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017-010170994429 SG f
JUDGEMENT NOTE 10
Mechanicsburg , Pennsylvania, 12/26/2008 , $1,650.02
FOR VALUE RECEIVED, Uwe promise to pay to the order of Erie Insurance Group
the sum of One thousand six hundred fifty and 02/100 said sum to be payable said
sum to be as follows: Fifty dollars, ($50.00) on the 1st day of February, 2009 and
Fiftv dollars $50.00 on the 1St day of every month thereafter until the entire amount is
paid in full.
Uwe hereby authorize and empower any attorney of any Court of Record of Pennsylvania
or elsewhere, to appear for and confess Judgment against me for the sum due and payable
hereon, pursuant to PA. R.C.P. 2951 (a) (1) with or without declaration, with costs of
suit, interest at the rate of 6% per annum, an attorney's fee, release of errors, and without
stay of execution; and Uwe also waive the right of inquisition on any real estate that may
be levied upon to collect this note; and Uwe do hereby voluntarily condemn the same and
authorize the Prothonotary to enter said voluntary condemnation upon any Fieri Facias
that may be issued to collect said Judgment; and Uwe further agree that said estate may
be sold on a Fieri Facia.s, and Uwe do hereby waive and release all relief from any and all
appraisement, stay of execution, exemption or bankruptcy laws of this or any other state
now in force or hereafter to be passed.
Myrea a Burnette
(S.G.)
This note is given executed without duress or coercion and with full and complete
understanding that upon failure to make payment as agreed, that legal action may be
filed.
Further, I do hereby acknowledge that the damage incurred in the accident of
September 3, 2008, for which this note is given resulted from my negligence and fault,
and I do hereby acknowledge and waive my right to any hearing or trial on that issue,
X pia S.G.)
Myrea a Burnette
X (S.G.) cis
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017-010170994429 S.G.
AFFIDAVIT TO ACCOMPANY JUDGMENT NOTE
Being duly sworn according to law, the undersigned jointly and severally depose and say
that:
1. UWe are over twenty-one years of age, not within the military service of the
United States and its allies nor otherwise within the civil relief provision of
the Soldiers and Sailors Civil Relief Act of 1947 as amended.
2. UWe have delivered to Erie Insurance a Judgment Note containing a
confession of judgment to secure certain payment obligations.
3. UWe understand that a confession of judgment allows for the entry of a
judgment by confession against them and that said judgment encumbers all
real estate that they own.
4. The note is not related to a consumer credit transaction.
IN WITNESS WHEREOF and intending to induce Erie Insurance to complete the
transaction asovided, the undersigned have affixed their hands and seals on this
` h day of ?`i , 20_e!L.
X 3..7.7
M reatha Burnette
Sworn to and subscribed before me
This day of 'R?u i 200.
(SEAL)
J?n?_
Notary Public
CHE' HOSEA SWAYNE
NOTARY PUBLIC STATE OF MARYLAND
My Commission Expires March 30, 2011
017-010170994429 SG
DISCLOSURE FOR CONFESSION OF JUDGMENT
I/We, Myreatha Burnette am executing this 26th day of December ,
2008 , a Judgment Note for One thousand six hundred fifty and 02/100
($1,650.02 DOLLARS obligating me to repay that amount.
Initials: X A4, M.B.
Initials:
It has been explained to me by representative of the Erie Insurance Group that the Note
contains wording that may permit them or their attorneys to enter Judgment against me at
the Courthouse, whether or not said Note is in default, without notice to me and without
offering me an opportunity to defend against the Entry of Judgment, and that the
Judgment may be collected by any legal means.
/'I
Initials: X_/74, -
M.B.
Initials:
In executing the Note, I/We am knowingly, understandingly, and voluntarily waiving any
rights to resist the Entry of Judgment against me at the Courthouse, and am consenting to
the Confession of Judgment.
Initials: X 1
M.B.
Initials:
017-010170994429 S.G.
I certify that my annual income (exceeds/is less than) TEN THOUSAND AND 00/100
DOLLARS, that the blanks in this disclosure were filled in when I initiated and signed it,
and that I received a copy at the time of signing.
Myreat a Burnette
Date: X ,2 -'/ - b 9
ACKNOWLEDGMENT
Commonwealth of Pennsylvania
County of )
B fore me, the undersigned. Notary, personally appeared 44 y fcn (t,
v rrc4t-( , whose initials appear above, and who acknowledges under
oath that they executed the above Disclosure for Confession of Judgment together with
the Confession of Judgment Note referred to in the First Paragraph of the Disclosure on
this date.
(SEAII
Notary Public
My commission expires on the me day of ,20-a.
CHE' HOSEA SWAYNE
NOTARY PUBLIC STATE OF iii Y 01
My Commission Expires March 30.2011
017-010170994429 S.G.
CERTIFICATE OF RESIDENCE
The parties to the transaction are X?, p 'Y?bA tar r? e e
Name
X -13 6 Gy : f?rc KL? S f
Address
X
Address
X
Address
I certify that these are the last known addresses of the parties to this matter.
I --44 -? _y-?
By: X ?? ?,gGuz n e