ON DEC 31, 2010 V-1 UU-A 7174125179 ~ " Hall- e Nationwide Insurance 08:51:57 a.m. 07-26-2010 7 l22 Page 02 of 02 POLICY COVERAGES Coverages ACCIDENT FORGIVENESS FEATURE - CURRENTLY ELIGIBLE TO USE LISTED DRIVERS: Limka Ot Liabilky Driver Birth Marital # Name Date Status 01 KATHY E DICK 08/03/72 SINpLE APPLIED DISCOUNTS: PASSIVE RESTRAINT SAFE DRIVER MULTI CAR MULTI LINE Six Month Premium INCL Policy Form & Endorsements: V0378 3329 3393 Office Use: B 302888 H0237748 DEC 04, 2009 $ 0.00 Issued By: NATIONWIDE MUTUAL INSURANCE COMPANY 23787 Home Office -Columbus, Ohio Countersigned At: HARRISBURl3, PA. By: MICHAEL C FERSTER CPCU IMPORTANT PRONE NUMBERS Nationwide 24-Hour Claims Number: 1-800-421-3535 For OUESTIONS About Your Policy, Call Your NATIONWIDE AGENT : MICHAEL C FERSTER 717-243-ls877 For Hearing Impaired: TTY t-80ae22-242t Nationwide Regional Office: 877-888-8877 GENERAL RELEASE FOR AND TN CONSIDERATION OF the payment to me/us of the sum of One Hundred Thousand Dollars ($100,000.00), and other good and valuable consideration, Uwe Misty Clifford, individually and as Administratrix of the Estate of Michael Alan Clifford, II, and on behalf of the Estate of Michael Alan Clifford, II, being of lawful age, have released and discharged, and by these presents do for myself/ourselves, my/our heirs, executors, administrators, assigns, release, acquit and forever discharge Kathy E. Dick and Nationwide Mutual Insurance Company, their heirs, executors, administrators, successors and assigns, any and all affiliated, associated and inter-related companies, its officers, agents, servants, employees, successors and assigns, each or any of them, of and from any and all claims, rights, demands and damages, actions or causes of action of whatsoever kind and nature which Uwe, now have or may have at any time hereafter, whether herein named or referred to or not, of and from any and all past, present and future actions, causes of action, claims, demands, damages, costs, loss of services, expenses, compensation, third party actions, suits at law or in equity, including claims of suits for contribution and/or indemnity, of whatever nature, and all consequential damage on account of, or in any way growing out of any and all known and unknown personal injuries, death and/or property damage resulting or to result from an accident that occurred on or about the 19~' day of January, 2010, on Trindle Road, Hampden Township, Cumberland Coun .Penns 1~. In making this release and agreement it is understood and agreed that Uwe rely wholly upon my/our own judgment, belief and knowledge of the claims, whether known or unknown, and that Uwe have not been influenced to any extent whatever in making this release by any representations of statements regarding said claims, or regarding any other matters, made by the persons, firms or corporations who are hereby released, or by any person or persons representing him or them, or by any person by him or them employed. I/we understand that this settlement is the compromise of a doubtful and disputed claim, and that the payment is not to be construed as an admission of liability on the part of the persons, firms and corporations hereby released by whom liability is expressly denied. It is further understood and agreed that I am responsible for the payment of any lien or charges against the settlement sum, including but not limited to Worker's Compensation liens, liens of the Department of Public Welfare or liens arising out of any other form of public assistance. Should any person or entity make a claim for payment of any liens or charges against the released parties, I hereby agree to indemnify and hold harmless the released parties, from any and all liens, charges, fees attorneys' fees, cost, interest and other sums. This release contains the ENTIRE AGREEMENT between the parties hereto, and the terms of this release are contractual not a mere recital. Uwe further state that Uwe have carefully read the foregoing release and know the contents thereof, and Uwe sign the same as my/our own free act. CAUTION! READ ENTIRE DOCUMENT BEFORE SIGNING!!! Date: / / Q ~} ~._ '~. , ,~ d Misty Clifford, individua and as Administratrix of the Estate of Michael