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HomeMy WebLinkAbout11-9312I= 1.Ea- F 1 C E f ! a'ii i RO 1 HONOTA.7e i MASTER WEINSTEIN i I 1 DES; 19 F i I: SCHATZ MOYER, P.C. f 1 ER pIA HD C 0 U I 1 By: STEPHEN E. FARBER, ESQUIRE" E 5 Y L V A lAorney for Petitioner Attorney ID No: 17535 1818 Market Street, Ste. 3620 Philadelphia, PA 19103 Phone: 215-561-2800 Fax: 215-561-0012 MARTIN AND MICHELE HUGHES, IN THE COURT OF COMMON PLEAS OF h/w, p/n/g KATELYN HUGHES CUMBERLAND COUNTY, PENNSYLVANIA 1126 Dry Powder Circle Mechanicsburg, PA 17050 Plaintiffs V. NO. CIVIL ACTION - LAW SEARS, ROEBUCK AND CO. : 1515 Market Street Suite 1210 : Philadelphia, PA 19102 And SEARS STORE #02624 : 3595 Capital City Mall Camp Hill, PA 17011 : Defendant PETITION FOR COURT APPROVAL OF MINOR'S ACTION TO THE HONORABLE, THE JUDGES OF THE SAID COURT: The Petition of MARTIN AND MICHELE HUGHES, as parents and natural guardians to minor Plaintiff, KATELYN HUGHES, by her attorney, STEPHEN E. FARBER, Esquire respectfully requests: CA) a.4 m9R ao Pj ??a?87so 1. Petitioner is MARTIN AND MICHELE HUGHES, as parents and natural guardians of Minor, KATELYN HUGHES, who resides at 1126 Dry Powder Circle, Mechanicsburg in the County of Cumberland in the Commonwealth of Pennsylvania. 2. Minor's social security number is: 196-80-7381. 3. The Minor, KATELYN HUGHES, was born on September 15, 2002 and resided with her parents, at 1126 Dry Powder Circle, Mechanicsburg, Pennsylvania at the time of the accident. 4. A guardian was not appointed for the Minor. 5. The Defendant was SEARS, ROEBUCK, AND CO. with a corporate address of 1515 Market Street, Suite 1210, Philadelphia, Pennsylvania, 19102. See Exhibit "A". 6. The Defendant owned a store named SEARS #02624 located at 3595 Capital City Mall, in the city of Camp Hill in the County of Cumberland in the Commonwealth of Pennsylvania. 7. On August 6, 2009, the Minor, KATELYN HUGHES, was in Sears store #02624 traveling in the aisle when, suddenly and without warning, she was caused to slip, trip and fall due to a negligent condition, namely a wet and slippery floor, causing her to suffer serious, grievous and severe personal injuries. 8. As a result of the incident which occurred, the minor sustained the following injuries: fractured second, third, and fourth metatarsals of her left foot. 9. A Complaint has not been filed in this matter. 10. Counsel for the Petitioner has negotiated a settlement with Respondent in the amount of seven thousand five hundred dollaars ($7,500). 11. Attached hereto as Exhibit "B" is emergency room report from Holy Spirit Hospital confirming the diagnosis of fracture in the second, third and fourth left metatarsal bones. See attached Exhibit "B". 12. Attached hereto as Exhibit "C" is the September 8, 2009 final report of Steven M. DeLuca, D.O., the orthopedist who treated minor KATELYN HUGHES for the injuries suffered in this accident; the report states she had no complaints, limped appropriately and x-rays demonstrated the fractures healed well with no displacement. See attached Exhibit "C". 13. Minor KATELYN HUGHES received no subsequent medical treatment for her injuries following the above-referenced September 8, 2009 visit with Dr. DeLuca. 14. The following settlement has been proposed: Your Petitioner recommends approval of a settlement in the amount of SEVEN THOUSAND AND FIVE HUNDRED DOLLARS ($7,500.00). 15. Attached hereto as Exhibit "D" is a statement, under oath, of the Minor's parents certifying the physical and/or mental condition of the Minor, as well as the parents' approval of the proposed settlement and distribution. See attached Exhibit "D". 16. A lien has been incurred with the Department of the Navy for medical treatment provided to the Minor in the amount of $1,124.98; counsel was able to obtain agreement from the Department of The Navy to compromise their lien for $850.00. Attached hereto as Exhibit "E" is a letter stating that the Department of the Navy will accept $850.00 in lieu of its original lien. See Exhibit "E". 17. Counsel is of the professional opinion that the proposed settlement is fair, reasonable and substantial in this case. 18. Counsel incurred the following expenses for which reimbursement is sought: Healthport (Medical Records) $39.74 Healthport (Medical Records) $35.33 Filiniz Fees $92.00 TOTAL COSTS: $ 167.07 19. Counsel requests a fee in the sum of $1,833.23 which represents 25% of the total settlement payable to the Minor. A copy of the Fee Agreement is attached hereto as Exhibit "E". See attached Exhibit "F". 