HomeMy WebLinkAbout03-0353PETITION FOR GRANT OF LETTERS OF ADMINISTRATION
Estate of William Robert Ratz No. 21-03-353
also known as To:
Register of Wills for the
Deceased. County of Cumberland in the
Commonwealth of Pennsylvania
Social Security No. 204-68-1415
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/Y4Y~18 years of age or older, appl les
for letters of administration
on the estate of
(d.b.n.; pendente lite; durante absentia; durante minoritate)
the above decedent.
Decendent was domiciled at death in Cumberland .County, Pennsylvania, with
h is last family or principal residence at 804 Rivervxew Rd., bemoyne, remoyne t~6rough,
(list street, number and municipality) 'l' 7043
Decendent, then 16 years of~tge, d. ied Au~rust 2 ~ 2002
at Huzzy Lake, 77737 ?~fcKee Rd., ,awton, Porter 'lWp., Wn Buren Co., Mi 49065
PA
Decendent at death owned property with estimated values as folllows:
(If domiciled in Pa.) All personal property $ 6:400.00
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $
situated as follows:
Petitioner after a proper search ha s
the following spouse (if any) and heirs:
Name
William P. Ratz
Dawn bi. Ratz
ascertained that decedent left no will and was survived by
Relationship
Father
bbther
Re.sidence
804 Riverv-~ew Rd.,
804 Rivervzew Rd.,
Lemoyne, PA 17043
Lemoyne, PA 17043
THEREFORE, petitiOner(s) respectfully request(s) the grant of letters of administration in the
appropriate form to the undersigned.
L~moyne, PA 17043
Wi±ti.am P. Ratz
/'2-
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA ]~ ss
COUNTY OF
The petitioner(s) above-named swear(s) or affirm(s) that the
statements in the foregoing petition are true and correct to the best
of the knowledge and belief of petitioner(s) and that as personal
representative(s) of the above decedent petitioner(s) will well and
truly administer the estate according to law.
Sworn to or affirmed and subscribed
before me this 22nd __ __ day of
_ APRIL Y'~-Y '? tiff ~
Estate of
No. 21-03-353
WILLIAM ROBERT RATZ
, Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW APRIL 22 ]flg,_d0__0_3, in consideration of the petition on
the reverse side hereof, satisfactory r~roof havi_ng been. presented before me,
IT IS DECREED that William F. Ratz
is~ntitled to Letters of Administration, and in accord with such finding, Letters of Administration
William F. Matz
are hereby granted to
in the estate of William Robert Ratz
FEES
Letters of Administration ..... $, 40.00
Short Certificates( ) .......... $, 18.00
Renunciation ................ $ 5.00
JCP $ 10. O0
TOTAL __ $
Filed ...~,]P~%Ie. ~.% ........ A.D. ~t20__~_3__
0 ~'( .Ct.l .No.)
- 07 76
P, O, B/ax 984. Harrisburg, PA :t_7108
ADDRESS
(717) 236-8000
PHONE
RENUNCIATION
In Re Estate of
To the Register of Wills of
William Robert Ratz
Cumberland
· deceased.
The undersigned Dawn M. Ratz, Mother
County, Pennsylvania.
of
the above decedent, hereby renounce(s) the right to administer the estate and respectfully ask(s) that Letters
of Administration
be issued to !Vi 1 liam P. Rat z
WITNESS
hand this /7I~) day of ~~_~ 2003
' (Sign'at~-e)
804 P~verview Rd.
Lemoyne, PA 17043
(Address)
(Signature)
(Address)
(Signature)
(Address)
ESTATE OF WILLIAM ROBERT
RATZ, a Minor Child, by WILLIAM
P. RATZ,
ADMINISTRATOR,
Petitioner
v.
CAROLYN KAY BROWNAWELL,
Respondent
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY.
: PENNSYLVANIA
:
: CIVIL ACTION - LAW
: No. 2003-00353
:
: ORPHANS' COURT DIVISION
:
PETITION FOR APPROVAL OF COMPROMISE
SETTLEMENT AND DISTRIBUTION OF PROCEEDS
FOR THE ESTATE OF A MINOR CHILD, WHO WAS INVOLVED IN A
COMPENSABLE ACCIDENT PRIOR TO HIS DEATH PURSUANT TO
Pa. C.S.A. ~3323 (a)
TO THE HONORABLE, THE JUDGES OF SAID COURT:
1. The Petitioner, William P. Ratz, was the father and
natural guardian of William Robert Ratz (hereinafter called the
"Minor Child") prior to the Minor Child's death on August 2,
2002.
2. The minor child died intestate on August 2, 2002, as a
result of an accident entirely unrelated to the accident which
gave rise to the within Petition.
3. On April 22, 2003, Petitioner was appointed
Administrator of the Estate of William Robert Ratz, the Minor
Child, Cumberland County Estate No. 2003-00353. Petitioner was
appointed Administrator with the express concurrence of his wife,
Dawn Ratz, who executed the necessary renunciation to permit her
husband to administer the Estate of the Minor Child. See Exhibit
C.
4. The respondent, Carolyn Kay Brownawell, is an adult
individual.
5. The facts and occurrences which gave rise to this
Petition occurred on June 26, 2001, at the intersection of North
17th Street and Market Street in Camp Hill, Cumberland County,
Pennsylvania.
6. At that time and place, the Minor Child, William Robert
Ratz, a passenger in a vehicle driven by his mother and natural
guardian, Dawn M. Ratz, was injured by Respondent, an adult
individual, as a result of the negligence of Respondent, who
operated a vehicle owned by herself, in such a manner as to cause
it to lose control and collide with the Ratz vehicle.
7. There is no dispute as to the liability in the above-
discussed accident.
8. The Minor Child did not initially appear to be injured
in the said accident, but subsequently developed low back pain
and neck soreness, as a result of which he was treated at Holy
Spirit Hospital Emergency Room, one day post-accident. A
diagnosis of cervical and lumbar strain was given, and the Minor
Child was instructed to use moist heat and over the counter
medications.
9. The Minor Child subsequently came under the treatment
of Gerhart Family Chiropractic, where he was first seen on July
10, 2001, two weeks post-accident. At this time his lumbar
strain had resolved, but he was suffering from mid-back and some
neck pain. He was diagnosed with a hyper extension/hyper flexion
cervical and thoracic sprain/strain, with attendant spasms of the
affected paraspinal muscles. The Minor Child was treated during
37 office visits with said Gerhart Family Chiropractic between
July 10, 2001 and February 19, 2002. During said treatment, he
received chiropractic adjustments, moist hot packs, and
electrical stimulation of the muscles.
10. During the time of his treatment with Gerhart Family
Chiropractic, the Minor Child experienced neck and back pain and
was deprived of some of the enjoyment of his life, although he
continued to attend school and pursue extracurricular and social
activities during this time.
11. Upon discharge by Gerhart Family Chiropractic on
February 20, 2002, the Minor Child was said by his doctor to have
reached "a point of maximum medical improvement" although he was
continuing to suffer from "periodic flare ups of the neck and
lower back, and stiffness at times of increased use and/or
stress." Subsequent to said discharge, however, the Minor Child
made a full recovery and was feeling entirely well preceding his
untimely death from a completely unrelated accident.
12. As a result of the above-stated injuries, the Minor
Child, through Petitioner and Petitioner's wife, incurred medical
expenses in the amount of One Thousand Six Hundred Seventy-Nine
Dollars and Eighty-Three Cents ($1,679.83), all of which medical
expenses were paid by State Farm Mutual Automobile Insurance
Company, insurer for Minor Child and Petitioner. Said amount is
not subject to subrogation.
13. Copies of all medical records pertinent to the above-
discussed accident are attached hereto and collectively marked
Exhibit A.
recovery.
d.
14. The Petitioner, acting on behalf of the Estate of the
Minor Child, is represented by counsel, to wit, Richard S.
Friedman, Esquire of Friedman & King, P.C.
15. The Petitioner has agreed to accept the sum of Six
Thousand Four Hundred ($6,400.00) Dollars from Progressive
Insurance Company, insurer of the Respondent.
16. Petitioner is satisfied that said sum is a fair and
satisfactory settlement of the claim of the Estate of the Minor
Child, taking into account the following factors:
a. The undisputed liability of Respondent.
b. The injuries sustained by the Minor Child and
treatment rendered therefore.
The fact that the Minor Child made a full
The difficulty inherent in pursuing litigation
against the Respondent in light of the subsequent untimely death
of the Minor Child.
17. The Petitioner has agreed to distribution of said
amount as follows:
a. The firm of Friedman & King, P.C. has advanced
certain expenses, for which it is entitled to reimbursement as
follows:
Gerhart Family Chiropractic $ 29.81
(records)
ChartOne $ 24.78
(records)
TOTAL: $ 54.59
b. Legal fees to Friedman & King, P.C., in accordance
with a Twenty-Five (25%) Percent contingent fee agreement. (A
copy of the fee agreement is attached hereto and made a part
hereof as Petitioner's Exhibit B).
Legal Fees $1,600.00
c. The sum of $4,745.41 to be deposited into an
Estate checking account to pay the expenses and outstanding
debts, if any, of the Estate, the balance to be distributed to
the Minor Child's heirs, Petitioner and his wife, Dawn M. Ratz,
in accordance with further approval of this Honorable Court.
18. Petitioner respectfully requests that a hearing not be
scheduled.
WHEREFORE, Petitioner respectfully requests that Your
Honorable Court enter an Order approving the aforesaid compromise
settlement and directing distribution of proceeds thereof as set
forth, and authorizing the Petitioner, upon payment of the
aforesaid sums, to execute good and sufficient releases to the
insurance carrier and the Respondent, and to discontinue the
action brought to the above term and number with prejudice. The
undersigned verifies that the statements made in this Petition
for Approval of Compromise Settlement and Distribution of
Proceeds are true and correct. The undersigned understands that
any false statements herein are made subject to penalties of 18
Pa.C.S. §4904 relating to unsworn falsification to authorities.
William P. R , ator
of the Estate of William
Robert Ratz, a Minor Child
RSF:ka:pleading\ratz.pet
FRIEDMAN AND~~~.~ C.
Richard S. /Friedman, Esq.
