HomeMy WebLinkAbout03-0957IN THE MATTER OF
RIO COSTA
BORN: 10/03/94
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: NO.
PETITION TO APPROVE COMPROMISE OF CLAIM
AND NOW, comes Rio Costa, a minor, by and through Melissa C. Foreman, her natural
guardian, and her attorneys, Irwin & McKnight, and petition this Court to approve a compromise
of a claim, making the following statements:
1. Melissa C. Foreman is an adult individual residing at 67 "F" Street, Carlisle,
Cumberland County, Pennsylvania.
2. Melissa Foreman is the natural mother of Rio Costa, a minor, whose date of birth
is October 3, 1994.
3. Rio Costa resides with and is supported by her mother at the same address
referenced above.
4. On or about August 18, 2001, Rio Costa was bitten in the facial area by a Great
Dane dog owned by J. Thomas Bower and Charlotte Bower. At the time of the incident, Mr.
Bower was holding the dog for the minor child to pet.
5. The minor child was immediately taken to the Carlisle Hospital Emergency Room
where she was examined by Dr. Peter Giesswein. The minor child suffered severe lacerations to
the left side of her face and upper lip as well as bruising and swelling of her face and
discoloration of her left eye.
6. Follow up treatment and medical appointments were required with Dr. Peter
Giesswein. Although significantly improved through treatment, the minor child continues to
have visible scarring on her face and there is a possibility for necessity of further surgery. Her
smile has also been affected due to the damage to the left side of her face and upper lip. A true
and correct copy of the medical statements dated 1/3/02 and 7/29/02 fi.om Dr. Giesswein are
attached hereto and incorporated herein as Exhibit "A".
7. Mrs. Foreman has sole physical custody of the minor child, and is desirous of
resolving a personal injury claim for her minor daughter through the homeowners policy of Mr.
and Mrs. Bower, Erie Insurance Group (Erie Insurance").
8. The parties to this action are willing to enter into a compromise of the action with
Erie Insurance agreeing to resolve Rio Costa's claim in this matter for the cost of Sixty Thousand
and no/100 ($60,000.00) Dollars.
9. Erie is providing an initial distribution of Twenty-Seven Thousand and no/100
($27,000.00) Dollars. Erie is also purchasing a structured settlement with guaranteed yields of
Eleven Thousand Two Hundred Twenty-Nine and no/100 ($11,229.00) Dollars to Rio Costa
when she reaches age 18 and Twenty-One Thousand Seven Hundred Seventy-One ($21,771.00)
Dollars when she reaches age 21. A true and correct copy of the proposed Structured Settlement
Agreement is attached hereto and incorporated herein as Exhibit "B."
10. Her natural guardian and attorneys believe that this compromise is in the best
interests of the minor.
2
11. Douglas G. Miller, Esquire is the attorney for Rio Costa and Mrs. Foreman and
has represented them in the negotiation of the minor child's claim and the preparation of this
Petition. Counsel in this action requests attorney fees equal to twenty-five percent (25%) of the
cost of the structured settlement for the minor child, which is a reasonable fee for the services
rendered in this action. A true and correct copy of the Settlement Distribution Sheet itemizing
the proposed division of the attorney fees and costs in this matter is attached hereto and
incorporated herein as Exhibit "C."
12. Mrs. Foreman also incurred medical expenses in the total amount of $122.68
which were not reimbursed by insurance. This amount shall also be paid out of the settlement
funds received by the minor as indicated on Exhibit "C".
13. A subrogation lien in the amount of $817.75 is being held by Capital Blue
Cross/Highmark Blue Shield. This amount shall also be paid out of the settlement funds
received by the minor as indicated on Exhibit "C".
14. The net balance of the initial distribution payable to Melissa C. Foreman as
guardian/custodian on behalf of the minor child, Rio Costa, is Ten Thousand Four Hundred
Forty-Nine and 22/100 ($10,449.22) Dollars.