20. Counsel has not and will not receive collateral payments as counsel fees for representation involving the same matter from third parties (i.e., subrogation). WHEREFORE, Petitioner respectfully requests that she be permitted to enter into the settlement recited above on behalf of Minor, KATELYN HUGHES, and that the Court enter an Order as follows: TO: Master Weinstein Schatz Moyer, P.C. Costs $167.07 Counsel Fees $1,833.23 TO: Department of the Navy (medical lien) $850.00 TO: Balance to Minor, KATELYN HUGHES $4,649.70 By: _ S WEINSTEIN SCHATZ MOYER, P.C. FARBER, ESQUIRE Petitioner/Plaintiff VERIFICATION I, MARTIN HUGHES, verify that the statements made in the foregoing Petition for Leave to Settle or Compromise Minor's Action are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa. C.S.A. §4904 relating to unworn falsification to authorities. MAR IN HUGHES DATED: /,? J/.3 Z/-/ VERIFICATION I, MICHELE HUGHES, verify that the statements made in the foregoing Petition for Leave to Settle or Compromise Minor's Action are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. MICHELE HUGHES DATED: /2 // 3//? MASTER WEINSTEIN SCHATZ MOYER, P.C. By: STEPHEN E. FARBER, ESQUIRE Attorney ID No: 17535 1818 Market Street, Ste. 3620 Philadelphia, PA 19103 Phone: 215-561-2800 Fax: 215-561-0012 MARTIN AND MICHELE HUGHES, h/w, p/n/g KATELYN HUGHES 1126 Dry Powder Circle Mechanicsburg, PA 17050 Attorney for Petitioner IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs V. NO. CIVIL ACTION - LAW SEARS, ROEBUCK AND CO. 1515 Market Street Suite 1210 Philadelphia, PA 19102 And SEARS STORE #02624 3595 Capital City Mall Camp Hill, PA 17011 Defendant CERTIFICATE OF SERVICE I, STEPHEN E. FARBER, Esquire, do hereby certify that service of a true and correct copy of the within Petition for Leave to Settle or Compromise Minor's Action was made on the 16TH day of December, 2011 to the below named by United States Mail, postage prepaid: SEARS, ROEBUCK AND CO. 1515 MARKET STREET SUITE 1210 PHILADELPHIA, PA 19102 c/o Joan Deluca-Cook Attn: L0908060451-0001 Sedgwick CMS P.O. Box 14448 Lexington, Kentucky 40512-4448 MASTER WEINSTEIN SCHATZ MOYER, P.C. By: STEPHE E. FARBER, ESQUIRE Attorney for Petitioners Corporations Search By Business Name By Business Entity ID Verify Verify Certification Online Orders Register for Online Orders Order Good Standing Order Certified Documents Order Business List My Images Search for Images Online Services i Corporations i Forms i Contact Corporations i Business Services Business Entity Filing History Date: 9/7/2011 (Select the link above to view the Business Entity's Filing History) Business Name History Name Name Type SEARS, ROEBUCK AND CO Current Name Business Corporation - Foreign - Information Entity Number: 322522 Status: Active Entity Creation Date: State of Business.: Registered Office Address: 9/30/1933 NY 1515 MARKET ST STE 1210 PHILADELPHIA PA 19102-0 Philadelphia Mailing Address: No Address Officers Name: W BRUCE JOHNSON Title: President Address: 3333 BEVERLY RD D768 B2-107B HOFFMAN ESTA IL 60179 Name: WILLIAM HARKER Title: Secretary Address: 3333 BEVERLY RD D768 132-1076 HOFFMAN ESTA IL 60179 Name: MICHAEL COLLINS Title: Treasurer Address: 3333 BEVERLY RD D768 B2-107B HOFFMAN ESTA IL 60179 Name: WILLIAM CROWLEY Title: Vice President Address: 3333 BEVERLY RD D768 62-1078 HOFFMAN ESTA IL 60179 fipfw'NPa O Home Copyright ® 2002 Pennsylvania Department of State. All Rights Reserved. Commonwealth of PA Privacy Statement Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Pennsylvania 17011 (717) 972-4900 PATIENT: HUGHES, KATELYN F DICTATION DATE: Aug 6 2009 4:36P MR#: 631061 TRANSCRIPTION DATE: Aug 6 2009 4:31 P PT CLASS: E ADM#: 35195114 ORD DR: RAJANA SHARMA ADM DATE: 08/06/2009 PT TYPE: E ARRIVAL DATE: DOB: 09/15/2002 HOSP SERVICE: ER1 LOCATION: ER1- ACC#: 3643967 ***Final Report*** EXAMINATION. FOOT LT -Aug 6 2009 COMMENTS: Exam: Left Foot, 3 views History: 6-year-old female with pain status post fall. Result: Routine projections of the left foot were obtained. No prior examinations are available for comparison. There is cortical irregularity involving the necks of the left second, third, and fourth metatarsal bones. Findings are concerning fc, acute nondisplaced fractures. The remaining visualized osseous structures and osseous articulations are intact without evidence of dislocation, lytic or blastic lesion. The joint spaces are preserved. Bone mineralization is unremarkable. No significant soft tissue abnormalities are identified. CONCLUSION: Findings concerning for nondisplaced fractures involving the necks of the second through fourth metatarsal bones. No apparent epi.Dhyseal involvement. DICTATED BY: BARRY LEVIN MD 1 DATE OF EXAM: Aug 6 2009 SIGNED BY: BARRY LEVIN MD DATEi'TIME: Aug 6 2009 4:31P ?i4EllJ . e?r I'rj i Y ... J. ?