PO Box 98~ ~
Harrisburg PA 17108
717-236-8000
Attorney ID Number: 07176
EXHIBIT A
303 ,' nd SI. · Camp Hill, PA 17011
(717) 761-2273
CONFIDENTIAL PATIENT INFORMATION
07/10/01
Name Mr. Wi ] ] into ]~ ]~gP~
Addre~ 804 Riverview Road
Age 15 Birth Date 01/1~/86
Occupation Stu(~ent *
Address
Insured's name if patten! is a dependent
Name of Insurance Company
Name of Wife or Husband
Employer ....
ReJerred by Jennif~ Moritz
Is condition due Io injury or sickne~ arising out oJ patient's employment? __
D,,e symptom, app,ared or a~ldenl hap~ned: ~'~6- 0~
Patienl ever had ~me or sim[~r condiaon: ' Yes No ~ ,
Social Securily ':zoq- 63- I~I~j
Cily T,Pmnynp; PA
Harnal: H [~ W D
Employer,
' Office phone
S~i~l Security
~ Address
Occupation
Address
Home Phone 975-8954 ·
Zip'Code I 7n,~'~
HoW many children? ..
Phone
· Ii yes ~,hen and des'cribe
Have you lost any days from work?
What operations have yo.'u h~d?
Serious illne~es? ' '
~ve you ever ~en under ~iroPra~c Care Yes ~, Ho ~
,'Female: Are you Pregnant
Fractured bones?'
Doctors Hame
Have You Eve~ Sufl*c=ed F~rom:
~ Allergy D Poor posture
(2] Dizziness ID Sciatica
[~ Fatigue I"'1 Spinal curvatures
Headache ID Swollen joints
~ Loss ol sleep n Colon n, ouble
[] Ulcers ID Diarrhea
[] Nervousness/Depression ..~ Ditlicult digestion
~m Numbness I-I Hemorrhoids
C,, Arthritis 'ID Nausea ..
~ Bursitis .lq Asthma
"5 Fool trouble. ~ Colds
[] Lo~ back pai.n n Dealness
[] Neck pain or stiffness r'l Ear noises
n Enlarged Thyroid
Tingling or numbness in: r-I Eye pain
CI Shoulders ID Hips [] Failing'vision
n Arms n L~gs ' ~ Venerai Disease
[] Elbows [] Knees
n Hands ID Feet
ID Tuberculosis
[2] Bruise easily
ID Hay fever
E.q' Nosebleeds
~ Sinus inlection
[] High blood pressure
[] Low blood pressure
[] Pain over heart
l-I Poor circulation
[] Rapid hearl bea~
[] Slow heart beat
C3 Anemia
[] Stroke
[] Chest pain
'[] Diflicult breathing
ID Pleurisy
[] Spit'ting
[] Swelling ot ankles
[] Cancer
" 'EJ Itching [] Varicose veins
[] Bed-wemng
[] Frequent urination
[] Kidney int~tion or s~onc
[-1 Prosla[e troubl~
El' Cramps or backache
E3 Excessive mensw, I fio~
[] Hot tbshes
[] Irregular cycle -
[] Lumps in breast
[] Alcoholism
[] Diabetes
[] Poho
HABITS:
Alcohol
Coilee
Tobacco
Drugs
ExercLse
Sleep
Appetite
Heavy Moderate Light
'DO YOU:
Now take Vitamins or minerals?
Think you may need viSiT, ins
or minerals? '
Yes __
, Yes__
Are you wearing: Heel lifts __
Inner soles ~ Arch supports
.od
Sole Wu __
PLEASE P'"' ~ ,'T
Pt!T?':,7 :'~'fhi.', ,\~;pa~nrrnent {Major~.., :~lain0
Mid back
pain.
Is this condition 0,aning progressively worse? Yes No
Is this condmon inharfering with your: Work Sleep
Constant , x/ .. Comes andooes
Daily Routine Other
How long h;~s il bee,: since you really I.~lt ~lood?~ ~,
What do you belier., is wrong with you? _ ~on~ ~
O,her Docto, s seen 'or lh~s condition
Have you been Ire ,led for ~ny heahh condilions by n physician in Ihe !~sl ye~?
Describe ~ · .-
Yes __No __
'0,'hal medicalions c'.¥ d~ugs are you Ialdng?
r~ .,marks ;,nd ~ddil::~n-~l i~orm,,tion
PAYMENT IS EXPECTED AT TIIH~E OF Vi'$1TI
Are you Insured? Yes ~ No Company _
I understand ::nd agree lha~ heald~ and accident insqrance policies are an arrangement between on insurance carrier
and myself. F.arlhermore. I under~tand that 1his chiropractic office will prepare any necessary reports and
si~t me in mak'ing collections from ehe insurance company and that any amount authorized 1o be paid d~reczly
chlroprocnc o~'/,¢:e ~ill be credited ~o my accoune on receipt. Ho~euer, I c/ear/~ understand and agree Ihu~
rendered me are char~ed direcll~ to rne and ~hal 1 am personall; responsible ~or pa;mem. ~ also under~u~td
mmediatcl~
suspend or ~erminale m~ catered ~rcatment. an~ ~ees ~or professional seruices reader.s, m~ ~ill be
Guardian or Spouse"i $ig~lu[e Aull.onz~ng Care ~ ' , )~ -
h,iorm~l~on Taken b~, Da~e
PERSONAL INJURY QUESTIONNAIRE
Employer's Name
Stare'PA
EmpJoy.er's Address
Yourlns. Co. ?')~Cx.~,~_. ~'O~'¢ ~"¢'~ Policy,
Drlver/OtherVehicle ~lg~'~l~ co..' ro,Nr,,,$sWo Policy#
Have you retained an attorney? ( ) Yes ( ) No Name
( ) Yes (Y,,) No Name(s)
Were there any wltnessess?
NATURE OF ACCIDENT:
1. Date of Accident G- ~ -et Time of Day.., L~" OO "~-"~.
2. Were you: ( ) Driver (~) Passenger ()<) Front Seat ( ) Back Seat
3. Number of people In your vehicle?
4. What direction were you heeded?.. ( ) North. ( ) East (~ South ': ( ) West
on (name of street).. \r-~ ~.~_ . .
5. What direction was other vehicle headed? ( ) North ( ) East (
on (name of street) ~(~ ~'~["
8. Were you struck from: ( )Behind ( )Front (~:~Leftslde ( )Right side
7. Were you k:mcked unconscious? ( )Yes (~No. If yes, for how long?
8. Were police notified? ('~,,) Yes ( ) No
) South (~ West
Dldyou have any physical complaints BEFORE THE ACCIDENT? ( )Yes (~(,)No. If yes, pleasedescrlbelndetalh
11.
12.
Please describe how you felt:
a. DURING the accident: 0
b. IMMEDIATELY AFTER tl~ accident:
What a~e your PRESENT complaints and symptoms?
13. Do you have any congenital (from birth) factors which relate to thts problem?
describe:
( )Yes' (~:K.)No.' If yes, please
14. Do you have a3y previous lllnesses whlch relate to thls case? ( )Yes
([:~,,) No. If ye~, please describe:
15. Have you 6vet ~.een Involved In an accident before?.
o
type(s) of acmdents, as well as Injury(les) received.
( ) Yes
· ' (V,,) No. If yes, please descrlbel Ir~clud. lr~g date(s) and
16. Where were you taken after the accldent? ~..{~'{M..P~.,
17. Have you been treated by another doctor since the accident?
and address:
(X) Yes 0J~) No. If yes, please list doctor's name
18. Since this ini'jr'/occurred, are' your symptoms: . ()~) Improving
19. Have you Io~'. ~,',me from work as a result of this accident? ( ) Yes
a. Last Da.v Wc;'~ed:
) Getting Worse ( ) Sam~
0/,,,) No. If yes, please complete this question.
b. Type of
c. Preset..:,,~ ary:
' d. Are you b~ i~:g compensated for time lost frorn work? (')Yes
(~ No; If yes, please state type of compe.nsatlon
you are r~ ceiving:
20. Do you no' ,ce any activity restrictions as a result of thls Injury? ( )Yes
(y_,,) No. If yes, please doscribe, In detalh
2 I. Other t' ertl[~.~.r~1 Information:
DATE
Sitting
1. Foramina Compression
2. Shoulder Depressor
3. Georges Test
4. Kemps Test
5. Biceps Reflex
6. Digital Reflex
7. Triceps Reflex
8. Patellar Reflex
9. Achilles Reflex
ORTHOPEDIC EXAMINATION :
Initial ~ ~Oost ~
L R L R
Prone:
10. Nachlas (Ely)
11. Yoeman's
Supine:
12. Soto Hall
13. Laseque's
14. Braggard's
15. Fabere Patrick
16. Leg Lowering
Misc. Tests.
17. Heal to Toe
18. Finger to Nose
19. Rhomberg
20,
21.
Heel Lifts
Orthopedic Supports:
Supplements:
X-Ray Info:
Views:
Case #
Weight
Date Taken:
St.
CERVICAL
MOVEMENT
Flexion -,~
,Extension
Lat. R. Flex
Lbs.
Initial: Progress:
,/ #1 #2 Norm.
Lat. Left Flex
Rotation Right
Rotation Left
DORSOLUMBAR
MOVEMENT
/,.,7_ !'7 ~.. 65°
..>~O S-'~ 45°--
~ ¢-0 45°
70°
70°
Flexion " -,,~,
Extension
Lat. R. Flex
Lat. Left Flex
Rotation Right
Rotation Left
REMARKS:
c//.~ /.--~ 40°
450
45°
L I I /4o~
L I I
MUSCLE STRENGTH: Initial:
Deltoid (C--5) /
Biceps (C--6) /
Wrist Ext. (6--C) -_._._7"
Wrist Flex (C--7) ___._./..
Finger Ext. (C--7).__._/
Finger Flex (C--8)____./
Interossei (T--l) /_
Post:
BDeltoid (C--5) ____/.
iceps (C--6) .. /
Wrist Ext. (6--C) ... /
,Wrist Flex (C--7) __..J.
ringer Ext. (C--7).. /.