15. The minor child, through her guardian/custodian Melissa C. Foreman, has agreed
to accept the initial and structured payments as full settlement with Erie Insurance for the injuries
sustained by the minor child as a result of the negligence of Mr. J. Thomas Bowers and Mrs.
Charlotte Bowers on or about August 18, 2001. A true and correct copy of the proposed Release
Agreement with Erie Insurance is attached hereto and incorporated herein as Exhibit "D".
16. The minor child's cash settlement is to be deposited in the name of Rio Costa,
with Melissa C. Foreman as guardian/custodian, in a savings account or certificate of deposit at a
federally insured banking institution and no withdrawal therefrom shall be made until the minor
reaches majority without Order of Court.
17. Partial distributions may be necessary prior to the age of majority for future
medical needs arising out of the dog bite incident.
WHEREFORE, the minor child, Rio Costa, and her mother, Melissa C. Foreman, by
and through their legal counsel, respectfully request this Honorable Court to approve said
compromise of the above-described claim, including the payment of attorney fees and costs
above stated.
Respectfully Submitted,
IRWIN & McKNIGHT
60 West Pomfret Street
Carlisle, Pennsylvania 17013
(717) 249-2353
Date: November 18, 2003
4
VERIFICATION
The foregoing document is based upon information which has been gathered by my
counsel and myself in the preparation of this action. I have read the statements made in this
document and they are true and correct to the best of my knowledge, information and belief. I
understand that false statements herein made are subject to the penalties of 18 Pa.C.S.A. Section
4904, relating to unswom falsification to authorities.
Date: November 18, 2003
EXHIBIT "A"
Giesswein Plastic Surgery
Peter Giesswein, M.D.
Center for Cosmetic ~ Reconstructive Surgery
5 Brookwood Avenue, Suite I · Carlisle, PA 17013
Phone: 717-24`9-2424
Fax: 717-24.9-4534
January 3, 2002
FEB - 8 2002
IRWIN, M KNlgHT & HIJGH£S
Douglas G. Miller
Irwin McKnight & Hughes
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, PA. 17013-3222
RE: Rio Costa (DOB 10/03/04)
Dear Attorney Miller:
This letter is in response to your request concerning a summary and
prognostic outlook on the treatment for my patient and your client,
Rio Costa.
I had treated Rio for the first time on August 19, 2001 in the
emergency room at the Carlisle Regional Medical Center.
Apparently, Rio was assaulted by a dog..As a result, she sustained
significant facial bite wounds. For the exact location and
procedure performed, please refer to my operative note from August
19, 2001. Subsequently, Rio has done very well from a healing
standpoint. About seven days after the trauma, the stitches were
removed. Over the past three months, the scars have already
matured significantly. The entire postoperative course was so far
uneventful with regard to complications.
It is impossible for me to look into my crystal ball and predict
the exact appearance in about a year or two. There is no doubt
that the patient will continue to have scars for the rest of her
life. It is, however, my hope that these scars will De as nice as
possible and when the child has reached the teenage years, she can
use some camouflage make-up in order to further enhance her
appearance. I can also not entirely exclude the need for scar
revision. I would wait until twenty-four months have passed. The
procedures available in order to diminish scar appearance would
include excision of the existing scar and resuturing, Z-plasties,
W-plasties or dermabrasion. Again, at this point, it is premature
to predict these needs. The cost of such procedures depend on the
extent of surgery needed. They are not predictable now. I will
Rio back in about three to six months and her mother knows that
available anytime she has a question.
Certified by:
The American Board ot' Surgery · The American Board of Plastic Surgery
Member
AMERICAN SOCIETY OF
PLASTIC SURGEQNS
January 3, 2002
Costa Rio
Page 2
I hope thai. you find this letter helpful. If I can be of any
future service, to your client, please do not hesitate to call upon
Very tyly yours,
:::~Giesswein, M.D.