Alan Clifford, II, and on behalf of the Estate of Michael Alan Clifford, II AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA : ss COUNTY OF CUMBERLAND ; Misty Clifford, administratrix of the Estate of Michael Alan Clifford, II, is over twenty-one (21) years of age, and being duly sworn according to law and depose says: 1. I have read and acknowledge my understanding of and agreement with the filing of the Petition to Settle Wrongful Death and Survival Actions on behalf of the Estate of Michael Alan Clifford, II. 2. I acknowledge the Petition is being filed with my understanding, consent, and knowledge that Swartz Campbell LLC has been retained by Nationwide Mutual Insurance Company, the insurance carrier of Kathy E. Dick, to assist me in the filing of this Petition. 3. I understand and acknowledge that Swartz Campbell LLC represents neither myself, individually or as administratrix of the Estate of Michael Alan Clifford, II, nor the Estate of Michael Alan Clifford, II, in this matter. 4. I further understand that Swartz Campbell LLC has not provided me with legal advice in regard to this matter and has not acted as my legal counsel and that I hereby relinquish any claims that could be made against Swartz Campbell LLC and its agents, whether now known or unknown. 5. I also understand that I have the right to obtain legal representation and consult with legal counsel in regard to this matter but voluntarily have elected not to do so. Page 1 of 3 6. I have read the foregoing and the Petition to Settle Wrongful Death and Survival Claims and fully understand same and affix my signature hereto under oath as a free, voluntary, and uncoerced act and deed. 7. I approve of the proposed settlement because, under the circumstances, I consider it fair, reasonable compensation for claims of the Estate of Michael Alan Clifford, II, and in the best interests of the Estate. 8. I am not aware of any entity, including the Department of Public Welfare, that has asserted or has a right to assert a lien against these settlement monies. 9. I state that neither the decedent Michael Alan Clifford, II, nor I owe any child support arrears. 10. I state that I have paid the related funeral expenses for the decedent Michael Alan Clifford, II. 11. I understand and agree that once the Court has approved the settlement as outlined in the petition, and once the settlement release is executed, no further claim can be made against Nationwide Insurance Company under the policy of insurance issued to Kathy E. Dick as a result of the accident of January 19, 2010, whether now known or unknown. 12. I request that the settlement proceeds be completely allocated to the Wrongful Death Claim and none to the Survival Claim as outlined in the Petition. 13. I have entered into this Settlement Agreement willingly and voluntarily. Page 2 of 3 14. I have willingly and voluntarily made this sworn Affidavit before a notary public on this __~~ day of 0 2010. .~ / Mis~ or , i d vidually and as Administratrix of the Estate of Michael Alan Clifford, II, and on behalf of the Estate of Michael Alan Clifford, II Sworn to and Subscribed Be ore me this o day of , 2010. ~.JCIt~.,~to Notary Public ~ NOTARIAL TEAL Al1ETTA 0 LANOIE-P@ROIBAO Notify PrMk CAMP ItlLI BOROUGH, CUMSffRLAND COUNTY My CotnnY~ofon ~P- 3, 201 Page 3 of 3 Pennsylvania Child Support Program Page 1 of 1 ~ - PA Child Support Program Lien Search Results As of 04•NOV•10 The information provided by this Internet site does not constitute an official certification by the Department of Public Welfare of the amount of support arrears. Certifications of arrears amounts must be obtained from the local Domestic Relations Sections under 23 Pa.C.S. 5 4352(d.1)(3) and (7). The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. The information provided by this Internet site does meet the requirements for insurance intercept purposes defined under 23 Pa.C.S. 4308.1 (a) and (b). The arrears balance returned under the search criteria may be utilized to process the insurance intercept action. The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. An Insurance Intercept may be disputed in accordance with 23 Pa.C.S. 4308.1 (h) and must be based on a mistake in the amount of overdue support, or a mistake in the identity of the obligor. Your Search Criteria Last Name: Social Security Number: Return To Liens Search Clifford 175740456 No Results has been found for your Search Criteria First Name: Date of Birth: The data is as of 04-NOV-10. Please try again with different criteria. michael 10/31/1988 https://www.humanservices.state.pa.us/CSWS/lien controller.aspx?PageId=DocketLien%... 