Finger Flex (C--8} /
Interossei (T--l) ~
PINWHEEL -- DERMATOME
Initial;
C5 C6 C7 C8 T1 L3 L4 L5 S1 S2
6 ;,_
Left
Right
Left
Right
Initial: Progress:
,/ #1 #2
6~
5(
4~
-- 7(:
7¢
MOTION PALPATION & INSTRUMENTATION INDICATIONS
IAME Mr. William k. Ra't - 01 057
DAlE
MAJOR COMPLAINTS
4.
Diagnosis
SPINAL
ANALYSIS
Con j
At
Ax t
3C
4
6 IcL
7
1D ~"
3 ocr
4
5
7 I
~ I
12 '
13
1L :
2 I
4 I
Sac
3oc
4D L
NAME' Mr., Willia~ R. katz :,' '057
DATE
.... Doctor's Oomments
~iJ~ ~ ~ 211111
L~ ~,, ,
I
~ I
~,-
.... ,.
MAJOR COMPLAINTS
1.
2.
3.
4.
Diagnosis
SPINAL
ANALYSIS
co.
At
AX
3C
4
5
6
7
1D
2
3
4
5
6
7
8
9
10
11
12
13
1L
2
3
4
5
6
~ac
;oc
R
ID
L
D
L
NAM,--, Mr. Willia~ R. ~atz
01057~
DATE
Doctor's Comments
~unv 1. 2 2001 ,Z~..~.~, _
~.~ ~ ~/~, I~~
75" L.~'
'Con
At
Ax
3C
4
5 ~T,.q
6 PT, T-]'
7 PLS
1D . PLI
2 PRI-~
3 PLS
5
6
7
8
9
10
12
2
4
$
~oc
R
D
L -
MAJOR COMPLAINTS
1. Mid back pain
2.
3.
4.
Diagnosis
847
Cervical Sprain/Strain847.
Cervical Kyphosis 737.1
C) ® (Z) ® ® (Z) ®
SPINAL
ANALYSIS
PERSONAL INJURY INITIAL REPORT
Gerhart Family Chiropractic
303 .South 32nd Street
Camp Hill PA 17011
(717)761-CARE(2273)
Patient's Name:
Date Of Injury:
Claim #:
Treating Doctor:'
Date Of This Report:
William R. Ratz
June 26, 2001
38-J726-621
Dr. David W. Gerhart
July 18, 2001
Brief History:
Patient was injured in an automobile accident when the car he was a passenger in was hit from the
side while pulling out from a stop sign. The striking vehicle was traveling approximately 45 mph.
Current Diagnosis: ,
1.) Acute traumatic hyper extension/hyper flexion sprain/strain injuries of the cervicothoracic soft
tissues, with attendant myositis and spasm of the affected paraspinal musculature.
2.) Lower thoracic sprain/strain.
Present Treatment Plan:
It is my intention to start care at 3 times per week for the first 3 weeks at which time an updated
report will be forwarded to your oftice.
Current Type Of Treatment:
Specific correction of osseous disrelationships using the Gonstead method of adjusting along with
supportive care usidg hot packs with low volt Galvanic muscle stimulation.
Prognosis:
Withheld until results of care are seen.
Signed:
PERSONAL INJURY PROGRESS REPORT
Gerhart Family Chiropractic
303 South 32nd Street
Camp Hill PA 17011
(717)761-CARE(2273)
Patient's Name:
Date Of Injury:
Claim #:
Treating Doctor:
Date Of This Report:
William R. Ratz
June 26, 2001
38-J726-621
Dr. David W. Gerhart
August 8, 2001
Current Diagnosis:
1.) Acute traumatic hyper extension/hyper flexion sprain/strain injuries of the cervicothoracic
soft tissues, with attendant myositis and spasm of the affected paraspinal musculature.
2.) Lower thoracic sprain/strain.
Present Condition:
Patient's condition is improving both subjectively and objectively.
subjective improvements are expected with continued chiropractic care.
Further objective and
Present Treatment Plan:
It is my intention to start care at 3 times per week for the fa'st 3 weeks at which time an updated
report will be forwarded to your office.
Current Type Of Treatment:
Specific correction of osseous disrelationships using the Gonstead method of adjusting along
with supportive care using hot packs with low volt Galvanic muscle stimulation.
Prognosis:
Withheld until results of care are seen.
PERSONAL INJURY PROGRESS REPORT
Gerhart Family Chiropractic
303 South 32nd Street
Camp Hill PA 17011
(717)761-CARE(2273)
Patient's Name:
Date Of Injury:
Claim #:
Treating Doctor:
Date Of This Report:
William R. Ratz
June 26, 2001
38-J726-621
Dr. David W. Gerhart
September 14, 2001
Current Diagnosis:
1.) Acute traumatic hyper extension/hyper flexion sprain/strain injuries of the cervicothoracic
soft tissues, with attendant myositis and spasm of the affected paraspinal musculature.
2.) Lower thoracic sprain/strain.
Present Condition:
Patient's condition is improving both subjectively and objectively.
subjective improvements are expected with continued chiropractic care.
Further objective and
Present Treatment Plan:
It is my intention to continue care at 1 time per week for the next 4 weeks at which time an
updated report will be forwarded to your office.
Current Type Of Treatment:
Specific correction of osseous disrelationships using the Gonstead method of adjusting along
with supportive care using hot packs with low volt Galvanic muscle stimulation.
Prognosis: '-
Withheld until results of care are seen.
PERSONAL INJURY PROGRESS REPORT
Gerhart Family Chiropractic
303 South 32nd Street
Camp Hill PA 17011
(717)761-CARE(2273)
Patient's Name:
Date Of Injury:
Claim #:
Treating Doctor:
Date Of This Report:
William R. Ratz
June 26, 2001
38-J726-621
Dr. David W. Gerhart
October 17, 2001
Current Diagnosis:
1.) Acute traumatic hyper extensionfayper flexion sprain/strain injuries of the cervicothoracic
soft tissues, with attendant myositis and spasm of the affected paraspinal musculature.
2.) Lower thoracic sprain/strain.
Present Condition:
Patient's condition is improving both subjectively and objectively.
subjective improvements are expected with continued chiropractic care.
Further objective and
Present Treatment Plan:
It is my intention to continue care at 1 time per week for the next 4 weeks at which time an
updated report will be forwarded to your office.
Current Type Of Treatment:
Specific correction of osseous disrelationships using the Gonstead method of adjusting along
with supportive care using hot packs with low volt Galvanic muscle stimulation.
Prognosis:
Withheld until results of care are seen.
PERSONAL INJURY PROGRESS REPORT
Gerhart Family Chiropractic
303 South 32nd Street
Camp Hill PA 17011
(717)761- CARE (2273)
Patient's Name:
Date Of Injury:
Claim #:
Treating Doctor:
Date Of This Report:
William R. Ratz
June 26, 2001
38-J726-621
Dr. David W. Gerhart
November 13,2001
Current Diagnosis:
1.) Acute traumatic hyper extension/hyper flexion sprain/strain injuries of the cervicothoracic
soft tissues, with attendant myositis and spasm of the affected paraspinal musculature.
2.) Lower thoracic sprain/strain.
Present Condition:
Patient's condition is improving both subjectively and objectively.
subjective improvements are expected with continued chiropractic care.
Further objective and
Present Treatment Plan:
It is my intention to continue care at I time per week for the next 4 weeks at which time an
updated report will be forwarded to yom' office.
Current Type Of Treatment:
Specific correction of osseous disrelationships using the Gonstead method of adjusting along
with supportive care using hot packs with low volt Galvanic muscle stimulation.
Prognosis:
Good with continued chiropractic care.
Signed:
PERSONAL INJURY PROGRESS REPORT
Gerhart Family Chiropractic
303 South 32nd Street
Camp Hill PA 17011
(717)761-CARE(2273)
Patient's Name:
Date Of Injury:
Claim #:
Treating Doctor:
Date Of This Report:
William R. Ratz
June 26, 2001
38-J726-621
Dr. David W. Gerhart
December 12, 2001
Current Diagnosis:
1.) Acute traumatic hyper extension/hyper flexion sprain/strain injuries of the cervicothoracic
soft tissues, with attendant myositis and spasm of the affected paraspinal musculature.
2.) Lower thoracic sprain/strain.
Present Condition:
Patient's condition is improving both subjectively and objectively.
subjective improvements are expected with continued chiropractic care.
Further objective and
Present Treatment Plan:
It is my intention to continue care at 1 time per week for the next 4 weeks at which time an
updated report will be forwarded to your office.
Current Type Of Treatment:
Specific correction of osseous disrelationships using thc Gonstead method (>f adjusting along
with supportive care using hot packs with low volt Galvanic muscle stimulation.
Prognosis:
Good with continued chiropractic care.
Signed:
PERSONAL INJURY PROGRESS REPORT
Gerhart Family Chiropractic
303 South 32nd Street
Camp Hill PA 17011
(717)761-CARE(2273)
Patient's Name:
Date Of Injury:
Claim #:
Treating Doctor:
Date Of This Report:
Current Diagnosis:
William R. Ratz
June 26, 2001
38-J726-621
Dr. David W. Gerhart
February'5, 2002
1.) Subaute traumatic hyper extension/hyper flexion sprain/strain injuries of the cervicothoracic
soft tissues, with attendant myositis and spasm of the affected pm'aspinal musculature.
2.) Lower thoracic sprain/strain.
Present Condition:
Patient's condition is improving both subjectively and objectively.
subjective improvements are expected with continued chiropractic care.
Further objective and
Present Treatment Plan:
It is my intention to continue care at I time per week for the next 4 weeks at which time an
updated report will be forwarded to your office.
Current Type Of :rreatment:
Specific correction of osseous disrelationships using the Gonstead method of adjusting along
with supportive care using hot packs with low volt Galvanic muscle stimulation.
Prognosis:
Good with continued chiropractic care.
Plan:
Re-exam scheduled to verify need for furore care.
PERSONAL INJURY FINAL REPORT
Gerhart Family Chiropractic
303 South 32nd Street
Camp Hill PA 17011
(717)761-CARE(2273)
Patient's Name:
Date Of Injury:
Claim #:
Treating Doctor:
Date Of This Report:
William R. Ratz
June 26, 2001
38 -J726-621
Dr. David W. Gerhart
February 20, 2002
Current Diagnosis:
1.) Initial traumatic hyper extension/hyper flexion sprain/strain injuries of the cervicothoracic soft
tissues, etc.