Enclosure: Operative Report
Giesswein Plastic Surgery
Peter Giesswein, M.D.
Center for Cosmetic ~ Reconstructive Surgery
5 Brookwood Avenue, Suite I · Carlisle, PA 17013
Phone: 717-249-2424
Fax: 717-249-4534
July 29, 2002
Attorney Douglas Miller
Irwin McKnight & Hughes
60 West ro~t~_'~ S'bree~
Carlisle, PA 17013
RE: Rio Costa (DOB 10/03/94)
Dear Attorney Miller:
This letter is in regard to your inquiry from July 24, 2002. It
concerns the injury that my patient, MiSs Rio Costa, sustained on
August 19, 2001.
Although as I indicated to you in my letter dating January 3, 2002,
it is difficult to completely predict all future medical care and
associated costs that may arise as a result of the injury.
Providing you an estimated cost would only include reimbursement
from my services as a surgeon. In the best scenario, no further
scar corrective surgeries would be necessary. In the worst
scenario, the patient would need a scar revision and possible
dermabrasion which ranges from about $600.00 to $1,400.00. The
estimated costs again would only include my services. The costs do
not include either medical facility charges or anesthesiology
charges or any other costs related to the direct expenses of my
surgical services. Accordingly, the costs provided would,
therefore, only represent a fraction of the possible total expense.
This correspondence as well as my previous correspondence are of
course stated to a reasonable degree of medical certainty and are
certainly subject to changes in the event of any unforeseen
circumstances arising. As you well know, future costs of the
procedures are subject to change--most likely increases.
Certified by:
The American Board o[ Surgery · The American Board of Plastic Surgery
AMERICAN SOCIETY OF
PLASTIC SURGEONS
Page 2
July 29, 2002
Rio Costa
In the eve~_ that you have any additional questions,
hesitate t~ contact me.
Very tru/~~ yours,
Peter/'~iesswein, M.D.
PG/n '~
please do not
EXHIBIT "B"
RINGLER ASSOCIATES
3ohn W. Cameron
jcameron @ringlerassociates.com
717) 728-1500
(soo) sis-s033
Fax (717) 728-1502
August 15, 2003
Individually Designed Settlement
Rio Costa
D/O/B 10/3/94
BENEFIT
COST GUARANTEED
YIELD
Immediate Cash and
Attorney Fees
$27,000 $27,000
Guaranteed Lump Sums
Tax-free payments:
$ 15,000 on 10/03/12 (age 18)
$ 32,011 on 10/03/15 (age 21)
11,229 15,000
21,771 32,011
$60,000 $74,011
4902 CARLISLE PIKE, PMB 395, MECHANICSBURG, PA 17050-3079
www.ringlermidam.com
EXHIBIT "C"
LAW OFFICES
IRWIN & McKNIGHT
ROGER B. IRWIN
MARCUS A. McKNIGHT, 11I
DOUGLAS G. MILLER
WEST POMFRET PROFESSIONAL BUILDING
60 WEST POMFRET STREET
CARLISLE. PENNSY£ VANIA 17013-3222
(717) 249-2353
FAX (717) 249-6354
£-MAIL: O£FIC£S@IMH£A W. COM
HAROLD X IRWIN (1925-1977)
HAROLD S. IRWIN, .IR. (1954-1986)
IRWIN, IRW1N & IR~TN (1956-1986)
IRWIN, IRWIN & McKNIGHT (1986-1994)
IRWIN, McKNIGHT & HUGHES (1994.2003)
IRWIN& McKNIGHT (2003- )
SETTLEMENT DISTRIBUTION SHEET
Rio Costa, a minor child, and Melissa Foreman, her parent and guardian
v.
