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HomeMy WebLinkAbout11-8199KENNETH E. MOOSE, SR. MARY C. MOOSE 799 Old Silver Spring Road Mechanicsburg, PA 17055-2883 Pro se 1 1% ['31 18C T 28 AM lip: r rl DUGALIC & LANDAU, PC Vanya Dugalic, Esquire Attorney I.D. No. 89914 Mark A. Landau, Esquire Attorney I.D. No. 90757 901 Carroll Rd. Wynnewood, PA 19096 (484) 412-8242 Attorneys f or Joint Petitioner Imperial Structured Settlements IN RE: KENNETH E. MOOSE, SR. a/k/a KENNETH MOOSE & MARY C. MOOSE a/k/a MARY C. HARLING - JORDAN a/k/a MARY MOOSE & WASHINGTON SQUARE FINANCIAL, LLC d/b/a IMPERIAL STRUCTURED SETTLEMENTS CUMBERLAND COUNTY COURT OF COMMON PLEAS :No. elIjI L r ?M PETITION TO TRANSFER STRUCTURED SETTLEMENT PURSUANT TO 40 P.S. 4000, ET SEO. TO THE HONORABLE JUDGE OF SAID COURT: Petitioners, Kenneth E. Moose, Sr. a/k/a Kenneth Moose, Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose and Washington Square Financial, LLC d/b/a Imperial Structured Settlements, by and through attorney Vanya Dugalic, Esq., hereby jointly petition this Honorable Court for approval of a transfer of structured settlement payment rights pursuant to the Pennsylvania Structured Settlement Protection Act, 40 P.S. § 4000 et seq., and in support thereof respectfully represents as follows: Payees, Kenneth E. Moose, Sr. a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose are adult individuals who reside at 799 Old Silver Spring Road, Mechanicsburg, PA 17055-2883 and 51 West Cabin Hollow Road, Unit 3, Dillsburg, PA 17019-9777, respectively. Payees have executed a Sworn Affidavit. A true and correct copy of that document is attached hereto, made apart hereof, and marked as Exhibit "A". 9?•oo pct ? J C Al 3/P g P-- b-L 2 66 ,E 2. Transferee, Washington Square Financial, LLC d/b/a Imperial Structured Settlements, is a Georgia limited liability company with a primary place of business at 701 Park of Commerce Boulevard, Suite 301, Boca Raton, FL 33487. 3. Payees are the beneficiaries of an annuity owned by Transamerica Annuity Service Corporation and issued by Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company. The structured settlement provides payment to the Payees as follows: Monthly payments in the amount of $425.00 commencing on or about January 8, 2008 and continuing for life only and 1 lump sum payment of $25,000.00 due and payable on or about January 8, 2013. COUNTI 4. Payees propose to enter into an Absolute Sale and Security Agreement ("Purchase Agreement") with Transferee. A copy of the Purchase Agreement is attached hereto, made apart hereof, and designated as "Exhibit B". The Purchase Agreement proposes that Transferee will purchase Payees' structured settlement (250 life contingent monthly payments of $425.00 commencing on or about January 8, 2012 and ending on or about October 8, 2032 ("Assigned Payments #I"). 5. The net amount payable to Payees on Assigned Payments #1 (the life- contingent payments) is $21,193.87. Based on the net amount that the Payees will receive from this transaction ($21,193.87) and the amounts and timing of the structured settlement payments that would be assigned, the Payees are, in effect, paying interest at a rate of 25.30% per year. COUNT II 6. Payees propose to enter into an Purchase Agreement with Transferee, which will purchase Payees' structured settlement; and 1 lump sum payment of $25,000.00 due and payable on or about January 8, 2013 ("Assigned Payments #2") 7. The net amount payable to Payees on Assigned Payment #2 is $18,928.27. Based on the net amount that the Payees will receive from this transaction ($18,928.27) and the amounts and timing of the structured settlement payments that would be assigned, the Payees are, in effect, paying interest at a rate of 24.30% per year. 8. Transferee furnished Payees with a Disclosure Statement pursuant to 40 P.S. 4003 ( See "Exhibit B") at least ten (10) days prior to the date on which Payees first incurred any obligation to the Transferee. The Statute also requires a Petition and Court Order, authorizing the sale and finding the sale is in the best interest of the Payees. 9. Payees jointly with Transferee have served written notice of the Transferee's name, address, and tax identification number, to the structured settlement obligor and issuer. A true and correct copy of said notices is attached hereto, made apart hereof, and designated as "Exhibit C". 10. Payees' best interest would be served by granting relief requested herein so that Payee, Kenneth E. Moose, Sr. a/k/a Kenneth Moose may be able to invest in his business and pay off medical debts. (see "Exhibit A"). 11. Payees have been advised to obtain independent professional representation concerning the legal, tax and financial implications of this transaction, including advice on any tax ramifications from this transaction, and has waived such representation. A true and correct copy of the Statement of Professional Representation is attached hereto, made apart hereof, and designated as "Exhibit D". 11. Payees do not have any dependents. 12. The proposed transfer does not contravene any federal or state statute or the Order of any court or responsible governmental or administrative authority. WHEREFORE, Petitioners respectfully request this Honorable Court to approve and authorize the sale of a structured settlement payment stream between Transamerica Annuity Service Corporation (issued by Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company) and Kenneth E. Moose, Sr. a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose to be sold and transferred to Imperial Structured Settlements' designated assignee. Date: /0 `l ! Res ectfully submitted; - Vanya Dugalic, Esquire Attorney for Joint Petitioner Imperial Structured Settlements VERIFICATION I, Dustin Nelson, Operations Manager for Imperial Structured Settlements, have read the foregoing Petition to Transfer Structured Settlement Payment Rights and hereby aver that the statements contained therein are true and correct to the best of my knowledge, information and belief. This Verification is made subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to the unsworn falsification to authorities. >SwA' 11?1 )e b" n Nelson CERTIFICATION OF ATTORNEY FOR TRANSFEREE I, Vanya Dugalic, Esquire, attorney for Transferee, Imperial Structured Settlements, hereby certify to the best of my knowledge, information and belief, formed after reasonable inquiry, that the transfer will comply with the requirements of the Act and will not contravene any other applicable federal or state statute or regulation or the order of any court or administrative authority. I verify that the statements made in this certification are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904, relating to unsworn falsification to authorities. Date: ( ti a7, u KENNETH E. MOOSE, SR. MARY C. MOOSE 799 Old Silver Spring Road Mechanicsburg, PA 17055-2883 Pro se DUGALIC & LANDAU, PC Vanya Dugalic, Esquire Attorney I.D. No. 89914 Mark A. Landau, Esquire Attorney I.D. No. 90757 901 Carroll Rd. Wynnewood, PA 19096 (484) 412-8242 Attorneys for Joint Petitioner Imperial Structured Settlements IN RE: KENNETH