_t.k?i .: ..._... Study interpretation provided by Quantum Imaging. To provide the best and safest patient care: During routine daytime "Qlaantum weekday, weekend and holiday on-site coverage, a Quantum Radiologist can be contacted at 717-763-2948 (Holy Spirit r .rr ,, rr JA r; Hospital). Alternatively, a Quantum Radiologist can be reached by phone 24 hours a day, seven cat's a week at 717.932- 8030. CONFIDENTIAL: This report contains private patient information. If you have received this report in error, please call 717-972-4941 immediately. Confidentiality Disclaimer: The information contained in this communication may be confidential, is intended for the use of the recipient named above. and may be legally privileged. K the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication. or any of Is contents, is strictly prohibited. If you received this communication in error, please resend this communication to the sender and delete the original message and any copy of it from your computer system. Thank You. Imaging Services Consultation Page 1 12 Foot or Ankle Injury (4) DATE: - G TIME f ? on arrival ROOM: EMS Arrival '--.. FMS treatments ordered _ HISTORIAN: pati? spous. param dies AGE M ' F?.•- Z.7 _HX 1 EXAM LlMl D BY: HPI hl m • Injury to: right ! eft foot ankle leg knee thigh great toe 2'toe 3rd toe 4'' toe 5°i toe to arrival "toda yesterday -days o _ seyarlty of mill: ' mild moderate severe ?- con fell twisted direct blow barefoot / wearing shoes. _ . where: home school neighbor's park work n street worse !p ersistent since - - - - - - - , pain iwtemrittent / lostina stubbed laceration burn associated symptoms: painful i snap I crack 1 pop sensation-_..- . __. to bear ROS _ loss Wng I wer arms I legs trou s breathing I chest pain _ _ - _- n:ling! mbnessdista1ly loss Isdderfunction i h acheack pain sue FB {skin lac} ; daub vision\\ I hearing loss - recen R / illness - nausea omidng ; ? all - - neg except as marked -? ----------------------------- ---------------- w SOCI?L HX smoker - drug use 1 abuse recent lives alone- , Gres at hom?i-?-- lives in nursing i I177C _negatve------ _------------' PAST HX _negative prior injury) ? .4-( o diabetes Type I Type 2 diet q 7iiiU-1 HTN heart disease un /ii I?Ii- nons..L?ieei nurses mt? ^- - NJ Nursing Amesfinent Reviewed (Vitals Reviewed [Tetanus immun. UTD PHYSICAL EXAM GENERAL P NC _no acute distress -mild / rate / severe distress ?,;iert -anxious I lethargic-------.._- . EXTREMITIES FOOT Be _nml inspection soft-tissue / bony -non-tender _ ng I ecchymosis limitadl';DPI .. , pain' junctional deficit rmrty - -- ---- -- _na Injury __,.--- com to /portiol ovuhion subungual hematorna 01996.201)6 T-,S sWrm Inc. Cirde or check a rmalives, baeblask n alivm Holy Spirit Hospital Camp Hill. PA John R. Dietz Emergency Centcr EMERGENCY PHYSIAN RECORD ANKLE _see diagram ,<:n-ml inspection -tenderness soft-tissue /bony T,,aen-tender -swelling/ ecchymosis m ROM* limited ROM _ - able -stable deformity-- ligamentous instability 1 ' t ? l j I M ?C I I. R L R L t ) C ? L R --, r R in T-Teoderan S-Swdlieg £-Ecrbyramis 11-Bern (..'-Cuntrrion Lac-Lscmdoa A-Abrasive M-pindore wound (0 -rWhh" ar-ewNd Nod-A+akrA* swevere) filar Tdv - re"ernecs on GAIT _limited by pain / unable to bear weight - _normal -jptalgiCZdr - -...-•--? fait not tested due to pain_ EN URO -digits n rv difi-di - _Awffsation intact decreased fine touch abnml 2-point disaim. motor intact _peroneal nerve deficit -post tibial nerve deficit VAS;LULAR _pallor I cool skin / abnml cap refill o vascular pulse deficit compromise dorsolis pedis post tibial TEN NS -tendon visualized / injury seen. - on function extensor flexor complete partial normal -- -deficit in tendon function limited extension limited flexion LEG KNEE I THIGH --- - - - injured see diagram above ankle . ,-tenderness soft-tissue /bony---- -deformity--- effusion- -knee limited ROM HUGHES , YATELYN F• 5 F ED GROUP 09/15/2002 631061 08/06/09 ER1 3519511` SKIN -see diagram- warm. dry _diaphoretic / cool / cyanodc.? HEAD 1 EN7 _tenderness- ____..... ' -nml inspection swelling/ ecchymosis -pharynx nntl NECK / BACK _tenderness _ -nmi inspection -swelling/ ecchymosis_-- . -non-tender -___-.- _-- _• , , CHEST tertderness__.. _.- , , _no rasp. distress ?swelling 1 ecchymosis ; non-tender wheezes / rates 1 rhonchi breath ands nml - ------ G1 (ABDOMEN) -tenderness 1 guarding - ' non-tender _ .