J. Thomas Bowers and Charlotte Bowers
Erie Claim # 010170569905
Date of Accident - August 18, 2001
TOTAL COST OF STRUCTURED SETTLEMENT: Immediate Cash = $27,000.00
Guaranteed Lump Sum Payment on 10/03/2012 = $11,229.00
Guaranteed Lump Sum Payment on 10/03/2015 = $21,771.00
TOTAL GUARANTEED YIELD OF STRUCTURED SETTLEMENT:
$60,000.00
$74,011.00
GROSS AMOUNT AVAILABLE FOR INITIAL DISTRIBUTION:
LESS FEES:
Attorney Fees = 25% of $60,000.00 ($15,000.00)
LESS LITIGATION COSTS:
11/13/01 - Giesswein Plastic Surgery Medical Records = $24.66
02/05/02 - Giesswein Plastic Surgery Medical Report = $250.00
10/15/02 - Giesswein Plastic Surgery Updated Medical Report = $250.00
11/04/02 - K-Mart - Copies of Photographs = $66.69
11/14/03 - Cumberland County Orphan's Court = $19.00
LESS REIMBURSEMENT OF MEDICAL EXPENSES
TO MELISSA FOREMAN:
$35.00 - Emergency Room costs not covered by Blue Cross
$55.00 - Emergency Room costs not covered by Blue Cross
$32.68 - Prescription costs
LESS SUBROGATION LIEN:
Socractes, Inc. (Blue Cross/Blue Shield)
NET CASH BALANCE TO RIO COSTA:
NET STRUCTURED SETTLEMENT FUNDS TO RIO COSTA:
TOTAL NET SETTLEMENT FUNDS TO RIO COSTA'
$27,000.00
$15,000.00
$610.35
$122.68
$817.75
$10,449.22
$33,000.00
$43,449.22
EXHIBIT "D"
Release & Structured Settlement Agreement
This Release & Structured Settlement Agreement, hereinafter "Release & Agreement" is
entered into this __ day of , 2003, between Melissa Foreman (hereinafter
"Releasor") and Erie Insurance Exchange (hereinafter "ERIE") and 3. Thomas Bower and Charlotte
Bower (hereinafter "Defendant(s)'9. The Releasor is the fiduciary and/or guardian of Rio Costa, a
minor, and Releasor acknowledges that he or she has full authority to enter and execute this Release
& Agreement, as evidenced by court approval thereof, attached hereto and made a part hereof. The
Defendant(s) is insured and covered under ERIE Policy No. Q56 0203527.
Release
It is agreed by and between the parties hereto that Releasor, in consideration for the sums
ERIE agrees to pay as hereinafter specified, receipt of which is hereby acknowledged, do hereby
remise, release and forever discharge the Defendant(s) and ERIE, its agents, servants or employees,
from any and all past, present and future claims arising out of an accident/loss which occurred on
August :~8, 2001, at 1l:00 a.m. at 111 Sunset Drive, in Carlisle, in the Commonwealth of
Pennsylvania, including any claims that could be asserted in the future by the Releasor, his/her or their
heirs, executors, fiduciaries, representatives or assigns as a result of the alleged acts or omissions of
the Defendant(s) and/or ERIE. This Release & Agreement shall apply to all demands, claims, causes of
actions and damages, whether known or unknown, on the part of all parties to this agreement with
regard to the above accident/loss, and this agreement shall have such effect as to be a full, binding
and complete settlement between the parties to this agreement, except as otherwise provided in this
Release & Agreement.
TI.
Payments & Schedule Thereof
All payments which ERIE makes, causes to be made, or guarantees under this Release &
Agreement are being made as the liability insurer for the Defendant(s). ERIE agrees to pay to Releasor
and Douglas Miller, her attorney, the lump sum of $27,000 upon approval of the court and the
execution of this Release & Agreement.
Further, ERIE agrees to purchase through Erie Family Life Insurance Company an Annuity
Contract to be owned by ERIE with Rio Costa designated as the measuring life for such Annuity
Contract. ERIE shall have all rights of ownership, with regard to this Annuity Contract. Payments under
this Annuity Contract shall be made to Rio Costa in accordance with the following schedule:
$15,000 guaranteed lump sum, payable on 10-03-2012
$ 32,011 guaranteed lump sum, payable on 10-03-20:[5
ERIE shall provide to Releasor evidence of the purchase of said Annuity Contract.