E. MOOSE, SR. a/k/a KENNETH MOOSE & MARY C. MOOSE a/k/a MARY C. HARLING - JORDAN a/k/a MARY MOOSE & WASHINGTON SQUARRE FINANCIAL, LLC d/b/a IMPERIAL STRUCTURED SETTLEMENTS CUMBERLAND COUNTY COURT OF COMMON PLEAS 2011 : No. FINAL ORDER OF COURT On this day of 201 it is ordered that the Petition for Court Approval for Transfer of Structured Settlement Payment Rights is granted. The Court specifically finds that: the payee has established that the transfer is in the best interest of the payee or the payee's dependents; 2. based on the certification by an attorney for the transferee, and the court having not been made aware of any statute, regulation or order that would be incompatible with the proposed order, the transfer will not contravene any applicable federal or state statute or regulation, or the order of any court or administrative authority; 3. the transfer complies with the remaining requirements of the Structured Settlement Protection Act, including Sections 3(a)(20, 3(a)(4), 3(a)(5) and 3(a)(6); 4. the payments are to be transferred to Washington Square Financial, LLC, d/b/a, Imperial Structured Settlement at 701 Park of Commerce Boulevard, Suite 301, Boca Raton, FL 33487 and are designated as follows: 250 life contingent monthly payments of $425.00 commencing on or about January 8, 2012 and ending on or about October 8, 2032 ("Assigned Payments #1"); and 1 lump sum payment of $25,000.00 due and payable on or about January 8, 2013 ("Assigned Payment #2") the terms of this order shall survive the death of the payee and shall be binding on the payee's heirs, beneficiaries and assigns; 6. the payee shall receive from the transferee, as of , the amount of $40,122.14, from which no funds are owed for counsel fees, administrative fees, or other costs, fees or expenses. BY THE COURT: KENNETH E. MOOSE, SR. MARY C. MOOSE 799 Old Salver Spring Road Mechanicsburg, PA 17055-2883 Pro se DUGALIC & LANDAU, PC Vanya Dugalic, Esquire Attorney I.D. No. 89914 Mark A. Landau, Esquire Attorney LD. No. 90757 901 Carroll Rd. Wynnewood, PA 19096 (484) 412-8242 Attorneys for Joint Petitioner Imperial Structured Settlements IN RE: KENNETH E. MOOSE, SR. a/k/a KENNETH MOOSE & MARY C. MOOSE a/k/a MARY C. HARLING - JORDAN a/k/a MARY MOOSE & WASHINGTON SQUARRE FINANCIAL, LLC d/b/a IMPERIAL STRUCTURED CUMBERLAND COUNTY COURT OF COMMON PLEAS 2011 SETTLEMENTS : No. CERTIFICATE OF SERVICE It is hereby certified that on this U day of b , 2011, a copy of the Petition to Transfer Structured Settlement Payment Rights has been mailed by U.S. First Class Certified Mail to the following: Kenneth E. Moose, Sr 799 Old Silver Spring Road Mechanicsburg, PA 17055-2883 Mary C. Moose 51 West Cabin Hollow Road Unit 3 Dillsburg, PA 17019-9777 Transamerica Life Insurance Company & Transamerica Annuity Service Corporation 4333 Edgewood Road Cedar Rapids, IA 52499 Esquire EXHIBIT "A" IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA PETITION OF WASHINGTON SQUARE ) FINANCIAL LLC d/b/a IMPERIAL ) STRUCTURED SETTLEMENTS ) No. TRANSFER STRUCTURED ) SETTLEMENT PAYMENT RIGHTS ) PAYEE'S AFFIDAVIT IN SUPPORT OF PETITION TO TRANSFER STRUCTURED SETTLEMENT PAYMENT RIGHTS We, Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose the payees, verify that the statements below are true and correct. 1. Payee's name, address and age: L Kenneth E. Moose a/k/a Kenneth Moose, am 63 -years old my current address is: 799 Old Silver Spdigg Road, Mechanicsburg, PA 17055-2883 and I Mary C Moose a/k/a Marv C. Harling-Jordan a/k/a Marv Moose, am 58 years old my current address is: 51 West Cabin Hollow Road, Unit 3, Dillsbm. PA 17019-9777 2. Marital Status: Never Married; X Married (Kenneth) ; X Married (Mary); Separated; Divorced etl? If married or separated, name of spouse: I. Kenneth E. Moose gLVA Kenn Moose's spouse is Rita Renee Moose and L Mary C. Moose a/k/a Mary C. Harling- Jordan a/k/a Mar +Moose's spouse isRpbert Jordan 3. Minor children and other dependents: Names, ages, and places of residence: I Kenneth E. Moose a/k/a Kenneth Moose do not have any dependents, 1. Marv C. Moose a/k/a Mary C. Harling- Jordan a/k/a Marv Moose do not have any dependents 4. Income: (a) Payee's monthly income and sources: I. Kenneth E. Moose a/k/a Kenneth Moose am the owner operator of K. Moose En rises with a monthly income ofdproximately $2 500 00 I Marv C Moose a/k/a Maly C Harting Jordan a/!c/a Mary Moose am a nurse with a mo"Ibly income of approximately $1,464,00. (b) If presently married, spouse's monthly income and sources: I. Kenneth E Moose a/k/a Kenneth Moose's spouse. Rita Renee Moose, is employed with monthly earnings of approximately $2,500.00. I Marv C Moose a/k/a Marv C Harling-Jordan a/k/a Mary Moose's spouse Robert Jordan, is employed with monthly earnings of $3.166.66. 5. Child support, alimony or alimony pendente llte: Obligation to pay: Yes X No (Kenneth) X No (Mary) . If yes, state the amount of the obligation, to whom payable, and whether there are arrearages: 6. Previous transfers: Have you previously filed a petition to sell and transfer payment rights under the structured settlement that is the subject of this petition? Yes X No If yes, for each petition that you filed, (a) If the transfer was submitted for court approval, list the court, the case caption and case number, and state whether the court approved or disapproved the sale and transfer: (b) If the sale and transfer was approved, (i) State the name of the transferee and identify (listing due dates and payment amount(s)) the payments involved in the sale and transfer: (c) Have you ever sold or transferred payments without court approval? If so, please explain: 7. Reasons for sale and transfer: Describe in detail your reasons for the proposed sale and transfer, including an explanation as to why a sale and transfer of a lesser amount of the structured settlement amount will not better serve your interests: L Kenneth E. Moose a/k/a Kenneth Moose, intend to use the pMeeeds we receive from Imperial under the Agreement to invest in my business and pay off medical debt. As stated above, I, Kenneth, am the owner operator of K. Moose Enterprise. I, Kenneth, will use appr i a?tely $35,000.00 to purchase outright a pick-un truck and enclosed trailer. I believe that with this investment I can make my business grow sifrniflontly and Yield a return in the form of inefgased personal income. Next, I, Kenneth, will use the remaining funds of approximately $5,122.14 to pay off medical debtas the resulting financial stress is causing me a get deal of anxiety. I wish to do everything I can to alleviate the added worry this is causing me. With the proceeds of this transaction I will be able to eliminate these obligations hindering my financial stability, Therefore we have decided to pursue this transaction with Imperial. 