- ?- -.-- _no organornegaly _T-- •- _nml bowel snds* i --------- ------------- - PROCEDURES _ _ _ __ __ _ _ _ _ ___ _ --"-"""__? Wound Description I Repair length cell location linear irregular flap stellate superficial -subcut 'muscle through-and-through ; ' contused tissue lip laceration ' , clean contaminated moderately/ -heaWly- distal NVT: neuro & vascular status intact no tendon injury anesthesia: loci! LET / tatracsine / adrenaline I cocaine mL marcaine 0.25% 0.5% idoc 1% 2% opi / bietrb digital / metacarpal block ; ? moderate sedation required; see attached 23d template , gyp' ? Betadine / normal saline ' irrigated / washed w/ saline debrided i minimal / mod. / •extensive minimal / -mod / -'extensive wound explored undermined foreign material removed minimal / mod ! "extensive ponk* completely "wound margins revised ; rnWmal / mad. / "extensive multiple flaps aligned no foreign body identified ' repair: Wound closed with- wound adhesive / Dermabond/ steri-strips SKIN- # -0 nylon/ proiene I staples/ ' interrupted running simpk mattress (h / v ) -NAIL BED- # -0 vicryl I chromic _ __-.....-- interrupted naming simple mattress (h I v ) OTHER- # -0 material--_ -..------ , korrupted running simple mattress (h l v) i -may indicate intetmed ate retmir "may indiate complex repair ' ace wrap -/ tape - boot orthosis ( -crutches post-op shoe- - - air cast neoprene sleeve splint sugar-ton L rt o (?C Ortho-glass I piaster ; Dr,liFtt Orthopedist e _ ' 1-01 nt rf`ent good 1 post splint appiiq C -ja , QItiER- toes "buddy-taped"_._.__._ subunguai hematoma drained with eiectrocautery ._ digital block Ndocaine 1% _mt_ marcaine 0.25% 0.596-m1. foreign body removed whh forceps with incision ; , indimmi organ system * equivalent or rninimitas required for organ ?vaere exam Foot Injury -12 Rev. 06 / 221 06 Page 2 of 2 YS !filnterp. by me []Reviewed by me ?Discsd wi 1 /L. oot? aakw- rbtala _..__roe nor / KA _DJD_.._._ _._ _ -no fracture -dislocation --_.-. -noel alignment soft-tissue swelling _no foreign body foreign body _-.. racture non-dispfaced.?displaced--- transverse oblique comminuted angulared - impeded tyros -r Other study: - []See separate report _..._ .............. ..........._......•... Pulse Ox % on RA /-L / % tnterp. PROGRESS Time unchanged improved re-examined j i ' fracture care provided: vea. -referred to / discussed with Dr. _-._.-..-Time will see patient in: ED / Hospital / office in days Fall ANued Assauk Contusion R / L knee ankle foot Hematoma great toe 2nd toe 3rdtoe 4d'toe 5"toe Laceration Sp?./ Strain / Dislocation rF actur R /Ci stabilized/restorative tibia distal / shaft / proximal fibula distal /shaft / proximal bimalleolar tr' alkoiar talus calcaneus navicularGetats phalan*'#ry-_ DISPOSITION- iffhome ? admitted KU1MJ 0 transferred Time CONDITION- ? unchanged 10 improved ? =bit -_.RESMNT / PA / NP SIGNATURE Resident I PA / NP's history reviewed. patien rviewed and examined. nefly, pertinent HM -. s°- 1y personal exam of patient reveal lssessment and plan rev "4. d wel. Lab and ancillary tudles show:..-.-.-. _. 'k l, confirm the diagnosis ------- __Car* plan rwlewe& Patie?k need:- 'lease see resident / midlevet note for details. Physician Signature RTI * turned can over at Physician Signature RTi 8 assumed Cara at aTemplr r't A-'A;rinnal T-Sheet ? Dictated Addendum HUGHES ,KATELYN F 6 F ED GROUP 09/15/2002 631061 08/06/09 3519 2ERI 14 follow-up 1 ..1 - . , Patient MRN: 402260 Date: 09-08-2009 Description: Office Visit Category: Transcription Provider ID:FD32453F-F4E3-4968-8805-F8E4C84F7AF5 Orthopedic Institute of Pennsylvania (717)7815530 Patient: Katelyn Hughes DOB: 09-15-2002 Physician: Steven M. Deluca, DO Date: 09-08-2009 Office: 3399 Trindle Road Office CHIEF COMPLAINT: One month status post left second, third, fourth metatarsal neck fractures- HISTORY OF COMPLAINT: Katelyn presents today for a cast off x-ray and exam. She has no complaints. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history, and social history have been reviewed and recorded. PHYSICAL EXAM: She has an appropriate limp. There is no tenderness to palpation over the toes. Ankle range of motion is unrestricted, not painful. Sensation is intact. No lesions, lacerations, or abrasions. DIAGNOSTIC TESTS: X-rays today demonstrate the fractures over the left second, third, fourth metatarsal necks have healed well with no displacement and no angulation. DIAGNOSIS: One month status post left second, third, fourth metatarsal neck fractures, healed. PLAN: At this point she is going to gradually get herself back to any and all activity without restriction. She is going to hold off on gymnastics for about 2 weeks and then she can return to that as well. I am going to see her on an as-needed basis. Mom and dad verbalized understanding and agreed to plan. SMD/cls CC: Debra Wewer, CRNP via fax MASTER WEINSTEIN SCHATZ MOYER, P.C. By: STEPHEN E. FARBER, ESQUIRE Attorney for Petitioner Attorney ID No: 17535 1818 Market Street, Ste. 3620 Philadelphia, PA 19103 Phone: 215-561-2800 Fax: 215-561-0012 MARTIN AND MICHELE HUGHES, IN THE COURT OF COMMON PLEAS OF h/w, p/n/g KATELYN HUGHES CUMBERLAND COUNTY, PENNSYLVANIA 1126 Dry Powder Circle Mechanicsburg, PA 17050 Plaintiffs V. SEARS, ROEBUCK AND CO. 1515 Market Street Suite 1210 Philadelphia, PA 19102 And SEARS STORE #02624 3595 Capital City Mall Camp Hill, PA 17011 Defendant NO. CIVIL ACTION - LAW AFFIDAVIT OF MICHELE HUGHES. P/N/G OF KATELYN HUGHES. A MINOR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF PHILADELPHIA SS. MICHELE HUGHES, being duly sworn according to law, deposes and says that the following facts are true and correct to the best of her knowledge, information and belief: 1) I am the mother and natural guardian of KATELYN HUGHES. 2) I approve the settlement and proposed distribution of my daughter's claim as set forth in the Petition for Leave to Settle or Compromise Minor's Action. 3) I believe that my daughter has fully recovered from the injuries that she sustained in her August 6, 2009 accident. MIC EL HUGH S COMMONWEALTH OF PENNSYLVANIA: : SS. COUNTY OF PHILADELPHIA On this, the ?rp day e ? 2011, before me, a Notary Public for the Commonwealth of Pennsylvania, residing in the City and County of Philadelphia, the undersigned officer, personally appeared MICHELE HUGHES known to me, or satisfactorily proven, to be the person who name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. I hereunto set my hand and official seal. Notary ic' cOMMOIVWEAL7H OF' PENNSYLVANIA NOTARIAL SEAL DEBBIE L. SUCCINO, Notary Public City of Philadelphia, Phila. County M COMMIselen EgIr MASTER WEINSTEIN SCHATZ MOYER, P.C. By: STEPHEN E. FARBER, ESQUIRE Attorney ID No: 17535 1818 Market Street, Ste. 3620 Philadelphia, PA 19103 Phone: 215-561-2800 Fax: 215-561-0012 Attorney for Petitioner MARTIN AND MICHELLE HUGHES, IN THE COURT OF COMMON PLEAS OF h/w, p/n/g KATELYN HUGHES CUMBERLAND COUNTY, PENNSYLVANIA 1126 Dry Powder Circle Mechanicsburg, PA 17050 Plaintiffs V. SEARS, ROEBUCK AND CO. 1515 Market Street Suite 1210 Philadelphia, PA 19102 And SEARS STORE #02624 3595 Capital City Mall Camp Hill, PA 17011 Defendant NO. CIVIL ACTION - LAW AFFIDAVIT OF MARTIN HUGHES, P/N/G OF KATELYN HUGHES. A MINOR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF PHILADELPHIA SS. MARTIN HUGHES, being duly sworn according to law, deposes and says that the following facts are true and correct to the best of his knowledge, information and belief: 1) I am the father and natural guardian of KATELYN HUGHES. 2) I approve the settlement and proposed distribution of my daughter's claim as set forth in the Petition for Leave to Settle or Compromise Minor's Action. 3) I believe that my daughter has fully recovered from the injuries that she sustained in her August 6, 2009 accident. HUGHES COMMONWEALTH OF PENNSYLVANIA: . SS. COUNTY OF PHILADELPHIA On this, the day of kuk?-l , 2011, before me, a Notary Public for the Commonwealth of Sylvania, residing in the City and County of Philadelphia, the undersigned officer, personally appeared MARTIN HUGHES known to me, or satisfactorily proven, to be the person who name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. I hereunto set my hand and official seal. o Pu C COMMI,oNV6'?AL'rH of PENNSYLVANIA NOTARIAL SEAL DEBBIE L. BUCCINO, Notary Public City of PWadeiphia Phila. County ay .a?,mt?er 9, 2013 M Gemmssipf? EAP7 r . EXHIBIT "E" MR STEPHEN E FARBER LAW OFFICES OF MASTER WEINSTEIN, PC 1818 MARKET STREET SUITE 3620 IN REPLY REFER TO 5890 NCO905418 30 Jun 11 PHILADELPHIA PA Re: Injured: Date of Incident: Place of Incident: Our File Number: Dear Mr. Farber: DEPARTMENT OF THE NAVY OFFICE OF THE JUDGE ADVOCATE GENERAL MEDICAL CARE RECOVERY UNIT NORFOLK 9053 FIRST STREET SUITE 100 NORFOLK, VA 23511-3605 19103 Miss. Katelyn F. Hughes, dependent of FSGT Martin Hughes, USMC (Ret) 8/6/2009 Pennsylvania NCO905418 I am in receipt of your request for a compromisetwaiver of the Navy's claim under the Medical Care Recovery Act, 42 U.S.C. §§ 2651 et seq., 10 U.S.C. § 1095 and 32 C.F.R. Part 757, in the above matter. Upon review of the