ST-29 6/03 Page
III.
Guarantee; Payments in Event of Death
All payments to be made under this Release & Agreement shall be guaranteed by ERIE and/or
Erie Indemnity Company in the event of any default on the Annuity Contract by Erie Family Life
Insurance Company. Further, in the event of the death of Rio Costa prior to all payments being made
as required by this Release & Agreement, the remaining payments shall be made to the
beneficiary(ies) named on the Direction of Payments Form. Should Releasor fail to designate a
beneficiary, any remaining payments shall be made to the intestate heirs of, or in accordance with the
Last Will & Testament of Rio Costa.
IV,
Riqhts with Reqard to Payments
All payments made under and in accordance with this Release & Agreement are being made on
account of personal physical injuries or physical sickness sustained by Rio Costa. The Releasor or
Payees under this Release & Agreement shall have no rights of control over the periodic payments.'
Neither the payments to be made in accordance with this Release & Agreement, nor any of the assets
of the Defendant(s) and/or ERIE are subject to execution or any legal process.
Specifically,. the Releasor acknowledges that Rio Costa is the certificate holder of the
Annuity Contract referenced herein. ERIE is the owner of the annuity. The periodic payments
to be made under this Release & Agreement cannot be accelerated, deferred, increased or
decreased by the Releasor or any Payee. Neither the Releasor nor any Payee has the power to
sell, assign, mortgage, encumber or anticipate the periodic payments or any part thereof in any
manner whatsoever. Any attempt by the Releasor or any Payee to sell, assign, anticipate,
mortgage or encumber any of the payments hereunder or any part thereof shall not be
recognized by ERIE.
Liens; Subroqation; Hold Harmless
It is further understood and agreed between the parties to this Release & Agreement
that it is inclusive of any and all present and future liens or claims for subrogation against the
payments to be made in accordance with this Release & Agreement. It is understood and agreed
between parties to this Release & Agreement that the Releasor is responsible for the payment of
any liens or charges against the payments to be made hereunder should any such liens,
subrogation claims or claims for expenses and charges be asserted. This includes, but is not
limited to, medical expense liens, workmen's compensation liens, ERISA liens, liens asserted by
any federal, state or local governmental entity or agency or any medical expense claim. Should
any person or entity make claim for payment of any liens or charges against the Defendant(s),
ERIE or their counsel, the Releasor agrees to indemnify and hold harmless the Defendant(s), ERIE
and their counsel from any and all such liens, charges, fees, claims, attorneys fees, costs, interests
and any other sum.
ST-29 6/03 Page 2
VI.
Tax Consequence
The parties hereto agree that ERIE makes no representation and/or warranty with
regard to the tax liability and consequences to the Releasor and/or Payees for any payments
made and received by them under this Release & Agreement. ERIE shall incur no tax liability or
consequence with regard to any payment or payment made under this Release & Agreement to
the Releasor and/or Payees.
VII. Compromise
It is understood and agreed that this Release & Agreement represents a compromise of
a disputed claim and that any payment made hereunder is not to be construed as an admission
of liability on behalf of any individual, corporation, entity, party or party named herein or
otherwise, and the Defendant(s) and ERIE expressly deny any liability for the accident and/or
loss occasioning this Release & Agreement.
The undersigned have carefully read and understand the.contents of this Release &
Agreement and hereby voluntarily execute it and accept its terms.