8. Payment of debts: If you seek the sale and transfer in order to pay debts, list each debt, including the name of the creditor and the amount presently owed: Debt Creditor Amount Owed Verification I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsifications to authorities. DATE: Z&-?, A?',?k-,4. ,y - Signature Kenneth E. Moose a/k/a Kenneth Moose J ll C. DATE: Sign Mary C. Moose awa Mary C. Harling-Jordan wk/a Mary Moose EXHIBIT "B" ABSOLUTE SALE AND SECURITY AGREEMENT (THE "AGREEMENT") 10/16/2011 We, Kenneth E. Moose alkla Kenneth Moose residing at 799 Old Silver Spring Road, Mechanicsburg, PA 17055-2883 and Mary C. Moose alkla Mary C. Harting-Jordan a/k/a Mary Moose, residing at 51 West Cabin Hollow Road, Unit 3, Dillsburg, PA 17019-9777 (Collectively Hereinafter "I", "Me" or "Seller"), am entitled to Monthly payments of $425.00 commencing on or about January 8, 2008 and continuing'for life only; 1 lump sum payment of $25,000.00 due and payable on or about January 8, 2013 (the "Periodic Payments"), which I am receiving as a result of the settlement of a personal injury claim. The terms of the settlement are set forth in an agreement (the "Settlement Agreement"). The Periodic Payments are due to Me from Transamerica Annuity Service Corporation (the "Settlement Obligor"). The Settlement Agreement provides for the Periodic Payments to be paid to Me through an annuity issued by Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company (the "Annuity Issuer), bearing Annuity Contract Number 8721031872103T001Z. A. I agree to sell and transfer to Washington Square Financial, LLC dba Imperial Structured Settlements ("You "or "Purchaser") all of my rights to and interest in the following payments, which I am due to receive under the Settlement Agreement 250 life contingent monthly payments of $425.00 commencing on or about January 8, 2012 and ending on or about October 8, 2032; AND 1 lump sum payment of $25,000.00 due and payable on or about January 8, 2013 ("the Settlement Payments") In consideration for selling and transferring to You my rights to receive these payments, You shall pay Me the sum of: $42,322.14 (the "Purchase Price"). B. I hereby make the following unconditional representations, warranties and promises: 1. No one other than Me has any interest or claim of any kind or nature in, to or under the Settlement Payments. 2. 1 am not indebted to anyone that would in any way affect either the sale and transfer of the Settlement Payments referenced above or Purchaser's absolute rights to receive the Settlement Payments. 3. 1 agree to conduct my affairs so as to ensure that You receive the Settlement Payments exactly as described in Paragraph A above. C. I understand and agree that I will be in breach of this Agreement If: 1. Any of the representations set forth In Paragraphs B (1) and B (2) at any time turn out to be untrue. 2. 1 fail to perform the promise set forth in Paragraph B (3) above. 3. Either the Settlement Obligor or the Annuity Issuer refuses or fails to make any one or more of the Settlement Payments as a result of any act by Me, my estate, my representatives, or any of my heirs. 4. 1 fail to promptly forward to You any of the Settlement Payments that might be received by Me from the Settlement Obligor or the Annuity Issuer after the sale and transfer to You has been completed. 5. 1 fail to fulfill any other obligation of mine under this Agreement. D. Your obligation to complete this transaction, and to pay Me the Purchase Price depends upon the following conditions being satisfied unless waived by You. 1. You shall be satisfied, in Your sole reasonable judgment, that there are no claims or interests of any kind or nature that do or could affect rights to or interest in the Settlement Payments and/or prevent or interfere with Your receipt of the Settlement Payments on the dates and in the amounts described above Paragraph A, exactly in such amounts and at the times set forth therein. 2. You have received a final non-appealable court order and/or a signed acknowledgment from Settlement Obligor and Annuity Issuer satisfactory to the Purchaser in its sole discretion (collectively referred to as the "Order"), which You, in Your sole judgment, consider sufficient to recognize, authorize, and provide for the transfer by sale of the Settlement Payments (which may continue to be made out to my name) to You, Purchaser, and to insure that the Periodic Payments due on or after the day of the Order will be forwarded directly to You. E. Security Interest Seller and Purchaser intend that the sale of the Settlement Payments referenced above shall constitute a "sale" from the Seller to the Purchaser under applicable law, which sales are absolute and irrevocable and provide the Purchaser with all indicia and rights of ownership of the Settlement Payments. Neither the Seller nor the Purchaser intends the transactions contemplated hereunder to be, or for any purpose to be characterized as, loans from the Purchaser to the Seller secured by the Settlement Payments. If, notwithstanding the intention of the parties expressed above, any sale by the Seller to the Purchaser of the Settlement Payments shall be characterized as a secured loan and not a valid sale or absolute transfer or such sale or transfer shall for any reason be ineffective or unenforceable, then this Agreement shall be deemed to constitute a security agreement under the UCC and other applicable law in the rights to and interest in payments due to Me under the Settlement Agreement which I am selling to You under this Agreement. This security interest secures payment of the rights sold by Seller to Purchaser and the performance of Seller's obligations above. Seller authorizes Purchaser to direct any account debtor or obligor on an instrument, without limitation, Settlement Obligor or Annuity Issuer, to make periodic payments directly to Purchaser and as contemplated by the Uniform Commercial Code. Purchaser is authorized to file a UCC-1 Financing Statement to perfect Purchaser's rights and the security interest intended to, be created under this Agreement. F. Except as otherwise required by applicable statutory law, this Agreement shall be governed by and interpreted in accordance with the law of the state of residence of the Seller on the date of this Agreement. ARBITRATION Any and all controversies, claims, disputes, rights, interests, suits or causes of action arising out of or relating to this Agreement and the negotiations related thereto, or the breach thereof, shall be settled by binding arbitration administered by the American Arbitration Association. The demand for arbitration shall be filed in writing with the other party to this Agreement and with the American Arbitration Association offices in your state of residence. The arbitration shall be held in the largest city in your state of residence. The arbitration shall be held before a single arbitrator selected in accordance with the Commercial Arbitration Rules of the American Arbitration Association in effect at the time that the demand for arbitration is filed. Discovery, specifically including interrogatories, production of documents and depositions shall be at the discretion of the arbitrator and to the extent permitted shall be conducted in accordance with, and governed by the f=ederal Rules of Civil Procedure. A demand for arbitration shall be made within a reasonable time after the claim, dispute or other matter in question has arisen. In no event, shall the demand for arbitration be made after the