2.) Initial lower thoracic sprain/strain injuries.
Patient now suffers from the residuals subsequent to the fibrosis of repair process of once damaged soft
tissues.
Present Condition:
p ' ,
auent s condition has reached a point of maximum medical improvement.' He continues to have
periodic flare-ups of the neck and lower back and stiffness at times of increased use and or stress.
Future Treatment Plan:
Continue to treat patient on an
increased use or stress.
"as need" basis subsequent to flare-ups of his condition at times of
Prognosis:
As the patient's condition has reached a point of maximum medical improvement, no additional
subjective and objective improvement can be expected with continued regularly scheduled treatment.
Therefore, the subjective and objective residuals noted must be considered to be permanent effects of
the injuries sustained in this accident. These residuals create a need for future treatment for palliative
purposes.
We will use this man's requirements for "as need' care as the basis for determining his future care.
Signed:~
DATE:
AHB: ..... -' F i RE
n~L.L
:'1E: RATZ ,DAWN
'3RESS: :z:04 RtVERVIEW RD
CONTACT INFORrdAT I ON REL 'FO PT:
-~RE:SS:
/LEMOYNE
/F'A/17c~a::: F'i-4~: 717 - --'= ....
' ' - :.' 7-_ -- ,:, :, rj 4
REL TO PT: ~ ....
~-~ORh. F'H~: -
/ ,/ F'H~: -
C'ASE INFORh!ATI
,=.-~,-,.r~,q RA:.",h._!:'-/'.~A ~£,M SOURCE: RP ='- ,PATIENT. TYPE: '..~.C.
SH¢~RFiA RAN,_.."A~.c~ HOSP SERV UC3 FINANCIAL-i:CLS: T
VISIT CLINIC CODE: UC3
ICD-9 DX:
':E ~
:'L. OYER:
3RESS:
F'LAN
GL'C~F:AN]'OR INFORMATION
/, ~,' ~'-/ -,~..:, F'H~: /.,, - ;,/._,-,-.~ ,.
'[ ..... .~RAr..,C.E I NFDRHAT I C')N
SUBSCRIBER REI .... PC VFY CARD F'RECERT
REb,_RT PHONE
4SLtR · ADE;RESS:
Iol AUTO INSURANCE I/0
F,A: Z DAbtr.~
4SIJR. ADDRESS:
".tSUR. ADDRESS:
..... ; ,. ADDRESS:
'- ..... ' .... : .... L/,-;OI',LS DALY r'n rlc,~, (
PT I]IO blOT HAVE HIS AUTO INS W
/aim AT REGISTRATION
F'T~: 17 ! 03:B75
John R. Dietz Emergency Services
Ur£iCenter
Date: ~0 /~?/ ~{ Time to Exam Room:/~0-0
DOB: / //'~ /[.q~Age: 15 (~male ()female
Chief Complaint:
Latex Allergy: (~Y~o ( ) Yes
Vital Signs: T:_~P:
HT: (/~ ~/' ~W~? ~ ~--(a~Z~"L MP
Subject
Vision:. OD OS., OU
() Corrected () Uncorrected / Color P or F
Hearing: Y=Response
Right
Le/t
500Hz 1000Hz
Social History:
N--No Response
2000HZ 4000Hz
Time: 1~/0 Physician Assessment
Past Medical History:
Medications: Time of Last Dose:
Objective:
JRD/UC 149
Chart Copy
Revised 10/00 sic
RN/MA Signature
Signature>~ Clh~tl)t,Z~?-~ s. lDil)O(~
.RN/.MA Signature
Report Called: Admission Called:
Admitted to: ~- al ( ) observation
Disposition: (/~Home ( ) AMA ( ) Morgue ( ) OR
RADIOLOGY
) AN~(LE
) CI-,:~ST
) CHEST- I VIEW'iS REA~ER
) CHEST - EMPLOYEE
) ELBOW
) FOOT
) KNEE
) SHOULDER
SPINE
( ) CERVICAL ( ) LUMBAR
( ) WRIST
MISCELLANEOUS
( ) CT SCAN
( ) ECHOCARDIOGRAM
( ) MAMMOGRAPHY
( ) MRI
ULTRASOUND
( ) ABDOMEN ( ) PELVIS
( ) OTHER
OTHER DIAGNOSTIC ) BOOTH AUDIOGRAM
) EEC
CULTURES
B STREP
THROAT
GENITAL- ROUTINE
CHLAMYDIA
HERPES
ROUTINE
I TRICH
i STOOL C&S
, STOOL O&P
, STOOL CLOSTRIDIA
URINE C&S
UA POST TREAT
;&S
) WOUND C&S
MISC
) AMYLASE
) LIPASE
) ANA
) CBCP
) CHOLESTEROL
) CPK - MS BAND
) DRUG SCREEN
) ESR
) GLUC-FAST
) H&H
) H~V
) LYME TITER
) MONOSPOT
) PAP
) PREG-SERUM
) RPR
) p'~-
) RA SCRN
) RHOGAM
) PSA
) UA PREG
( ) RUBELLA
( ) OTHER
PANELS ) CMP
) EMP EXPOSURE
) HEP 1
) HERPES TITER
) INDUSTRIAL
) LIPID ( ) LDL
) LIVER ( ) TP
) LYTES
) REGIONAL ALLERGY
SCREEN
) SUP
) THYROID
) THYRP
) TSH
) TRIG
OFFICE DIAGNOSTIC
( , HEARING ( ) TYMPANOMETRY
( HEMOCULT X ~
TREATMENT/SUPPLIES ) ACE TO
) CERVICAL COLLAR
( ) AWAKE
( ) SLEEP
) EKG
) PFT
( ) SIMPLE
( ) COMPLETE
( TINE
( PPD
( UA DIAG
( UA DIP
( UA MIC
VISION ( ) COLOR (
( ) BBGT
)FAR( )NEAR
) CRUTCHES
) DRESSING
) EAR IRRIGATION
) IMMOBILIZER
) SLING
) SPLINT
) OTHER
S~f Not Ch~cked Below) A
,CD-9 / t° d
lCD-9
REFERRAL
TO
FOR
APPT DATE /
APPT TIME :
INSTRUCTIONS:
ABDOMINAL PAIN 789.00 ( ) HEADACHE 784.0
ALLERGY 995.3 ( ) HYPERTENSION 401.9
ARTHRITIS -- DJD 716.90 ( ) OTITIS MEDIA 382.9
~ASTHMA 493.9 ( ) PHARYNGITIS 462
BRONCHITIS (ACUTE) 466.0 ( ) PNEUMONIA 486
CHEST PAIN 786.50 ( ) PREMARITAL V70.3
CONJUNCTIVITIS 372.30 ( ) RASH 782.1
COUNSELING V65.40 ( ) RHUS DERMATITIS 692.6
DEPRESSION 311 ( ) SINUSITIS 473.9
DIABETES 250.00 SOMATIC DYSFUNCTION 739.9
DIZZINESS 780.4 ( ) CERVICAL 739.1
FATIGUE 780.7 ( ) LUMBAR 739.3
FLU 487.1 ( ) THORACIC 739.2
GASTROENTERITIS 558.9 ( ) RIBCAGE 739.8
OFFICE VISITS
CPT CODE
( ) PT WILL
MAKE APPT
STRAIN/SPRAIN
( ) CERVICAL 847.0
( ) LUMBAR 847.2
( ) THORACIC 847.1
( ) OTHER SPECIFIED SITE 848.8
) URI 465.9
) UTI 599
) URTICARIA 708.9
) VAGINITIS 618.10
) WELL CHILD V20.2
IMM UNIZATION/INJECTIONS
( ) CHOLERA VACCINE
( ) DEPOMEDROL .. mg.
( ) DPT
( ) DT- ADULT OR PEDS
FLU VACCINE
GAMMA GLOBULIN ~ ML
HEPATITIS A
HEPATITIS B VACCINE
HIB
IPV
) JAP ENCEPHALITIS
MENNINGOCCAL
,MMR
OPV
PNEUMOVAX ~
RABIES IMM GLOBULIN
RABIES VACCINE
RHOGAM ,
ROCEPHIN _
TETRAMUNE
TYPHOID INJ VI
YELLOW FEVER
OTHER
MEDICATIONS
) 4118 NURSE VISIT
) 0023 LEVEL I
0031 LEVEL II
O072 LEVEL III
0056 LEVEL IV
0041 LEVEL V
1106 FOLLOW UP
EPSDT
4020 (UNDER 19 MOS)
4018 (19 MOS - 21 YRS)
OPR
rIME OUT~ ~
99201
99202
99203
99204
99205
D.C.
__M.D.
( ) 1072 PHYSICAL LEVEL 1
( ) 1023 PHYSICAL LEVEL 2
( ) 1031 PHYSICAL LEVEL 3
( ) 1049 PHYSICAL LEVEL4
( ) 1056 PHYSICAL LEVEL 5
( ) TRAVEL SERVICE
( ) TRAVEL SERVICE SECOND PERSON-
IMMED FAMILY
( ) SUTURE REMOVAL
( ) OTHER PROCEDURES
2._
DATE OF SERVICE
REQUEST MEDICAL RECORDS FROM/TO
CHARGES OV $
( )CASH $_
( )CHECK $__
( )MCNISA $
--HC-201 (12/99)
URGI CENTER
HOLY SPIRIT HOSPITAL
503 North 21st Street
Camp Hill. PA 17011-2288
Phone (717) 763-2461
HSH Federal I.D. #23-1512747
PATIENT'S NAME
L~- ,..,;
....: . . -,:_.- ;~ ~.
CONSENT TO MEDICAL TREATMENT
I HE, ',EBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and employees, to the rendering of medical care, which may include
routine diagnostid"procedures and such medical treatment as my attending or consulting physician considers to be necessary. I also under-
stand it is customary, absent emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or
until I have had an opportunity to discuss them with a physician or other health care professional to my satisfaction. If I am a competent adult, I
have the right to consent or refuse to consent. I understand that the practice of medicine and surgery is not an exact science and that diagno-
sis and treatment .may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any
examination or treatment in this Hospital.