Witness:
Melissa Foreman, individually and as parent
and natural guardian of Rio Costa, a minor
NOT~CE: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information or
conceals for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
ST-29 6/03 Page 3
IN THE MATTER OF
COSTA, RIO
BORN: 10/03/94
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: NO. 21-03-957
ORDER OF COURT
AND NOW, this
__~day of
,2003, upon consideration of
the Petition a hearing is scheduled for ~,~'~.~ ,~-//,,°~,~a3t ~/_/: dt9 o'clock
/~- .M. in Courtroom ? of the Cumberland County Courthouse. ~~: ~~
Jo
IN THE MATTER OF
RIO COSTA
BORN: 10/03/94
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: NO.
ORDER OF COURT
ANDNOW, this dayof ~e-~.¢,..,~e_9- ,2003, upon consideration of the
attached Petition to Approve Compromise of Claim, the parties may compromise this action
upon the terms of the proposed compromise set forth in the Petition. Melissa C. Foreman,
guardian and natural parent in custody of Rio Costa, a minor, is authorized to sign the Release
and any and all information necessary to effectuate the settlement of this matter. Further,
Melissa C. Foreman, is authorized to pay the following counsel fees and expenses fi.om the
amount said minor is entitled to receive in this action:
$15,000.00 to Irwin & McKnight for counsel fees and $610.35 for costs of litigation;
$122.68 to Melissa C. Foreman for medical expenses; and
$817.75 to SOCRACTES, INC. (Blue Cross/Blue Shield) for subrogation lien.
The sum of $10,449.22 is to be deposited in the name of Rio Costa with Melissa C.
Foreman as guardian and/or custodian, into a savings account or Certificate of Deposit at a
federally insured banking institution and no withdrawal therefrom can be made until Rio Costa
reaches majority, except as authorized by Order of Court. Further, approval is granted for the
structured settlement payments as itemized in the Petition in the amounts of $15,000.00 on
10/03/2012 and $32,011.00 on 10/03/2015.
Counsel shall file with the Clerk of the Orphans' Court and forward a copy to the
chambers of this Judge proof of compliance with this Order.
' ' BY THE COURT,
LAW OFFICES
IRWIN & McKNIGHT
ROGER B. IRWIN
MARCUS A. McKNIGHT, III
DOUGLAS G. MILLER
WES T POMFRET PROFESSIONAL BUILDING
60 WEST POMFRET STREET
CARLISLE, PENNS YL VANIA 17013-3222
{717) 249-2353
FAX (717) 249-6354
E-MAIL: OFFICES@IMHLA W. COM
HAROLD S. IRWIN (1925-1977)
HAROLD S. IRWIN, JR. (1954-1986)
IRWIN, IRWIN & IRWIN (1956-1986)
IRWIN. IRWIN & McKNIGHT (1986-1994)
IRWIN, McKNIGHT & HUGHES (1994-2003)
IRWIN & McKNIGHT (2003- )
SE TTLEMENT DIS TRIB UTION SHEET
Rio Costa, a minor child, and Melissa Foreman, her parent and guardian
v.
J. Thomas Bowers and Charlotte Bowers
Erie Claim # O1 O170569905
Date of Accident - August 18, 2001
TOTAL COST OF STRUCTURED SEI'TLEMENT: Immediate Cash = $27,000.00
Guaranteed Lump Sum Payment on 10/03/2012 = $15,000.00
Guaranteed Lump Sum Payment on 10/03/2015 = $32,011.00
TOTAL GUARANTEED YIELD OF STRUCTURED SETTLEMENT:
$60,000.00
$74,011.00
GROSS AMOUNT AVAILABLE FOR INITIAL DISTRIBUTION:
LESS FEES:
Attorney Fees -- 25% of $60,000.00 ($15,000.00)
LESS LITIGATION COSTS:
11/13/01 - Giesswein Plastic Surgery Medical Records = $24.66
02/05/02 - Giesswein Plastic Surgery Medical Report = $250.00
10/15/02 - Giesswein Plastic Surgery Updated Medical Report = $250.00
11/04/02 - K-Mart - Copies of Photographs = $66.69
11/14/03 - Cumberland County Orphan's Court = $19.00
LESS REIMBURSEMENT OF MEDICAL EXPENSES
TO MELISSA FOREMAN:
$35.00 - Emergency Room costs not covered by Blue Cross
$55.00 - Emergency Room costs not covered by Blue Cross
$32.68 - Prescription costs
LESS SUBROGATION LIEN:
Socractes, Inc. (Blue Cross/Blue Shield)
NET CASH BALANCE TO RIO COSTA:
NET STRUCTURED SETTLEMENT FUNDS TO RIO COSTA:
TOTAL NET SETTLEMENT FUNDS TO RIO COSTA:
$27,000.00
$15,000.00
$610.35
$122.68
$817.75
$10,449.22
$47,011.00
$57,460.22
IN THE MATTER OF
RIO COSTA
BORN: 10/03/94
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: NO. 21-03-957
AFFIDAVIT OF SERVICE OF PETITION
COMMONWEALTH OF PENNSYLVANIA :
: SS:
COUNTY OF CUMBERLAND :
NOW, Douglas Miller, Esquire, being duly sworn according to law, does depose and state:
That he is a competent adult and attorney for the minor, Rio Costa, in the captioned
action.