date when institution of legal or equitable proceedings based on such claim, dispute or other matter in question, would be barred by the applicable statute of limitations. No arbitration arising out of or relating to this Agreement shall include, by consolidation or joinder or in any other manner, an additional person or entity not a party to this Agreement, except by written consent of the parties hereto, containing a specific reference to this Agreement and signed by the entity sought to be joined. Consent to arbitration involving an additional person or entity shall not constitute consent to arbitration of any claim, dispute or other matter In question not described in the written consent or with a person or entity not named or described therein. The foregoing agreement to arbitrate and other agreements to arbitrate with an additional person or entity duly consented to by parties to this Agreement, shall be specifically enforceable in accordance with applicable law in any court having jurisdiction thereof. The award rendered by the arbitrator shall be final, and judgment may be entered upon it in accordance with applicable law in any court having jurisdiction thereof. Such arbitrator shall identify the substantially prevailing party and shall include legal fees and expenses for the substantially prevailing party. This provision does not apply to the extent inconsistent with applicable state law regarding the transfer of structured settlement payments. In such case any disputes between the parties will be governed in accordance with the laws of the domicile state of the payee and the domicile state of the payee is the proper venue. G. I hereby grant You an Irrevocable Power of Attorney with full powers of substitution to do all acts and things that I . might do regarding the Settlement Payments, and any and all rights I have under the Settlement Agreement. I understand and intend that by doing so, I am giving You all of the power and right I'currently have under the Settlement Agreement to endorse checks, drafts or other instruments, to alter, edit and change payment instructions and/or beneficiary designations, and/or to perform any other act in my name that in Your sole discretion as my Attorney-in-Fact is necessary or expedient for You to obtain all of the benefits of the bargain contemplated by this transaction. This power of attorney is coupled with an Interest and shall survive my death or disability. H. Payments Received by Party father Than the Party Intended to Receive the Payments. 1. If prior to the completion of the transfer provided for in this Agreement, I receive any of the Settlement Payments or any portion thereof, I understand and agree an equal amount shall be deducted from the Purchase Price, and the Purchase Price shall be reduced in the same amount as these payments, and that the terms of this Agreement regarding the payments to be assigned, shall be treated as amended to reflect for the adjusted amount. 2. In the event You receive or otherwise come into possession of any of the Periodic Payment(s) or portlon(s) thereof which are not included in the payments being absolutely sold to You pursuant to this Agreement, You agree to forward such amount(s) to Me at the address set forth above within seven (7) days of receipt of such amount(s). 1. You shall be entitled to, and are authorized by Me to discharge any liens or adverse claims against Me or any of the Settlement Payments, whether of not such adverse claims are disclosed, .and You are further authorized by Me, provided You furnish prior written notice to Me, to pay any and all amounts necessary or if the Purchase Price has been deposited into an escrow account, to instruct the escrow agent to pay any and all amounts necessary to discharge such liens or other adverse claims. I understand and agree that any such amounts that You pay are payments You are making on my behalf and shall reduce the Purchase Price. Adverse claims may include disclosed amounts to be deducted by You from the Purchase Price to pay You, as servicer for Washington Square Financial, LLC dba imperial Structured Settlements, to enable Me to obtain Washington Square Financial, LLC dba Imperial Structured Settlements' release of its encumbrance on a portion of the Settlement Payments relating to a prior transfer transaction(s) that occurred before the enactment of the applicable statue ("Transfer Act's regulating such transfers. I understand and acknowledge that the law currently in effect requires that such encumbrance be released in order to complete the transfer that Is the subject of this Agreement. J. This Agreement shall take effect on the date it is signed by Me (the Seller) or on such later date prescribed by applicable law. K. All disclosure statements I receive from You in connection with this transaction are a material part of this Agreement and shall be considered part of the terms of this Agreement and shall be read as if the contents of the disclosure statement were set forth in full in the body of this Agreement. L. I know that it will take some time for the Settlement Obligor and the Annuity Issuer to receive and process the court order once it is granted. i would like to receive the Purchase Price or a portion thereof as soon as possible thereafter. Accordingly, I hereby request Purchaser to pay Me a portion of the Purchase Price as soon as possible after the court order is granted and authorize Purchaser to hold in escrow an amount it deems necessary or advisable from the Purchase Price (the "Escrow Amount") until all conditions precedent have been satisfied, including, without limitation, the receipt by Purchaser of the Settlement Obligor and the Annuity Issuer's acknowledgment of the terms of the court order in writing and their agreement to honor and comply with same. At such time or earlier as Purchaser may determine, I understand that Purchaser will send the Escrow Amount to Me minus any Settlement Payments that the Annuity Issuer and/or Settlement Obligor sent to Me. while the Settlement Obligor and the Annuity Issuer were processing the court order. M. I have the right to cancel this Agreement, without penalty or further obligation, within the first three business days after the date the Agreement is signed, by providing You with written notice within three (3) day period, as provided for in Paragraph N. N. All notices, demands, and other communications required or permitted under this Agreement must be made in writing, and delivered by hand, via the United States Post Office, Certified Mail, Return Receipt Requested, or by overnight delivery service, to You or Me as the recipient at the address set forth in the beginning of this Agreement and must be. evidenced by a receipt showing time, date of delivery and the person receiving the delivery. In witness whereof I hereunto set my hand. C?? r/ Fr. o&a/k/a Mary C. Harling- Z& C Kenneth . Moo fie alkla en eth Moose ` M . M J ?J / ordan alkla Mary Moose STATE OF! eu ?yS JVQ ?V I -A _ COUNTY OR CITY OF?R 14 ovd( On the _ All, day of © 0 41t . in the year 2 i t before me, the undersigned, personally appeared Kenneth E. Moose a/k/a Kenneth Moose, personally