particular facts of this case, it has been determined that full collection of the Navy's claim would result in an undue hardship to your client. Therefore, the Navy agrees to compromise the amount of its claim and accepts $850.00 in full and complete satisfaction of its claim. Please forward a check in the amount of $850.00 made payable to the "United States Treasurer" to the letterhead address. Please include the name of the injured party and our file number for proper identification. Be reminded, 5 USC §3106 prohibits government employment of counsel to litigate matters on behalf of the United States. As stated in our agreement, this requires the payment of our compromised amount prior to assessing your attorney fee. Thank you for your cooperation in resolving this matter. Should you have any questions, please contact me at (757) 440-6305. fDC , errel MEDICARE Claims Examiner -2/20.11 9:43:04 AM vrT t, n• 4< s .y SEARS 8t K MART INCIDENT CENTER ATTN JOAN DELUCA-COOK PO BOX 14448 LEXINGTON KY 40512 NOTICE OF CLAIM PAGE 2 OF 2 IN REPLY REFER TO 5890 NCO905418 19 Mar 10 1 Re: Injured: Miss. Katelyn F. Hughes, dependent of FSGT Martin Hughes, USMC (Ret) Date of Incident: 8/612009 Place of Incident: Pennsylvania Your Insured: Hughes Martin % S FS a t. u 5 r ?? ii iii Your Claim Number: L090806045 1-000 1 Our File Number: NCO905418 Dear Claims Examiner: We have information indicating that the individual identified above was injured in an accident. Further, we have information indicating that your insured may be legally responsible for the injuries. As a result of the injuries sustained, medical care and treatment was provided by or through the United States. The Medical Care Recovery Act, 42 U.S.C. §§ 2651 et seq., and 10 U.S.C. § 1095 entitle the United States to recover the reasonable value of medical care and treatment provided by or through the United States to the individual identified above. Therefore, the United States makes claim to any and all available insurance coverage including, but not limited to, Personal Injury Protection, Medical Payments, Underinsured or Uninsured benefits, Worker's Compensation, and liability coverage for the reasonable value of medical care provided the injured party identified above. Proof of medical expenses will be forwarded as soon as it is received by this office. Thank you for your cooperation in this matter. Should you have any questions, please contact me (757) 440-6305. Sin ely, l De 11 MEDCARE Claims Examiner SEDGWICK CMS DEPARTMENT OF THE NAVY OFFICE OF THE JUDGE ADVOCATE GENERAL MEDICAL CARE RECOVERY UNIT NORFOLK 9053 FIRST STREET SUITE 100 NORFOLK, VA 23611-3606 3/25/2010 L09080604510001 5120100325021851 3/25/2010 L09080604510001 5120100325021851 01/25/2011 06:10 7574443527 MCRU NORFOLK PAGE 02/02 DEPARTMENT OF THE NAVY OFFICE OF THE JUDGE ADVOCATE GENERAL MEDICAL CARE AGCOVERY LOW NORFOLK 9= FIRST STREET SUMS 100 NORFOLK, VA 23611.3605 IN RMY" ER TO 5890 NC0905418 24 Jan 11 MR STEPHEN E FARBER LAW OFFICES OF MASTER WEWSTEIN, PC 1818 MARKET S'T'REET SL= 3620 PHILADELPHIA PA 19103 Re: Injured: Date of Incident: Place of Incident: Our File Number: Final Amount Claimed: Dear Mr. Farber. Miss. Katelyn F. Hughes, dependent of MGT Martin Hughes, USMC (Ret) 8/612009 Pennsylvania NC0905418 $1,124.98 I write in response to your remit inquiry. The amount of the Nays claim in this case is $1,124.98. Once settlement has been reached, please forward to 1& letterhead address a check wade payable to the'U.S. Tre suree. If you have any a"tional,pestions, please contact me. sincerely, Z)ebbiRl Tewre, L Debbie Terrell MEDICARE Claims Examiner EXHIBIT "F" LAW OFFICES OF MASTER WEINSTEIN, P.C. SUITE 3620 1818 MARKET STREET PHILADELPHIA, PENNSYLVANIA 19103 (215) 561-2800 FAX: (215) 561-0012 MINOR'S CONTINGENT FEE AGREEMENT Date: A0G. 13_, 2001_ I hereby constitute and appoint the law firm of Master Weinstein, P.C. as my attorneys to rosecute a claim for bodily injury against all responsible parties. The claimant is 1 (a minor) and the cause of action arose on I hereby agree that the compensation of my attorneys for services shall be determined, as follows: THAT OUT OF WHATEVER SUM IS SECURED BY MY ATTORNEY OR BY ME FROM ALL RESPONSIBLE PARTIES AND/OR INSURERS (INCLUDING UNDERINSURED OR UNINSURED MOTORIST COVERAGE CLAIMS) O W EMENT OR ab VERDICT, THE LAW FIRM SHALL RECEIVE REOF FOR PROFESSIONAL SERVICES PLUS EXPENSES, INCLUDING THE FEES OF WITNESSES, INVESTIGATION COSTS, PHOTOGRAPHS, EXPERT WITNESS FEES, SUIT COSTS, COPYING COSTS, COURT REPORTER'S COSTS, MEDICAL RECORDS COSTS OR OTHER