11/5/2010 Pennsylvania Child Support Program Page 1 of 1 PA Child Support Program Lien Search Results As of 08-NOV-10 The information provided by this Internet site does not constitute an official certification by the Department of Public Welfare of the amount of support arrears. Certifications of arrears amounts must be obtained from the local Domestic Relations Sections under 23 Pa.C.S. § 4352(d.1)(3) and (7). The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. The information provided by this Internet site does meet the requirements for insurance intercept purposes defined under 23 Pa.C.S. 4308.1 (a) and (b). The arrears balance returned under the search criteria may be utilized to process the insurance intercept action. The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. An Insurance Intercept may be disputed in accordance with 23 Pa.C.S. 4308.1 (h) and must be based on a mistake in the amount of overdue support, or a mistake in the identity of the obligor. Your Search Criteria Last Name: Clifford First Name: michael Social Security 160387592 Date of Birth: 09/18/1950 Number: Ret.urn_ T.o..._L.enS....Search. No Results has been found for your Search Criteria The data is as of 08-NOV-10. Please try again with different criteria. https://www.humanservices.state.pa.us/CSWS/lien_controller. aspx?PageId=DocketLien%... 11/9/2010 Pennsylvania Child Support Program Page 1 of 1 • ~ • PA Child Support Program Lien Search Results A5 Of o8-NOV-10 The information provided by this Internet site does not constitute an official certification by the Department of Public Welfare of the amount of support arrears. Certifications of arrears amounts must be obtained from the local Domestic Relations Sections under 23 Pa.C.S. g 4352(d.1)(3) and (7). The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. The information provided by this Internet site does meet the requirements for insurance intercept purposes defined under 23 Pa.C.S. 4308.1 (a) and (b). The arrears balance returned under the search criteria may be utilized to process the insurance intercept action. The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. An Insurance Intercept may be disputed in accordance with 23 Pa.C.S. 4308.1 (h) and must be based on a mistake in the amount of overdue support, or a mistake in the identity of the obligor. Your Search Criteria' Last Name: Clifford First Name: misty Social Security 202543915 Date of Birth: 10/15/1964 Number: R..etu.r.n To.Lens...~e.~.r..ch. No Results has been found for your Search Criteria The data is as of 08-NOV-10. Please try again with different criteria. https://www.humanservices.state.pa.us/CSWS/lien controller.aspx?PageId=DocketLien%... 11/9/2010 VERIFjCATION I, Alicia Gerakinis, a duly authorized agent of Nationwide Mutual Insurance Company, hereby certify that I have the authority to make these averments and verify that the statements made in the foregoing Petition to Settle V4'rongful Death and Survival Actions are true and correct to the best of my knowledge, information, and belief. I understand that the statements made herein are subject to the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsification to authorities. Date ll' IU",SID r Alicia Gerakinis Nationwide Mutual Insurance Co. 7 ~ s M CERTIFICATE OF SERVICE I, the undersigned, do hereby certify that I served a true and correct copy of the Petition to Approve Settlement of Wrongful Death and Survival Claims on this 10"' day ofNovember, 2010, by depositing it in the United States mail, postage prepaid and addressed as follows: Gelnda Farner Strasbaugh Register of Wills & Clerk of Orphans' Court Cumberland County Courthouse 1 Courthouse Square Suite 102 Carlisle, PA 17013 Misty Clifford 326 Bobcat Road Newville, PA 17241 YA l.ll. No.:LU7U4S