known to me, or proved to me on the basis of satisfactory evidence to the individuals(s) whose name(s) Is (are) subscribed to the within instrument, and acknowledged to me that he/shelthey executed the same in his/her/their capacity(€es), and that by his/her/their signature(s) on the Instrument, the individuals(s), or the person upon behalf of which the individual (s) acted, executed the instrument. STATE OF PCNA!S ,A COUNTY OR CITY OF kjk bt'Rk&t On the 1101 day of O AD bell in the year 2a l l before me, the undersigned, personally appeared Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose, personally known to me, or proved to me on the basis of satisfactory evidence to the Individuals(s) whose name(s) is (are) subscribed to the within Instrument, and acknowledged to me that he/she/they executed the same In his/her/their capacity(ies), and that by h€s/her/their signature(s) on the instrument, the individuais(s), or the person upon behalf of which the individual (s) acted, executed the instrument. OZ%4,4 Lft:7 ??n ad. ?? ?e" Notary Notary My Commission expires on 7-9 Ta K Zoi s- My Commission expires on lam Z oII NOTARIAL SEAL ARTHUR JAMES JONES PLEASE DO NOT SIGN THIS Notary Public DOCUMENT UNTIL 10/1612011 HAMPOEN TWP, CUMBERLAND COUNTY My Commfsslon Expires Jan 28, 2045 Accepted: Washington Square Financial, LLC dba Imperial Structured Settlements 71? .6 Tme 4Date: Jc t t ?yt.' DISCLOSURE STATEMENT PENNSYLVANIA DATE PROVIDED: 9/2912011 PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose This Disclosure Statement is being provided by Washington Square Financial, LLC dba IMPERIAL STRUCTURED SETTLEMENTS ("Imperial" or "Us") to Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose, ("Payee" or "You") in connection with Payee's agreement to transfer and sell to Imperial certain structured settlement payment rights due Payee. 1. Schedule of Payments Transferred. The Payee intends to transfer or sell to Imperial all of Payee's rights, title and interest in the following payments: 250 life contingent monthly payments of $425.00 commencing on or about January 8, 2012 and ending on or about October 8, 2032 2. Auregate Amount of Payments Transferred. The aggregate amount of payments to be sold and transferred to Imperial totals $106,250.00. 3. Discounted Present Value. The discounted present value of the aggregate payments sold and transferred at 2.00% is $86,659.04. The discounted present value is the calculation of current value of the sold and transferred structured settlement payments under federal standards for valuing annuities. THIS IS NOT THE RATE USED TO CALCULATE THE PURCHASE PRICE. 4. Calculation of Discounted Present Value. The discounted present value of payments shall be calculated as follows: The applicable federal rate used in calculating the discounted present value is 2.00%.. 5. Gross Amount Payable. In exchange for these payments, the Payee will receive the gross amount of $22,293.87, which represents a nominal annual discount rate of 21.71% assuming monthly compounding and an assumed funding date of 9/29/2011. Funding will not occur until everything necessary under the Absolute Sale and Security Agreement has taken place. 6. Fees and Expenses. The Payee will be responsible for the following approximate commissions, charges, fees, expenses, and costs in connection with the closing of this transaction: Legal Fees - $1,000.00 Processing Fees - $ 100.00 Insurance Company Administration Fee paid to Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company to be paid by Imperial, NOT customer: $750.00 7. Net Amount-Payable . The net amount payable to Payee after the deduction of all commissions, fees, costs, expenses and charges described in paragraph 6 of this disclosure is $21,193.87. 8. uotient. The net amount that you will receive from us in exchange for your future structured settlement payments represents 24.46% of the estimated current value of the payments based upon the discounted value using the applicable federal rate. The quotient is 24.46%. 9. Effective Annual Interest Rate: Based on the net amount that you receive from us and the amounts and timing of the structured settlement payments that you are selling to us, you will, in effect, be paying interest to us at a rate of 25.30% per year. 10. Penalty In The Event Of Breach Of Contract. The amount of any penalty and the aggregate amount of any liquidated damages (inclusive of penalties), payable to Imperial, by the Payee in the event of the Payee's breach of the transfer agreement are NONE. 2 11. Independent Professional Advice. The Payee has been advised to consult with Payee's own attorney, certified public accountant, actuary, or other professional adviser concerning the legal, tax, and financial implications of a sale and transfer of structured settlement payment rights, including the federal and state income tax consequences of a sale and transfer. I have read and understand everything set forth in this Disclosure Statement. Kenneth E. Moose a/k/a Kenneth Moose Maif C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose Dated: Dated: /C)19/? br/ [The remainder of this page intentionally left blank] 3 DISCLOSURE STATEMENT IOWA DATE PROVIDED: 9/29/2011 PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose This Disclosure Statement is being provided by Washington Square Financial, LLC dba IMPERIAL STRUCTURED SETTLEMENTS ("Imperial" or "Us") to Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose, ("Payee" or "You") in connection with Payee's agreement. to transfer and, sell to Imperial certain structured settlement payment rights due Payee. 1. Schedule of Payments Transferred. The Payee intends to transfer or sell to Imperial all of Payee's rights, title and interest in the following payments: 250 life contingent monthly payments of $425.00 commencing on or about January 8, 2012 and ending on or about October 8, 2032 2. Ag regate Amount of Payments Transferred. The aggregate amount of payments to be sold and transferred to Imperial totals $106,250.00. 3. Discounted Present Value. The discounted present value of the aggregate payments sold and transferred at 2.00% is $86,659.04. The discounted present value is the calculation of current value of the sold and transferred structured settlement payments under federal standards for valuing annuities. THIS IS NOT THE RATE USED TO CALCULATE THE PURCHASE PRICE. 4. Calculation of Discounted Present Value. The discounted present value of payments shall be calculated as follows: The applicable federal rate used in calculating the discounted present value is 2.00%. 5. Gross Amount Payable. In exchange for these payments, the Payee will rocelve the gross amount of $22,293.87, which represents a nominal annual discount rate of 21.71% assuming monthly compounding and an assumed funding date of 9/29!2011. Funding will not occur until everything necessary under the Absolute Sale and Security Agreement has taken place. 