I understand many of the physicians on the staff of Holy Spirit Hospital are not employees or agents of the Hospital, but rather are independent..
contractors who have been granted the privilege of using these facilities for the care and treatment of their patients. Further, I realize this
Hospital is a teaching Hospital and at the Hospital are health care personnel in training who, unless expressly requested otherwise, may participate
or may be present during my care as part of their education. Still or motion pictures and closed circuit monitoring of patient care may also be
used for educational purposes, unless I expressly request otherwise.
I understand that in order to ensure a safe environment for patients, visitors and staff all property on the premise spiral is
subject to reasonablesearch and/or seizure at any time without further notice. ~ S~
RELEASE OF MEDICAL INFORMATION ~ .... --"
I authorize Holy Spirit Hospital to release to requesting health insurance carrier(s), their representatives and auditors, and any referring health
care providers, such diagnostic and therapeutic information (including any information relating to treatment for alcohol and substance abusn
and/or treatment of Psychiatric disorders, and/or confidential HIV related information~ as may be:necessary for them to determine benefit enti-
tlement; to process payment claims for health care services provided during this hospitalization/treatment episode, and for continuing
care/treatment. A photocopy or carbon copy of this authorization shall be considered as effective and valid as the original. The undersigned
also. authorizes Medicare, when applicable, to release to another insurance carrier, upon their request, medical information needed to make
payment upon that claim.
I understand and consent that the manufacturer of any implantable.device inserted by my physic an during the course of . rg_e ./p. edure
INSURANCE ASSIGNMENT OF BENEFITS
I authorize payment directly to Holy Spirt Hospital and my treating physic ans of all benefits payable under my insurance ' les. un stand
I am responsible to the Hospital and physicians for all charges not-covered by this assignment. .
request payment of Authorized Medicare benefits to me or on my behalf for any services furnished me by or in Holy Spirit Hospital including
iSTATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS.TO PROVIDERS, PHYSICIANS ~A-'I'I;~' ''}
physician services. I authorize any holder of medical and other information about me, to release to Medicare and its agencies any information
needed to determine these benefits for related services.
MEDICAL ASSISTANCE RECIPIENT Initials
My signatures certifies that I received a service or items from Holy Spirit Hospital and Dr. on the date listed below.
I understand that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or
concealment of material may be prosecuted under applicable Federal and State Laws. I understand that certain tests and procedures may not
be reimbursed by Federal and State funds and that I may be responsible for non covered charges. Aisc, I agree that if at the time of service, if
am not eligible for Medical Assistance, I will be responsible for balances owed to Holy Spirit Hospital.
Initials
I have read and understand each of the sections contained above. I understand that by signing this document, I am agreein and
providing the author~.ation/can'l~ent contained in each of the above sections where my initials are located I have had the o ~grtu
ty to a_,%k questions re'harding eX,ach of these sectiefi's and all such questions asked have been ans . · pp ni-
~ ~- I~'.,~ ....'_= ~"~",,~"~ ~-~-'~ ~ . s,~ered to my satisfaction.
--ess
Time Date
HOLY SPIRIT HOSPITAL, CAMP HILL, PA
CONSENT FOR TREATMENT/RELEASE OF INFORMATION
INSURANCE ASSIGNMENT
MED REC 166 F-D. (11/99)
CHART CC3pv
EMERGENCY CENTER. i UI~GI'C~NTER : ~ _., DISCHARGE ~TRUCTIONS HOLY SPIRIT HOSPITAL
The exarmna~on and ~xeatment you h~e--a~.ved~e Eme~ency Cent~ have been rendered on an emergency basis on/y, and am not intended to be a substitute for or an effort to' Provide
compl' ': medical cam. ff yo~ ,develop new problems or complications contact your physician or ~he Emergency Center. FOLLOW THE INSTRUCTIONS CHECKED BELOW.
Patient Informa'fioth'laaflent Information sheets contain Important information to review and keep.
) Abdominal pain
} Alcohol reaction
) Allergic reaction
) Asthma
) Back pain
) Bites-Human/Animal/Insect
) Bum
) Chest Pain
) Conjunctivitis
) COPD
WOUND CARE
( ) Corneal abrasion/foreign body ( ) Headache ( ) Pain Management
( ) Croup/bronchitis' - :'-{'~- .: ( ) Head Injury - ( ) Pediatric Head Injury
( ) Crutch walking '-" J'Z - ( ) Hypertension ( ) Pediatric URI
( ) Diarrhea and Vomiting~3ed. Vomiting ( ) Immunizatior'v'Tetanus ( ) PID/STD
( ) Dislocation ' ' ( ) Kidney Stones ( ) Pneumoma
( ) Drug/Alcohol abuse/addiction - ( ) Lablynthitis ( ) Rash
( ) Febdle Convulsion ( ) Laceration ( ) Seizure
( ) Fever/Ped. Fever ( ) Neck Strain ( ) Sore ThC'oat
( ) Flu ( ) Nosebleed ( ) Sprains and Strains
( ) Fracture - ' '~ -4 ~ ' - ( ) Otitis Media ( ) Suture Care & Removal
.... '"':~ -' ' - ' MEDICATIONS
( ) Continue present medications except:
( ) May gently wash over wound in 24 hours with soap and water or
peroxide. Do not soak in water. '
( ) Change dressing times daily. Redress with Bacitracin/Neospodn
and stedle dressing.
( ) Keep wound clean, dry, covered. ( ) Tetanus/Diptheda Booster given.
SPRAINS, STRAINS, BRUISES, FRACTURES : ~''*- '
) Elevate the injured part for da~;s to reduce swelling.
) Apply ice packs intermittently for days to reduce swelling.
) Ace wrap for support for days. ' - .**.
) Wear splint ( ) At all times until follow-up
( ) For activity as needed.
) Use sling for support.
) Use crutches: ( ) As needed, weight bearing as tolerated.
( )At all times. NO WEIGHT BEARING
NECK/BACK
( ) Wear cervical collar for support for~days.
( ) Rest, avoid bending, lifting, strenuous activity for days.
( ) Apply moist-heat for minutes times daily
beginning in hours. -
( ) Threatened Misca~ag~
( )Toothache - ~'
( ) URI and Colds
( ) UTI and Pyetooephdtis
( ) Wound Reci"~d~
( ) 24 hr. Phan'nacies
( ) Other
( ) Use Advil (Ibuprofen) or Tylenol as needed for pain, fever -
according to package instructions for age, weight.
( ) Use the following medicines according to package
instructions: _
1:
2:
3:
( ) The following medicines may cause drowsiness:
DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING:
FOLLOW-UP This is our recommendation for follow-up. If your
insurance (HMO) requires a physician referral for specialty
consultation, IT IS YOUR RESPONSIBILITY TO OBTAIN THE
NECESSARY APPROVAL.
) Follow-up with: ( ) Urgi Center
( ) Family Doctor
ADDITIONAL INSTRUCTIONS
( ) Off work/school from
( ) Return to work on
( ) Light Duty until:
Restrictions:
( ) No gym/sports until ' *
( ) Follow instructions on Workmen's Compensation Form. -.
( ) Wear eye patch for. hours. ' *'~ .'
( ) If nose bleed recurs, pinch nose firmly for 5 minutes
continuously, return if bleeding not controlled.
( ) The prescribed antibiotic may reduce the effectiveness of
medication you are currently taking. Check package ....
instructions or consult with Pharmacist.
( ) The interpretation of' your X-Rays are prelininary reading.-
Your films will be reviewed by a radiologist. You or your : '
physician will be contacted if there is a change in the -.
diagnosis.
Additional Instructions: -: :..
in days for:. ( ) Follow-uP
_. ( ) Suture [emoval
( ) Call as soon as possible for appointment
) Pick up your X-Rays from the Radiology Department pdor to
your follow-up appointment. Call 763-2696 to have films
ready. ·
) See your physician or specialist if not improved in _ ~.~
days. .
) Return to Emergency Center if you feel your condition is worsening,
especially if the pain increases despite pain relief medication.
) Your blood pressure was elevated. Please have it
rechecked by your physician.
) Test results have been given to you. Take them with you to
the follow-up appointment. ' '
Test results given: [] CBC [] CMP [] EKG [] X-RAY COPY :--
[]BMP []RECORDS COPY CHART []GLUC.
A copy of your dictated Emegency Room Report is available to ]four'
physician from Medical Records (763-2660), if not already sent.
I hereby acknowledge receipt of these instructions and understand th~m~" .~ ...
I understand that I have had emergency treatment only a/iii:that I ma~y + :'
be released before all of my medical problems are known or tma~ed...' .
. . ~,,. :~ '-~-: ~'"_'-' ' I will arrange for fo ow-up care as I have been instructed'. It is'Y~r~T'--:. ~ '
~va~om ~o, M.D. ~502E' ~ T; ...... ' :~ ) M~ly~'~s°;, ~.D. 07~"~3~ ( ) ~cacc Paul, M.D. 039524-L
Ramcsh ~ M.D. 016727E ...... ~- - ~ :'~(- ) Jo~ p. ~u~a, M~. 038368-E: ( ) How~d Rud~c~ M.D. ~862-[ - : :. ~; _: ,.
Glen Dau~, D.O. 0S~6776E ~ ~c~ Lulcy, M~. ~99~-E ( ) R~j~a Sh~a,'M~. 031265-E.
Nicolau DaCosa, M.D. 053288-L ~) ~sh~M~. 051514L ~ ( ) AI~ Tcplis, M.D. 03~8-E .
( ) Elevate t~he injured part for ,_L_ days to reduce swelling.
( ) Apply ice packs intermittently for~days to reduce swelling.
( ) Ace wrap for support for ~ days.
( ) Wear splint ( ) At all times until follow-up.
-'- : ~_. ( ) For activity as needed.
( ) Use sling for support.
( ) Use crutcheS: ( )As needed, weight beadng as tolerated.
.. ( )At all times. NO WEIGHT BEARING
NECK/BACK ' '- :
( ) wear C~rvi~al collar for suppOrt for~days.
'{ ) Rest'avoid b6fid rig, tiffing, strenuous activity for days.
( ) Appl~'m(~ist'heat for. minutes times daily
beginning in - hours.