SIMILAR COSTS OR EXPENSES INCURRED IN THE PREPARATION, TRIAL OR SETTLEMENT. ALL MEDICAL BILLS SHALL BE CHARGEABLE TO MY SHARE EXCLUSIVELY, UNLESS OTHERWISE PAID BY INSURANCE AND NO REIMBURSEMENT IS REQUIRED TO THE PAYING INSURANCE COMPANY. SHOULD NO MONEY BE RECOVERED BY SUIT OR SETTLEMENT, SAID ATTORNEY SHALL HAVE NO CLAIM AGAINST ME OF ANY KIND FOR SERVICES RENDERED. If, after investigation, arbitration or trial of this matter, my attorney(s), in their sole discretion decide not to proceed with the matter or enter an appeal, then they may with- draw their representation and I am free to seek other counsel. Furthermore, all costs of appeal, if any are required, shall be paid for by the client prior to the taking of such appeal. I hereby_ acknowledge receipt of a duplicate copy of this Contingent Fee Agreement. Sign ure Address 12/05/2011 09:38 FAX 18004361479 M T R MAIN OFFICE: 4940 Dlsston St. Phila., Pa 19135 215.335.3212 FAX PRICE QUOTE TO: SjjQkz)t, 4wym FROM: l X?) YI i?7?1 t L naei T ?,i RE: au Websit,c: www.mcdleg,com E-mail. legal@imedleg.com Pltone: 800-436-1479 Fax: 600-220-2871 FAX #: DATE. aop-- Tr MLR FILE #:? 14711j Please note that the following records on the above person are now available. If you wish to order a copy of any of these records, kindly complete and sign this form. Please fax the form back as soon as possible as records will only be held available for a short period of time. PROVICDER PGS X-RAYS COST CIRCLE CHOICE . k l,'? - ?1 36 S ?Q . ?a YES NO AS MARKED . YES NO AS MARKED YES NO AS MARKED YES NO AS MARKED YES NO AS MARKED YES NO AS MARKED YES NO AS MARKED YES NO AS MARKED I have indicated my desire to order documents by circling my choice beside the desired documents. By my signature affixed hereon I agree to pay the noted price for said records. SIGNATURE OF REQUESTING COUNSEL zoo, /001 MEDICAL LEGAL REPRODUCTIONS, INC. " PROFESSIONALS IN RECORD PROCUREMENT" s? PHILADELPHIA PITTSBURGH W. LALREL NEWYORK MIAMI MARTIN AND MICHELE HUGHES, h/w, p/n/g KATELYN HUGHES 1126 Dry Powder Circle Mechanicsburg, PA 17050 Plaintiffs V. I! SEARS, ROEBUCK AND CO. 1515 Market Street Suite 1210 Philadelphia, PA 19102 And SEARS STORE #02624 3595 Capital City Mall Camp Hill, PA 17011 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. t CIVIL ACTION - LAW Defendant ORDER AND NOW, on this / f ?tA- day of 2012, upon consideration of the Petition for Leave to Settle or Compromise Minor's Action, it is hereby ORDERED and DECREED that Petitioner is authorized to enter into a settlement with Defendant, SEARS STORE #0264, to be paid by its claims adjusters Sedgwick Claims Management which shall forward the settlement draft or check to Petitioner's counsel for proper distribution. IT IS FURTHER ORDERED AND DECREED that the Settlement funds of $7,500.00 shall be allocated as follows-. KATELYN HUGHES, A Minor Date of Birth 09/15/2002 $7,500.00 Social Security Number 196-80-7381 It is further ORDERED and DECREED that settlement funds be distributed as follows: TO: Department of the Navy (health insurance lien) $850.00 TO: Master Weinstein Schatz Moyer, P.C.: Costs $167.07 Counsel Fees $1620.73 The balance, the sum of TO THE MINOR. $4,862.20 COUNSEL (and not the parents and/or guardians to the Minor) is hereby AUTHORIZED and specifically DIRECTED to execute all documentation necessary to deposit the funds belonging to the Minor in an interest bearing savings certificate in a federally insured bank or savings institution having an office in Cumberland County IN THE NAME OF THE MINOR ONLY. The certificate shall be marked as hereinafter directed. The certificate shall be titled and restricted as follows: KATELYN HUGHES, a Minor, not to be redeemed except for renewal in its entirety, nor to be withdrawn, assigned, negotiated, or otherwise alienated before the Minor attains majority, except upon prior Order of Court. If no withdrawals are made from the investments authorized by this Decree, the depository may pay over the balance on deposit when the Minor attains majority, upon the order of the late Minor, without further Order of this court. Within tj!ly 4W days from the date of this Decree, counsel for Petitioner shall file an Affidavit with the Clerk of the Court of Common Pleas certifying compliance with this Decree. Counsel shall attach to the Affidavit a copy of the savings certificate reflecting the required restrictions and shall pay such fee as may be required by the Clerk. ll further contain a specific averment by h counsel that counsel, and not the a The Affidavit s arent(s) and/or guardian(s) of the Minor, established the account(s) and deposited the funds therein p as directed above. ? ??? "-- 3. N b Lle ;?