6. Fees and Expenses. The Payee will be responsible for the following approximate commissions, charges, fees, expenses, and costs in connection with the closing of this transaction: Legal Fees - $1,000.00 Processing Fees - $ 100.00 Insurance Company Administration Fee paid to Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company to be paid by Imperial, NOT customer: $750.00 7. Net Amount Payable. The net amount payable to Payee after the deduction of all commissions, fees, costs, expenses and charges described in paragraph 6 of this disclosure is $21,193.87. 8. Right To Cancel. The Payee shall have the right to cancel the Absolute Sale and Security Agreement, without penalty or further obligation, not later than the third (3r) business day, after the Absolute Sale and Security Agreement is signed by the Payee. 9. Penalty In The Event Of Breach Of Contract. The amount of any penalty and the aggregate amount of any liquidated damages (inclusive of penalties), payable to Imperial, by the Payee in the event of the Payee's breach of the transfer agreement are NONE. 10. Independent Professional Advice. The Payee has been advised to consult with Payee's own attorney, certi0ed public accountant, actuary, or other professional adviser concerning the legal, tax, and financial implications of a sale and transfer of structured settlement payment rights, including the federal and state income tax consequences of a sale and transfer. I hay read a yd underst? nd everything R enneth E. Moose a/k/a Kenneth Moose Dated: ?U q set forth in this Disclosure tatement. C• IMA C. Moose a/k/a Mary C. Harling-Jordan aAda Mary Moose Dated: 2 DISCLOSURE STATEMENT NEW MEXICO DATE PROVIDED: 9/29/2011 PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose This Disclosure Statement is being provided by Washington Square Financial, LLC dba IMPERIAL STRUCTURED SETTLEMENTS ("Imperial" or "Us") to Kenneth E. Moose alk/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling Jordan a/k/a Mary Moose, ("Payee" or "You") in connection with Payee's. agreement to transfer and sell to Imperial certain structured settlement payment rights due Payee. 1. Schedule of Payments Transferred. The Payee intends to transfer or sell to Imperial all of Payee's rights, title and interest in the following payments: 250 life contingent monthly payments of $425.00 commencing on or about January 8, 2012 and ending on or about October 8, 2032 2. Aggregate Amount of Payments Transferred. The aggregate amount of payments to be sold and transferred to Imperial totals $106,250.00. 3. Discounted Present Value. The discounted present value of the aggregate payments sold and transferred at 2.00% is $86,659.04. The discounted present value is the calculation of current value of the sold and transferred structured settlement payments under federal standards for valuing annuities. THIS IS NOT THE RATE USED TO CALCULATE THE PURCHASE PRICE. 4. Calculation of Discounted Present Value. The discounted present value of payments shall be calculated as follows: The applicable federal rate used in calculating the discounted present value is 2.00%. 5. Gross Amount Payable. In exchange for these payments, the Payee will receive the gross amount of $22,293.87, which represents a nominal annual discount rate of 21.710/6 assuming monthly, compounding and an assumed funding date of 9/2912011, Funding will not occur until everything necessary under the Absolute Sale and Security Agreement has taken place. 6. Fees and Expenses. The Payee will be responsible for the following approximate commissions, charges, fees, expenses, and costs in connection with the closing of this transaction: Legal Fees - $1,000.00 Processing Fees - $100.00 Insurance Company Administration Fee paid to Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company to be paid by Imperial, NOT customer: $750.00 7. Net Amount Payable. The net amount payable to Payee after the deduction of all commissions, fees, costs, expenses and charges described in paragraph 6 of this disclosure is $21,293.87. 8. Right To Cancel. The Payee shall have the right to cancel the Absolute Sale and Security Agreement, without penalty or further obligation, not later than the third (3'd) business day, after the Absolute Sale and Security Agreement is signed by the Payee. 9. Penalty In The Event Of Breach Of Contract. The amount of any penalty and the aggregate amount of any liquidated damages (inclusive of penalties), payable to Imperial, by the Payee in the event of the Payee's breach of the transfer agreement are NONE. 10. Independent Professional Advice. The Payee has been advised to consult with Payee's own attorney, certified public accountant, actuary, or other professional adviser concerning the legal, tax, and financial implications of a sale and transfer of structured settlement payment rights, including the federal and state income tax consequences of a sale and transfer. I have read and understand everything set forth in this Disclosure Statement. c ,/?,/ / Kenneth E. Moose a/k/a Kenneth Moose Dated: //4 2 C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose Dated: DISCLOSURE STATEMENT PENNSYLVANIA DATE PROVIDED: 9/29/2411 PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose This Disclosure Statement is being provided by Washington Square Financial, LLC dba IMPERIAL STRUCTURED SETTLEMENTS ("Imperial' or "Us") to Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose, ("Payee" or "You") in connection with Payee's agreement to transfer and sell to Imperial certain structured settlement payment rights due Payee. 1. Schedule of Payments Transferred. The Payee intends to transfer or sell to Imperial all of Payee's rights, title and interest in the following payments: 1 lump sum payment of $25,000.00 due and payable on or about January 8, 2013 2. Aggregate Amount of Payments Transferred. The aggregate amount of payments to be sold and transferred to Imperial totals $25,000.00. 3. Discounted Present Value. The discounted present value of the aggregate payments sold and transferred at 2.00% is $24,376.85. The discounted present value is the calculation of current value of the sold and transferred structured settlement payments under federal standards for valuing annuities. THIS IS NOT THE RATE USED TO CALCULATE THE PURCHASE PRICE. 4. Calculation of Discounted Present Value. The discounted present value of payments shall be calculated as follows: The applicable federal rate used in calculating the discounted present value is 2.00°l0, 5. Gross Amount Payable. In exchange for these payments, the Payee will receive the gross amount of $20,028.27, which represents a nominal annual discount rate of 17.52% assuming monthly compounding and an assumed funding date of 9!29/2011. Funding will not occur until everything necessary under the Absolute Sale and Security Agreement has taken place. 6. Fees and Expenses. The Payee will be responsible for the following approximate commissions, charges, fees, expenses, and costs in connection with the closing of this transaction: Legal Fees - $1,000.00 Processing Fees - $ 100.00 Insurance Company Administration Fee paid to Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company to be paid by Imperial, NOT customer: $750.00 7. Net Amount Payable. The net amount payable to Payee after the deduction of all commissions, fees, costs, expenses and charges described in paragraph 6 of this disclosure is $18,928.27. 