ADDITIONAL INSTRUCTIONS
( ) Off work/school from to
':'"'~' ( ~ Retur~ to work on '-
· '. (~ ! Lighi Duty until: --~ - '
· - Restrictions:- -
( ) No gYm/sports until.
( ) FollOw. instructions on Workrnen's Compensation Form.
( ) Wear eye patch for hours.
! ) If nose bleed recurs, pinch nose firmly for 5 minutes
continuously, return if bleeding not controlled.
( ) The prescribed antibiotic may reduce the effectiveness of
medication you are currently taking. Check package
instructions or consult with Pharmacist.
( )The interpretation o~your X-Rays are preliminary reading.
Your films will be reviewed by a radiologist. You Or your
physician will be contacted if there is a change in the
diagnosis.
Additional Instructions:
1:
2:
3:
The following medicines may cause drowsiness:
DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING:
FOLLOW-UP This is our recommendation for follow-up. If your
insurance (HMO) requires a physician referral for specialty
consultation, IT IS YOUR RESPONSIBILITY TO OBTAIN THE
NECESSARY APPROVAL
( ) Foli°w~up with: ( ) Urgi Center
( ) Family Doctor
in days for:. ( ) Follow-up
( ) Suture removal
( ) Call as soon as pOssible for appointment
.* ( ) Pick Up your X-Rays from the Radiology Department pd'~)r to
your follow-up appointment. Call 763-2696 to have films
' ready.
( ) See *your physician or ~pe~ialist if not improved in
.days.
· ( )-Return to Emergency Center if you feel your condition is worsening,
especially if the pain increases despite pain relief medication.
( ) Your blood pressure was elevated. Please have it
rechecked by your physician.
( ) Test results have been given to you. Take them with you to the follow-up appointment.
Test results given: [] CBC [] CMP [] EKG [] X-RAY COPY
[] BMP [] RECORDS COPY CHART [] GLUC.
A copy of your dictated Emegency Room Report is available to your
physician from Medical Records (763-2660), if not already sent.
I hereby acknowledge receipt of these instructions and understand them.
I understand that I have had emergency treatment only and that I may
be released before all of my medical problems are known or treated.
I will arrange for follow-up care as have been nstrugted. It is your
responsibility to notify your Pnmary Care Ph s~c~an o h~s
. ^ y"
Cl!?cal Impres~.ions:
~ PATIENT VERBALIZES UNDE ST
SIGNATURE:
P~ent Pr Responsible Person ' I ' '~6 'a~'
....... ~ ~ -~ ........
HOLY SPIRIT HOSPITAL EMERGENCY CENTER
503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316
( ) Vanitha Abraham, M.D. 038840L
( ) Thomas Aldous, M.D. 017075E
( ) Salvatore Alfano, M.D. 025502E
( ) Ramesh Arora, M.D. 016727E
( ) Glen Daughtry, D.O. 0S006776E
( ) Nicolau DaCosta, M.D. 053288-L
DATE
( ) Son Dubin, D.O. OS 006991L
( ) Marlys Hasson, M.D. 072553L
( ) John P. Judson, M.D. 038368-E
) Richard Luley, M.D. 029960-E
M.D. 015063-E
a, M.D. 051514L
Lawrence Paul, M.D. 039524-L
Howard Rudnick, M.D. 040862-L
Ranjana Sharma, M.D. 031265-E
Alan Teplis, M.D. 030018-E
David Zimmerman, M.D. 005636-E
SIGNATURE
M.D./D.O.
IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, TIIE
PRESCRIBER MUST HAND WRITE "BRAND NECESSARY" OR "BRAND
MEDICALLY NECESS.~RY'" 1N THE SPACE BELOW.
LABEL
D SUBSTITUTION PERMISSIBLE
178 (3/01) --
iLEM~a£ PA
Sa d04-b.o-l¢15 DATE
REFU_,L
UC3
17043'
06127/O1
EXHIBIT B
POWER OF ATTORNEY
AND
CONTINGENT FEE AGREEMENT
KNOW ALL MEN BY THESE PRESENTS, That I, William Ratz on
behalf of my minor child, William Robert Ratz, do hereby retain
Friedman & King, P.C., of Harrisburg, Pennsylvania, as my
attorneys to negotiate for an adjustment, or to institute child,s
child and in his name any legal actions or proceedings that in
for my
their judgment are necessary, in connection With the claim for
damages as a result of injuries or damages sustained by William
Robert in an accident on 8-2-02.
NOW THEREFORE i .
~e rendered by my c~_ n ~nslderation of t
hereby c~,,~-~ ~ -~u ~ sal~ atto~ ...... he services so
for t~ei~'~u' promise and a~ree 2~=~' ~rledman & Kin~
, .... ' ~=oressiona~ .... ~ = ~u pay to my s={~ _~='
~zs{; of whateve~ .... -~o==¥~ces rendered t = _-?u u~=orneys
- ~u~,. xs recovered, whe~__w~nty five percent
~,~=r from the party
responsible for William Rob ,
or any other thir _ er~ s damages, his ' -
the institu~- _~ ~art~ carrier, if the ~surunce carrie
third (33 ~ ur legal proceedin s cas~ ~e~les prior tor'
procee~in,~'~_~n~ if it is n~s~h~ft~-tp~e and one
fi ' ~ ' ~ns~ltutin le ~ uo institute
_ling a complain+ ..... g _gal proceedings,, ow,~ ~ _legal
f ~ommenclng a le~ - ~.r legal document re-,,~ .... defined as
~o~ is commence~n~=~;~owever, in cas~.~Or ~urposes
minor settlement, ~ ~u= court approval of a
without any further legal proceedings, 'legal
proceedings shall not be deemed to have been instituted and
Will pay as if the case had settled.
This agreement only COVers damages recove
responsible driver and or
~arrier and or . / ~he responsib ' . ~ table from t
/ m unl le drive , . he
mo fees Will be ~h=~-~u~ed or underinsur~ __~r ? ~nsurance
combe v ~_ ~ 7---~w=u rot any recove =u_~ouorlsts COVera e.
· -- nz -ua £lrst part · ry from m · g
zn securin- =:- - Y benefits F_:_~ Y own lnsura,~
at no charge. However i f ~ou wages an~ medical bills
:~st~tute proceedings ~,a~_~e_event it becomes ne _
azrst part ben ~- ~ ~.~u my com an cessary to
· Y e~u~, a se~=~-~- ~ P Y for recover
z =--~=~-=n~ Wlll be entered
I further agree on behalf of my minor child to be
responsible for all costs advanced b F '
his behalf. I Understan _ Y rledman & .
reports from all of h~ f_~at_my child,s atto~__~?g~ F-C. on
the accident £e or ' . = -~u=~
P t if a 1 , as Well
PP lCable, and that th .... as ? copy of
medical providers char efe "= a'u3ority of
o{ medical recor g es for written
line com _ds. ? also Unders re~orts and/or co ' .
pUter re · tend t Pies
search t~me ~ ..... hat costs ma,- ~
These costs will be payable b-~ P=rSonnel at FriedmanZ&~oe on- me on my child,s behalf at the
time of settlement of his accident case or at such time as it
becomes necessary to institute legal proceedings. I understand
that costs will be subtracted from my child's net proceeds of
settlement (after subtraction of Friedman & King's fees). I will
also be responsible for costs of proceeding in court if
applicable, such costs to include filing fees and costs of
service by Sheriff or private process server. In the event no
recovery is made, or in the event I substitute attorneys prior to
completion of the accident case, I agree individually to pay for
all costs upon presentment of a bill.
In the event I substitute attorneys or otherwise
terminate the representation of Friedman & King, P.C. in this
matter prior to settlement with any responsible carrier or
carriers or prior to verdict, I understand that I will be billed
for the fair value of the services performed by Friedman & King,
P.C. up to that time, which bill shall reflect the time spent by
Friedman & King, P.C. on my child's behalf and the results of any
negotiations which have resulted in an offer prior to the date of
said termination of Friedman & King's services.
This Contingent Fee Agreement and Power of Attorney
has been read, approved and understood by me and the receipt of a
copy thereof acknowledged. The terms set forth are agreeable.
IN WITNESS WI~EREOF, I have hereunto set my hand and
seal this //' day of ~/~/ , 2002.
WITNESS:
~illiam Ratz, parent an~
natural guardian of William
Robert Ratz
mf.accident\ratz.chi
EXHIBIT C
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
estate of RATZ WILLIAM ROBERT
(LAs'±', ~'±~$'±', ~±UU~)
in said county, deceased, to
SHORT CERTIFICATE
DONNA M. OTTO
Register for the Probate of Wills and Granting
Letters of Administration &c. in and for said
County of CUMBERLAND do hereby certify that on
the 22nd day of April A.D.,
Two Thousand and Three,
Letters of ADMINISTP~ATION
in common form were granted by the Register of
said County, on the
, late of LEMOYNE BOROUGH
RATZ WILLIAM P
(~AS'I', ~'ig~'i', M±UU~)
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 23rd day of April
A.D., Two Thousand and Three.
File No.
PA File No.
Date of Death
s.s. #
2003-00353
21-03-0353
8/02/2002
204-68-1415
Register
NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL
ESTATE OF WILLIAM ROBERT
RATZ, a Minor Child, by WILLIAM
P. RATZ,
ADMINISTRATOR,
Petitioner
v.
CAROLYN KAY BROWNAWELL,
Respondent
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY.
: PENNSYLVANIA
:
: CIVIL ACTION - LAW
: No. 2003-00353
:
:
: ORPHANS, COURT DIVISION
..ORDER
consideration of the foregoing Petit:
[o~ this Court being
satisfied of the propriety of the settlement and compromise in
the amount of Six Thousand Four Hundred ($6,400.00) Dollars to be
received from Progressive Insurance Company, and that such
settlement is in the best interest of the Petitioner
IT IS HEREBY ORDERED AND DECREED THAT:
1. The compromise settlement in the amount of $6,400.00 be
approved as fair and equitable and being in the best interest of
the Petitioner.
2. Distribution of the total settlement amount of $6,400.00
is hereby directed as follows:
a. The Firm of Friedman and King, P.C., has advanced
certain expenses for which it is entitled to reimbursement, as
follows:
Gerhart Family Chiropractic
(records)
$ 29.81
ChartOne
(records) $ 24.78
TOTAL: $ 54.59
b. Legal fees to Friedman & King, P.C., in accordance
with a Twenty-Five (25%) Percent contingent fee agreement.