- ?u ?na ter, ?S - :sea , 5;= ? ._ a r wp; Ps n? ; ? A? 3I?S?/f Sedgwick CMS Sedgwick Claims Management Services, Inc. Hoffman Estates, IL Office mailing address: P.O. Box 14448, Lexington, Kentucky 40512-4448 866 352-1521 Facsimile 866 876-7050 June 16, 2011 Law Offices of Master Weinstein, P.C. 1818 Market Street Suite 3620 Philadelphia, PA 19103 Via fax 215-561-0012 & mail RE: Your Client: File Number: Date of Incident: Store Number: Dear Mr. Farber: Katelyn Hughes L0908060451-0001 08/06/2009 Sears #02624- CAMP HILL PA Enclosed, please find the release for the sum of $7,500.00. Please complete the required information, sign, and notarize the document, then return the release to our office. Upon receipt of the properly executed document, and court approval, a check in the amount of $7,500.00 will be promptly issued. If you have any questions, please feel free to contact me at the number below. Sincerely, wj7?"'- Joan DeLuca-Cook (847)645-0658 Fax: (866)876-7050 Sears/Kmart Customer Incident Center Encl: Settlement Release MASTER WEINSTEIN SCHATZ MOYER, P.C. By: SEAN M. FULMER, ESQUIRE Attorney ID No: 309245 1818 Market Street, Ste. 3620 Philadelphia, PA 19103 Phone: 215-561-2800 Fax: 215-561-0012 y ?+ r f t_{ ? 1?1 i _A Attorney for Petitioner Fj v4 PL'?fgp UN T w ?'?'SYLVANIA MARTIN and MICHELLE HUGHES, h/w IN THE COURT OF COMMON PLEAS OF as parents and natural guardians of CUMBERLAND COUNTY, PENNSYLVANIA KATELYN HUGHES, a minor, Plaintiffs, V. AFFIDAVIT : Case :tiro.: 11-9312 SEARS ROEBUCK AND CO. and SEARS STORE Defendants. I, Sean M. Fulmer, Esquire, hereby state and affirm that I have complied with the Order issued on March 15, 2012, by the Honorable Christylee L. Peck, as follows: Copy of Certificate of Deposit, number 0000456450, evidencing deposit of settlement funds is attached hereto. I verify that the statements in this Affidavit are made subject to the penalties of 18 Pa. C.S.A. §4904, relating to unsworn falsification to authorities. SWORN TO AND SUBSCRIBED before me this alt day ofl?'- ? , 2012. NOTARY PUBLIC CIVIL DIVISION BY: S' 7h rk SEAN M. FULMER, ESQUIRE Attorney for Petitioner(s) COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL MICHELLE L. ULASCHKIN, Notary Public City of Philadelphia, Phila. County Commission Expires August 19, 2013 Pit WQ list FWARM,CR111)[I'Vr I(M Carlisle Pike 6280 Carlisle Pike Mecha•'nsburg PA 17050 Inqu._. ?-a Call: 717-697-4432 Acct x:.. _.: 45, HUGHES,KATELYN F Eff• 74/03'12 Date: 04/03/12 Tl? "- Time: 3:57pm Deposit to 60 MONTH CERT 0040 Prev Sal: 0.00 r Maturity date: 09/15/20 Amount: 4,649.70 New Bal: 4,649.70 Seq: #642963 Check Received 4,649.70 Authorized by - ID Source: ? Drv Lic ? SigCard ? Known ? Other V'SA Balance Transfer 1.90% APR NO balance transfer fees. Ask an associate for more details. KATELYN ^ HUGHES 5000 Louise Drive MEMBERS V Mechanicsburg, PA 17055 PEDERALCREDIT UNION (800)283-2328 -CERTIFICATE APPLICATION AND RECEIPT I/We hereby apply for a Members I" Certificate in the amount and term listed below. Maturity Date: 04/02/2017 Please Print: Account #: 0000456450 Member Name: KATELYN F HUGHES SSN: 19 6 - 8 0 - 7 3 81 Street: 1126 DRY POWDER CIR Extra Address: City: MECHANICSBURG State: PA Zip Code: 17050 JOINT OWNERS Last: First: MI: Suffix: I Street: City: State: Zip Code: Extra Address: _ Date Of Birth: - - / - - / - - - - SSN: - - Last: First: NIL Suffix: 2 Street: City: State: Zip Code: Extra Address: Date Of Birth: - - / - - / - - - - SSN: - - Last: First: MI: Suffix: 3 Street: City: State: Zip Code: Extra Address: Date Of Birth: - - / - - / - - - - SSN: - - Last: First: MI: Suffix: 4 Street: City: State. Zip Code: Extra Address: Date Of Birth: - - / - - / - - - - SSN: - - X' Deposit Amount: $ 4,649.70 Transfer Amount $ From Account: Share ID: CERTIFICATE nF.TATTA Certificate Type Minimum Amount Original Deposit Amount Annual Percentage Yield Dividend Rate Share ID 60 MONTH CERT $500.00 $4,649.70 1.500% 1.490% 0040 Dividends Payment Method: By: To Share To: Account Number: Member's Signature: iSt r?/ , Share ID: Date: 04/03/2012 This is to certify that the above named person(s) is (are) the owner(s) of a Certificate account at Members 0 Federal Credit Union. The Certificate is in accordance with the terms of the Membership and Account Agreement and the Credit Union's current Truth-in- Savings Rate and Fee Schedule which shall accompany the receipt of deposit for this Certificate and is incorporated by this reference.