8. uotient. The net amount that you will receive from us in exchange for your future structured settlement payments represents 77.65% of the estimated current value of the payments based upon the discounted value using the applicable federal rate. The quotient is 77.65%. 9. Effective Annual Interest Rate: Based on the net amount that you receive from us and the amounts and timing of the structured settlement payments that you are selling to us, you will, in effect, be paying interest to us at a rate of 24.30% per year. 10. Penalty In The Event Of Breach Of Contract. The amount of any penalty and the aggregate amount of any liquidated damages (inclusive of penalties), payable to Imperial, by the Payee in the event of the Payee's breach of the transfer agreement are NONE. 11. Independent Professional Advice. The Payee has been advised to consult with Payee's own attorney, certified public accountant, actuary, or other professional adviser concerning the legal, tax, and financial implications 2 of a sale and transfer of structured settlement payment rights, including the federal and state income tax consequences of a sale and transfer. I have read and understand everything set forth in this Disclosure Statement. Kenneth E. Moose a/k/a Mary C. Moose a/k/a Kenneth Moose Mary C. Harling-Jordan a/k/a l!l" Mary Moose Dated: l?lnz?j- _ Dated: /'b [The remainder of this page intentionally left blank] 3 DISCLOSURE STATEMENT IOWA DATE PROVIDED: 9/2912011 PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a.Wa Mary Moose This Disclosure Statement is being provided by Washington Square Financial, LLC dba IMPERIAL STRUCTURED SETTLEMENTS ("Imperial" or "Us") to Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose, ("Payee" or "You") in connection with Payee's agreement to transfer and sell to Imperial certain structured settlement payment rights due Payee. 1. Schedule of Payments Transferred. The Payee intends to transfer or sell to Imperial all of Payee's rights, title and interest in the following payments: 1 lump sum payment of $25,000.00 due and payable on or about January 8, 2013 2. Aggregate Amount of Payments Transferred. The aggregate amount of payments to be sold and transferred to Imperial totals $25,000.00. 3. Discounted Present Value. The discounted present value of the aggregate payments sold and transferred at 2.00% is $241376.85. The discounted present value is the calculation of current value of the sold and transferred structured settlement payments under federal standards for valuing annuities. THIS IS NOT THE RATE USED TO CALCULATE THE PURCHASE PRICE. 4. Calculation of Discounted Present Value. The discounted present value of payments shall be calculated as follows: The applicable federal rate used in calculating the discounted present value is 2.00%. 5. Gross Amount Payable. In exchange for these payments, the Payee will receive the gross amount of $20,028.27, which represents a nominal annual discount rate of 17.52% assuming monthly compounding and an assumed funding date of 9/29/2011.. Funding will not occur until everything necessary under the Absolute Sale and Security Agreement has taken place. 6. Fees and Expenses. The Payee will be responsible for the following approximate commissions, charges, fees, expenses, and costs in connection with the closing of this transaction: Legal Fees - $1,000.00 Processing Fees - $ 100.00 Insurance Company Administration Fee paid to Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company to be paid by Imperial, NOT customer: $750.00 . 7. Net Amount Payable. The net amount payable to Payee after the deduction of all commissions, fees, costs, expenses and charges described in paragraph 6 of this disclosure is $18,928.27. 8. Right To Cancel. The Payee shall have the right to cancel the Absolute Sale and Security Agreement, without penalty or further obligation, not later than the third (3rd) business day, after the Absolute Sale and Security Agreement is signed by the Payee. 9. Penalty In The Event Of Breach Of Contract. The amount of any penalty and the aggregate amount of any liquidated damages (inclusive of penalties), payable to Imperial, by the Payee in the event of the Payee's breach of the transfer agreement are NONE. 10. Independent Professional Advice. The Payee has been advised to consult with Payee's own attorney, certified public accountant, actuary, or other professional adviser concerning the legal, tax, and financial implications of a sale and transfer of structured settlement payment rights, including the federal and state income tax consequences of a sale and transfer. I have read and understand everything set forth in this Disclosure Statement. k14 Kenneth E. Moose a/k/a MWY C. Moose a/k/a Kenneth Moose Mary C. Harling-Jordan a/k/a Mary Moose Dated: Dated: /a??la4'// 2 DISCLOSURE STATEMENT NEW MEXICO DATE PROVIDED: 9/29/2011 PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose This Disclosure Statement is being provided by Washington Square Financial, LLC dba IMPERIAL STRUCTURED SETTLEMENTS ("Imperial" or "Us") to Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling Jordan a/k/a Mary Moose, ("Payee" or "You") in connection with Payee's agreement to transfer and sell to Imperial certain structured settlement payment rights due Payee. 1. Schedule of Payments Transferred. The Payee intends to transfer or sell to Imperial all of Payee's rights, title and interest in the following payments: I lump sum payment of $25,000.00 due and payable on or about January 8, 2013 2. Aggregate Amount of Payments Transferred. The aggregate amount of payments to be sold and transferred to Imperial totals $25,000.00. 3. Discounted Present Value. The discounted present value of the aggregate payments sold and transferred at 2.00% is $24,376.85. The discounted present value is the calculation of current value of the sold and transferred structured settlement payments under federal standards for valuing annuities. THIS IS NOT THE RATE USED TO CALCULATE THE PURCHASE PRICE. 4. Calculation of Discounted Present Value. The discounted present value of payments shall be calculated as follows: The applicable federal rate used in calculating the discounted present value is 2.00%. 5. Gross Amount Viable. In exchange for these payments, the Payee will receive the gross amount of $20,028.27, which represents a nominal annual discount rate of 17.52% assuming monthly . compounding and an assumed, funding date of 9/29/2011. Funding will not occur until everything necessary under, the Absolute Sale and Security Agreemept has taken place. 6. Fees and Expenses. The Payee will be responsible for the following approximate commissions, charges, fees, expenses, and costs in connection with the closing of this transaction: Legal Fees - $1,000.00 Processing Fees - $ 100.00 Insurance Company Administration Fee paid to Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company to be paid by Imperial, NOT customer: $750.00 7. Net Amount Payable. The net amount payable to Payee after the deduction of all commissions, fees, costs, expenses and charges described in paragraph 6 of this disclosure is $18,928.27. 