Legal Fees $1,600.00
c. The sum of Four Thousand Seven Hundred Forty-Five
($4,745.41) Dollars and Forty-One Cents to be deposited into an
Estate checking account to pay the expenses and outstanding
debts, if any, of the Estate, the balance to be distributed to
the Minor Child,s heirs, Petitioner and his wife, Dawn M. Ratz,
in accordance with further approval of this Honorable Court.
3. Upon payment of the aforesaid sum in the manner above
described, Petitioner is directed to execute good and sufficient
releases in favor of Progressive Insurance Company and the
Respondent, and to discontinue the action brought against Carolyn
Kay Brownawell, with prejudice.
4. Payment of the aforesaid sum constitutes conclusive
evidence of a complete settlement in satisfaction of all claims
and demands of whatsoever kind or nature now or hereafter arising
on behalf of Petitioner, the Estate of William Robert Ratz, by
and through the Estate,s Administrator, William Ratz, against
Respondent, Carolyn K. Brownawell.
BY THE COURT:
Je
Name of Decedent:
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
William Robert Ratz
Date of Death: August 2, 2002
2003-00353
Will No. Admin. No.
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of theOmhans' Court Rules was
served on or mailed to the following beneficiaries of the above-captioned estate on 8/5~t03 :
Name Address
William P. Ratz. 804 Riverview Rd., Lemo)qle, PA 17043
Dawn M. Ratz 804 Riverview Rd., Lemo)me, PA 17043
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
Date: 9/10/03
Signature
Name
Richard S. Friedmm~, Esquire
Address 600 N. Second St., 5th Floor
Harrisburg, PA 17101
Telephone (717 236-8000
Capacity: __
Personal Representative
XX Counsel for personal representative
FRIEDMAN & KING, P.e.
2kTTORNEYS AT LAW
8OO N. SECOND ST.
FIFTH FLOOR
P.O. Box ~)84
HARRISBURG, PENNSYLVANIA 17108
(?,?) ~oe-8ooo
TEL~COPI]~ No. (717) ~6'8080
fricdinanandking~hot mail. coln
RICHAHD S. FHI]~DMAN
JOHN F. KING
October 31, 2003
Cumberland County Register of Wills
Cumberland County Court House
1 Courthouse Square
Carlisle, PA 17013-3387
In re:
Estate of William Robert Ratz
File No. - 2003-00353
PA File No. - 21-03-0353
Dear sir or madam:
As your records will indicate, this office represents the Estate of William Robert
Ratz, who died as a minor on August 2, 2002. He had previously been in an automobile accident
on June 26, 2001, which we settled after his death, and the estate netted $4,745.41, after payment
of fees and costs.
The father of the decedent, William P. Ratz, is the Administrator, and we are
unable to communicate with him. We were in communication until several months ago when he
moved due to a change of his employment. Thereafter, he called once and indicated that he was
terminating that employment and would contact me. He never did contact me, and I've been
attempting to contact him for the last several months. I have no work number for him, and his
home number is not in operation. I believe he may have left the jurisdiction with his wife due to
the circumstances surrounding the death of their son. I have written to him on several occasions
and have not received any response.
You will note that we have listed no value for the estate, since obviously the
funeral expenses, which included the cost of transporting the body to this area from Michigan,
was well in excess of $4,745.41. I am requesting that you accept this letter as an explanation,
and accept the inheritance tax return as filed. I have enclosed an original and two (2) copies of
the inheritance tax return, as well as a check in the amount of $15.00 to cover the cost of filing.
Cumberland County Register of Wills
October 31, 2003
Page 2
I have also enclosed an extra copy of this letter of explanation to be forwarded to the Department
of Revenue, along with their copy of the inheritance tax return. Please clock in the extra copy of
the inheritance tax return and remm it in the enclosed envelope.
If you have any questions, kindly contact me at your convenience.
RSF/bp:corresafkcumbcoreg.ltr
Very truly yours,
/'
Enclosures
REV- 1 500
DEPARTMENT OF REVENUE I FILE NUMBER
DEPT. HERITANCE TAX RETURNI 2
280601
HARRISBURG, PA 17128-0601 RESIDENT DECEDENT
DECEDENTS NAME (LAST FIRST, AND MIDDLE INITIAL)
' SOCIAL SECURITY NUMBER
z Ratz, William Robert
m,, 204 - 68 - 1415
t't DATE OF DEATH (MM-DB-YEAR) DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
uJ 08-02-02
o 01-12- 86 REGISTER OF WILLS
LLI (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
t't SOCIAL SECURITY NUMBER
"' E~ 1. Original Return E~ 2. Supplemental Return [~ 3. Remainder Return (date of dee~h prior to 12-13-82)
~] 4. Limited Estate ~] 4a. Future Interest Compromise (date o, deem after 12-12-82) [] 5. Federal Estate Tax Return Required
~-~6. Decedent Died Testate (^~ach copy of wi~) [~ 7. Decedent Maintained a Living Trust (A~ac~ copy el'Trust) 0 8. Total Number of Safe Deposit Boxes
[~ 9. Litigation Proceeds Received [] 10. Spousal Povedy Credit (date of death between 12-31-91 and 1-1-95) [----] 11. Election to tax under Sec. g113(A)(^~ch sm o)
m
Z
z ard S. Friedman, Esquire
o.. FIRM NAME (If AppliCable)
,,, Friedman & King, P.C.
'"' TELEPHONE NUMBER
o
° (717) 236-8000
COMPLETE MAILING ADDRESS
P. O. Box 984
Harrisburg, PA
17108
1. Real Estate (Schedule A) (1) - 0-
2. StOcks and Bonds (Schedule B) (2) - 0- ii:~ ~,.,
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) - 0-
4. Mortgages & Notes Receivable (Schedule O) (4) - 0-
5. Cash, Bank Deposits & Miscellaneous Personal Property (5) 4,745,41
(Schedule E)
6. Jointly Owned Property (Schedule F) (6) - O-
--"]Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) - 0 -
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(8)
242.91 (plus
-0-
(11)
(12)
(13)
OFFICIAL USE ONLY
745.41
unkno~a~ f~eral expenses)
242.91 (plus L~known
(14) 0
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPUCABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2) x .0 __ (15)
16. Amount of Line 14 taxable at lineal rate x .0 _ (16)
17. Amount of Line 14 taxable at sibling rate x .12 (17)
18. Amount of Line 14 taxable at collateral rate x .15 (18)
19. Tax Due (19)
0
: 47 BE SURE TO ANSWER ALL'QUESTIONS ON REVERSE*'SIDE AND RECHECK MATH <* ~' ~L~' ~ ' ~
Decedent's Complete Address:
ISTREET ADDRESS
804 Riverview Rd.
, CITY Lemoyne
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Interest/Penalty if applicable
D. Interest
E. Penalty
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT,
Check box on Page I 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.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
ISTATE PA I zip 17043
(1) 0
Total Credits ( A + B + C ) (2)
Total Interest/Penalty ( D + E )
0
0
(3)
(4) 0
(5) 0
(5A) 0
(5B) 0
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
Yes No
1. Did decedent make a transfer and:
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? ...................................................................... []
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
w,thout receiving adequate consideration? ..............................................................................................................
3. £ d decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. []
4. g~d decedent own an individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of per]ur~, 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 complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN
DATE
ADDRESS
SIGNATURE~. EPA~E. o~SENTATIVE
ADORES/ _l-~.c.h. ATd. 5. Priedman, lgsqlJl'r~
P. O. Box 984, Harrisburg, PA
17108
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3%
[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 0% [72 P.S. {9116 (a) (1.1) (ii)].
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 beneficiary.
For dstes 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 at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [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 4.5%, except as noted in 72 P.S. {9116(1.2) [72 P.S. {9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. {9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common with the decedent, whether by blood or adoption.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
ESTATE OF
F. state of William
SCHEDULE E
J CASH, BANK DEPOSITS, & MISC. J
Robert Ratz FILE NUMBER
21-03-0353
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM ~
NUMBER DESCRIPTION VALUE ,~
OF DEATH
1. Progressive Insurance (proceeds of settlement received from
car accident of 6/26/01) - See copy of Order~ $4,745.41
TOTAL (Also enter on line 5. Recapitulation) $ 4,745.41
(If more space is needed, inse~ additional ~heet$ of ,he ~ame ~.ize~
ESTATE OF WILLIAM ROBERT
RATZ, a Minor Child, by WILLIAM
P. RATZ,
ADMINISTRATOR,
Petitioner
v.
CAROLYN KAY BROWNAWELL,
Respondent
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY.
: PENNSYLVANIA
:
: CIVIL ACTION - LAW
: No. 2003-00353
:
:
: ORPHANS' COURT DIVISION
ORDER
AND NOW, this ~q-~
day of i%~i~ , 2003, upon
consideration of the foregoing Petition, this Court being
satisfied of the propriety of the settlement and compromise in
the amount of Six Thousand Four Hundred ($6,400.00) Dollars to be
received from Progressive Insurance Company, and that such
settlement is in the best interest of the Petitioner
IT IS HEREBY ORDERED AND DECREED THAT:
1. The compromise settlement in the amount of $6,400.00 be
approved as fair and equitable and being in the best interest of
the Petitioner.
2. Distribution of the total settlement amount of $6,400.00
is hereby directed as follows:
a. The Firm of Friedman and King, P.C., has advanced
certain expenses for which it is entitled to reimbursement, as
follows:
Gerhart Family Chiropractic $ 29.81
(records)
ChartOne
(records) $ 24.78
TOTAL: $ 54.59
b. Legal fees to Friedman & King, P.C., in accordance
with a Twenty-Five (25%) Percent contingent fee agreement.
Legal Fees
$1,600.00
c. The sum of Four Thousand Seven Hundred Forty-Five
($4,745.41) Dollars and Forty-One Cents to be deposited into an
Estate checking account to pay the expenses and outstanding
debts, if any, of the Estate, the balance to be distributed to
the Minor Child's heirs, Petitioner and his wife, Dawn M. Ratz,
in accordance with further approval of this Honorable Court.
3. Upon payment of the aforesaid sum in the manner above
described, Petitioner is directed to execute good and sufficient
releases in favor of Progressive Insurance Company and the
Respondent, and to discontinue the action brought against Carolyn
Kay Brownawell, with prejudice.
4. Payment of the aforesaid sum constitutes conclusive
evidence of a complete settlement in satisfaction of all claims
and demands of whatsoever kind or nature now or hereafter arising
on behalf of Petitioner, the Estate of William Robert Ratz, by
and through the Estate's Administrator, William Ratz, against
Respondent, Carolyn K. Brownawell.
BY THE COURT:
Jo
A TRUE COPY FROM RECORD
In Testimony wflerof, I hereunto
set my hand and the seal
of said'Court at Carlisle, PA
Cle~k. pf the Orphans Coutt -~mberland County
REV-1511 EX+ (12-99) ~
COMMONWEALTH OF PENNSYLVANIA J FUNERAL EXPENSES &
RESIDENT DECEDENT I /'~l.~/Ylll~ll,,~ I KAl l¥~' COSTS
ESTATE OFINHERITANCE TAX RETURN / ADMINISTRATIVE COSTS
William Robert Ratz FILE NUMBER
21-03-0353
Debts of decedent must be reported on Schedule I. --'-"-'--'--'---
NUMBEF
A. FUNERAL EXPENSES:
1.
5.
6.
7.
8.
9.
DESCRIPTION
Unknown Funeral Expenses
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(si'
Street Address
City
Year(s) Commission Paid:
State__Zip
Attorney Fees
Family Exemption: (If decedenrs address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
Cumberland Law Journal (estate advertising)
The Sentinel (estate advertising)
Register of Wills (filing of Petitic~a)
State _ Zip
TOTAL (Also enter on line 9, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
AMOUNT
73.00
75.00
67.91
27.00
$ 242.91
'~ I SCHEDULE J J
COMMONW~L~, OF PEN,SY,V^N ^ I BENEFICIARIES
'N"E.~'T^NCE ~X "E?URN
RESIDENT DECEDENT ·
~,sta~e of l'~illiam Robert Ratz FILE NUMBER --
----------- 21-03-0353
Nt?JBER
I.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS (include outdght spousal distributions)
~illiam P. Ratz
Dawn M. Ratz
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Father
~bther
AMOUNT OR SHARE
OF ESTATE
50%
5O%
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINEI 15 THROUGH 17, AS APPROPRIATE,
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
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)
ON REV 1500 COVER SHEET
ESTATE OF WILLIAM ROBERT RATZ,
a Minor Child, by WILLIAM P. RATZ,
ADMINISTRATOR,
Plaintiff/Petitioner
Vo
CAROLYN KAY BROWNAWELL,
Defendant/Respondent
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: No. 2003-00353
:
: C~'V,~ ACTION - LAW-
: ORPHANS' COURT DIVISION
PRAECIPE
Kindly discontinue with prejudice the action against Carolyn Kay Brownawell,
Defendant/Respondent, in the above-captioned matter.
Respectfully submitted,
FRIEDMAN & KING, P.C.
Rich~jta~. ~, Esquire
P. O. Box 984
Harrisburg, PA 17108
(717) 236-8000
f/p:estates~ratz.pra
~ 'BI~REAU OF TNDTVTDUAL TAXES
/NHER/TANCE TAX DTVTSTON
DEPT. 180601
HARRXSBURG, PA 17118-0601
RICHARD S FRIEDHAN
FRIEDHAN & KING PC
P 0 BOX 98q
HARRISBURG
CONHON#EALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
PA 17108
NOT/CE OF INHERITANCE TAX
APPRAZSEHENT, ALLONANCE OR DZSALLO#ANCE
OF DEDUCT/ONS AND ASSESSHENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUHBER
COUNTY
ACN
REV-16~7 EX AFP
12-15-2003
RATZ WILLIAM R
08-02-2002
21 05-0355
CUHBERLAND
101
Amount Remitted I
HAKE CHECK PAYABLE AND RENZT PAYHENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSEHENT, ALLONANCE OR
DZSALLONANCE OF DEDUCT/ONS AND ASSESSHENT OF TAX
ESTATE OF RATZ HILLIAH R FXLE NO. 21 03-0555 ACN 101 DATE 12-15-2003
TAX RETURN HAS: ( ) ACCEPTED AS FILED (X) CHANGED SEE ATTACHED NOTICE
RESERVATION CONCERNXNG FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock~Partnership Interest (Schedule C) ($)
q. Hortgegas/Notas Receivable (Schedule D) (q,)
5. Cash/Bank Daposits/HAsc. Personal Property (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVE]:) DEDUCTIONS AND EXEHPTTONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9)
10. Debts/Hortgaga Liabilities/Liens (Schedule T) (10)
11. Total Deduct ions
12, Nat Value of Tax Return
15.
Charitable/Governmental Bequests; Non-elected 9115 Trusts (Schedule J)
Nat Value of Estate Sub~ect to Tax
.00
.00 NOTE: To insure proper
.00 credit to your account,
.00 submit the upper portion
.00 of this form with your
tax payment.
.00
(8)
~,7~5.ql
.00
NOTE:
q,7q5.ql
ZF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
(15) .00 x O0 = .00
(16) .00 x Oq5 = .00
(17) . O0 x 12 = . O0
(18) .00 x 15 : .00
(19)= . O0
ASSESSMENT OF TAX:
15. Amount of Line lq at Spousal rata
16. Amount of Line lq taxable at Lineal/Class A rate
17. Amount of Line lq at Sibling rate
18. Amount of Line lq taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
PAYMENT RECEZPT DISCOUNT (+)
DATE NUMBER INTEREST/PEN PAID (-)
AMOUNT PAID
TOTAL TAX CREDIT
BALANCE OF TAX DUEI
INTEREST AND PEN.
TOTAL DUE
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A 'CREDIT' (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTXONS.)
reflect figures that include the total of ALL returns assessed to date.
.00
.00
.00
.00
Tf an assessment was issued prev/ously, lines lq, 15 and/or 16, 17, 18 and 19 w111
(11) ~ .7~5.~1
(12) .00
(Ks) .00
(1~) .00
RESERVATION:
PURPOSE OF
NOTICE:
PAYNENT:
REFUND ICR):
OBJECTIONS:
ADNIN-
ZSTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
Estates of decedents dying on or before December 12, 1982 -- if any futura interest in the estate is transferred
in possession or enjoyment to Class B (calIateral) beneficiaries of the decadent after the expiration of any estate for
life or for years, the CommonmeaZth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B icollateral) rata on any such future interest.
To fulfill the requirements of Section 2140 of the Inheritance and Estate Tax Act, Act Z$ of 2000. (72 P.S.
Section 9140).
Detach the top portion of this Notice and submit with your payment to the Register of Nills printed on the reverse side.
--Hake check or money order payable to: REGISTER OF #ILLS, AGENT
A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-ISIS). Applications are available at the Office
of the Register of Nills, any of the 25 Revenue District Offices, or by calling the special Z4-hour
answering service for forms ordering: 1-800-562-2060; services for taxpayers with special hearing and / or
speaking needs: 1-800-447-:50E0 iTT on[y).
Any party in interest net satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. ZSIOZ1, Harrisburg, PA 171ZS-10Z1, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Ceurt.
Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. 280601, Harrisburg, PA 17128-0601
Phone (717) 767-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an expZanation of administratively correctable errors.
If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (52) discount of
the tax paid is allowed.
The 152 tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and net
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
Interest is charged beginning with first day of delinquency, or nine (9) months end one il) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 1982 bear interest at the rate of
six (62) percent par annum calculated at a daily rate of .000164. All taxes which became delinquent on and after
January 1, 1982 will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 1982 through 200:5 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1982 ZOZ . 000548 1987 92 . 000247 1999 77. . 000192
198:5 162 .0004:58 1988-1991 112 .000301 2000 82 .000219
1984 117. · 000:501 1992 92 . 000247 2001 92 . O00247
1985 1:57. . 000:556 199:5-1994 77. .000192 ZOOZ 6Z .000164
1986 107. · 000274 1995-1998 92 .000247 2003 57. .0001:57
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUNBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen i15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional Jntarest must be calculated.
REV-1470 EX (6-88)
INHERITANCE TAX
COMMONWEALTH OF PENNSYLVANIA EXPLANATION
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES OF CHANGES
DEPT. 280601
HARRISBURGI PA 17128-0601
DECEDENT'S NAME
Ratz, William R. FILE NUMBER
REVIEWED BY 2103-0353
Daniel Heck ACH
101
ITEN
SCHEDULE NO. EXPLANATION OF CHANGES
H Increased the total on this schedule to $4,745.41. The estate is insolvent.
ROW Page 1
PLEASE FILE THIS REPORT WITHIN TWO YEARS OF DATE OF DEATH REGARDLESS OF
THE STATUS OF THE ESTATE. IF ESTATE IS NOT COMPLETED, FILE a 6.12 FORM YEARLY
UNTIL COMPLETION -
Name of Decedent:
Date of Death:
STATUS REPORT UNDER RULE 6.12
William Robert Ratz Estate
Estate No.: 2003 - 00353
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect
to completion of the administration of the above-captioned estate:
State whether administration of the estate is complete:
Yes ×X No
o
o
(MAH:rmt/AM3)
If the answer is No, state when the personal representative reasonably believes
that the admifiistration will be complete:
(date)
If the answer to No. 1 is yes, state the following:
A. Did the personal representative file a final account with the court?
Yes No XX
B. The separate Orphans' Court No. (if any) for the personal representative's
account is: (Not Applicable in Dauphin County)
C. Did the personal representative state an account informally to the parties in
interest? Yes XX
No
D. Copies of receipts, releases, joinders and approvals of formal or informal
accounts may be filed with the Clerk of the O/~ns' Court and may be attached
to this report. ..... ·
// /
/ /
Signatur/
Richal/l~d $. Friedma~, Esquire
" Name (Please type or print)
600 N. Second St., 5th Floor
HarrS_sburg~ PA 17101
Address
(717) 256-8000
Telephone No.
R.W. - 5t5
Capacity:
Personal Representative
Counsel for Personal Representative