8. Right To Cancel. The Payee shall have the right to cancel the Absolute Sale and Security Agreement, without penalty or further obligation, not later than the third (3rd) business day, after the Absolute Sale and Security Agreement is signed by the Payee. 9. Penalty In The Event Of Breach Of Contract. The amount of any penalty and the aggregate amount of any liquidated damages (inclusive of penalties), payable to Imperial, by the Payee in the event of the Payee's breach of the transfer agreement are NONE. 10. Independent Professional Advice. The Payee has been advised to consult with Payee's own attorney, certified public accountant, actuary, or other professional adviser concerning the legal, tax, and financial implications of a sale and transfer of structured settlement payment rights, including the federal and state income tax consequences of a sale and transfer. I have read and understand everything set forth in this Disclosure Statement. Kenneth E. Moose a/k/a a C. Moose a/k/a Kenneth Moose Mary C. Harling-Jordan a/k/a Mary Moosp Dated: a 19 la Dated: "d J.? 9 1a 0// 2 EXHIBIT "C" Notice to Annuity Issuer and Structured Settlement Obligor Transamerica Annuity Service Corporation Attn: Structured Settlements Legal Department, 4333 Edgewood Road Cedar Rapids, IA 52499 RE: Transfer of structured settlement rights Kenneth Moose and Mary C. Moose a/k, Mary Moose Annuity Contract #: 872103/872103TOOIZ DOB: 04/26/1948 Payments to be Transferred: Transamerica Life Insurance Company, successor by merger with Transamerica Occidental Life Insurance Company Attn: Structured Settlement Department, 4333 Edgewood Road Cedar Rapids, IA 52499 by Kenneth E. Moose Sr. a/k/a a Mary C. Harling-Jordan a/k/a 1 lump sum payment of $25,000.00 due and payable on or about January 8, 2013; AND 250 life contingent monthly payments of $425.00 commencing on or about January 8, 2012 and ending on or about October 8, 2032. This letter shall serve as formal notice to you, as required by PA ST 40 PS §4003(a)(6) of Kenneth E. Moose Sr. a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling- Jordan a/k/a Mary Moose pending transfer of certain structured settlement payment rights. Pursuant to PA ST 40 PS §4003(a)(6), the transferee's name and address is: Name: Washington Square Financial, LLC d/b/a Imperial Structured Settlements Address: 701 Park of Commerce Blvd., Suite 301 Boca Raton, FL 33487 Tax I.D.: 26-0207198 Any other statutory requirements that may apply to this transaction will also be complied with. 701 Park of Commerce Blvd., Suite 301 866.744.9881 www.fundmysettlement.com Boca Raton, Florida 33487 866.704.0772 Fax EXHIBIT "D" Notice (PA) PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose IMPORTANT NOTICE: You are strongly urged to consult with an attorney who can advise you of the potential tax consequences of this transaction. Kenneth 119. Moose a/k/a Kenneth Moose !a 4,416L Mary C. Harling-Jordan a/k/a 'MO y- Dated: 10// C. Moose a/k/a Mary Moose Dated: /ish q/cqD// [The remainder of this page intentionally left blank) 4 ACKNOWLEDGEMENT (PA) PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose (Please initial one) I have received independent legal advice regarding the implications of the transfer, including considerations of the tax ramification of the transfer: I expressly waive independent legal advice regarding the A imp ations of the transfer, including considerations of the tax ramifications of the transfer. I have received independent professional advice regarding the implications of the transfer, including considerations of the tax ramifications of the transfer. x/j,h . Moose a/k/a MWy C. oose a/k/a Kenneth Moose Mary C. Harling-Jordan a/k/a /<KA Mary Moose Dated: D r /I( Dated: /v<<g !/ 6 Notice PA PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose IMPORTANT NOTICE: You are strongly urged to consult with an attorney who can advise you of the potential tax consequences of this transaction. Kenneth E. Moose a/k/a Kenneth Moose 101 Dated: 1 6 Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose Dated : / v // cJ 020// [The remainder of this page intentionally left blank] 4 ACKNOWLEDGEMENT (PA) PAYEE: Kenneth E. Moose a/k/a Kenneth Moose and Mary C. Moose a/k/a Mary C. Harling-Jordan a/k/a Mary Moose (Please initial one) . I have received independent legal advice regarding the implications of the transfer, including considerations of the tax ramification of the transfer. ?I expressly waive independent legal advice regarding the imp ations of the transfer, including considerations of the tax ramifications of the transfer. I have received independent professional advice regarding the implications of the transfer, including considerations of the tax ramifications of the transfer. Kenneth . Moos a C. Moose a/k/a Kenneth Moose Mary C. Harling-Jordan a/k/a Mary Moose Dated: Dated: /d / 5 5 KENNETH E. MOOSE, SR. MARY C. MOOSE 799 Old Silver Spring Road Mechanicsburg, PA 17055-2883 Pro se DUGALIC & LANDAU, PC Vanya Dugalic Esquire ! r? ? (!I Qv_ Attorney I.D. No. 89914 Mark A. Landau, Esquire Attorney I.D. No. 90757 901 Carroll Rd. Wynnewood, PA 19096 (484) 412-8242 Attorneys for Joint Petitioner Imperial Structured Settlements C:) g, • . ; IN RE: KENNETH E. MOOSE, SR. a/k/a KENNETH MOOSE & MARY C. MOOSE a/k/a MARY C. HARLING - JORDAN a/k/a MARY MOOSE & WASHINGTON SQUARRE FINANCIAL, LLC d/b/a IMPERIAL STRUCTURED SETTLEMENTS CUMBERLAND COUNTY COURT OF COMMON PLEAS o o (?, j2011 No. V/ e 7 P-1? j Initial Order of Court On this JI day of , 2011, it is ordered that a hearing will be held on this Petition to Transfer Structured Settlement Payment Rights on ? rin Courtroom at 9. 36) o'clock. The payee shall bring income tax returns for the prior two (2) years to the hearing. Within seven (7) days, the transferee shall give notice to the hearing date to the payee, the structured settlement obligor, the annuity issuer, the payee's spouse and any person receiving child support, alimony, or alimony pendent lite. The transferee shall attach a certificate of service to the notice of hearing date. A copy of the notice with the certificate of service shall be filed with the Court prior to the hearing. BY E COURT: KENNETH E. MOOSE, SR. MARY C. MOOSE 799 Old Silver Spring Road Mechanicsburg, PA 17055-2883 Pro se DUGALIC & LANDAU, PC Vanya Dugalic, Esquire Attorney I.D. No. 89914 Mark A. Landau, Esquire Attorney I.D. No. 90757 901 Carroll Rd. j. r . Pl'i 2: t EF=tiLA,140 c0W-1T ., i-T NINSYLVAfjIA Wynnewood, PA 19096 (484) 412-8242 Attorneys for Joint Petitioner Imperial Structured Settlements IN RE: KENNETH E. MOOSE, SR. a/k/a KENNETH MOOSE & MARY C. MOOSE a/k/a MARY C. HARLING - JORDAN a/k/a MARY MOOSE & WASHINGTON SQUARRE FINANCIAL, LLC d/b/a IMPERIAL STRUCTURED SETTLEMENTS CUMBERLAND COUNTY COURT OF COMMON PLEAS 2011 : No. 11-8199 Civil Term CERTIFICATE OF SERVICE It is hereby certified that on this 1(0 day of UoVQ.M , 2011, a copy of the Petition and Notice of Hearing has been mailed by U.S. First Class Certified Mail to the following: Kenneth E. Moose, Sr. & Rita Renee Moose 799 Old Silver Spring Road Mechanicsburg, PA 17055-2883 V a Dugalic, Esquire