That a copy of the Petition was served upon the natural father, Steve Costa, on
November 25, 2003 by certified mail, return receipt requested, addressed to Steve
Costa, 1038 South Cranberry Way, Springville UT 84663, with return receipt
number 7002 0860 0000 1074 2632.
That the said receipt for certified mail is signed and attached hereto and made a part
hereof.
I verify that the statements made in this affidavit are true and correct. I understand that false
statements herein made are subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn
falsification to authorities.
IRWIN & McKNIGHT
Date:
ouglas (~. Mdler, Esqmre
SupremeEourt Id # 83776
60 West Pomfret Street
Carlisle, PA 17013
(717) 249-2353
Attorney for Rio Costa
I'r3
i-3 Postage
I-1
I-1
r-t Certified Fee
r-~ .Return Receipt Fee
,..[] (Enoorsemeet Required)
cO Restricted Delivery Fee
I-~ (Endorsement Required)
Total Po~tage &Feos
1,7~
i Sent To
Steve Costa
~;~'t;'Ji~Z',,i/~;~ ..............................................................................
P~/~j~o. South Cranberry Way
· .Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
· Print your name and address on the reverse
so that we can return the card to you.
· Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addreased to:
Steve Costa
1038 South Cranberry Way
Springville, I]T 84663
A. Si
//- 2
J I b. ~s ~ a~ d~ ~ ~ 17 ~ Yes ~
If ~S, ent~ ~liv~ ~ ~ow: ~ No
3. Service Type
I~Certified Mail [] Express Mail
[] Registered I]D Return Receipt for Merchandise
[] Insured Mail [] C.O.D.
4. Restricted Delivery? (Extra Fee) [] Yes
2. Article Number
(Transfer from service label)
7002 0860 0000 1074 2632
PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1035
IN THE MATTER OF
RIO COSTA
BORN: 10/03/94
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: ORPHANS' COURT DIVISION
: NO. 21-03-957
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA :
: SS:
COUNTY OF CUMBERLAND :
NOW, Douglas Miller, Esquire, being duly sworn according to law, does depose and state:
That he is a competent adult and attomey for the minor, Rio Costa, in the captioned
action.
That a check in the amount of $10,449.22 has been deposited at Orrstown Bank in a
restricted account on January 30, 2004.
3. That the deposit slip for this transaction is attached hereto and made a part hereof.
That the account number and information indicating that this account is restricted for
withdrawals without an Order of Court is attached hereto and made a part hereof
I verify that the statements made in this affidavit are true and correct. I understand that false
statements herein made are subject to the penalties of 18 Pa.C.S. Section 4904, relating to unswom
falsification to authorities.
IRWIN & McKNIGHT
Date:
Dot~glas ~. Mill;r,VEsquire
Supreme'Court Id # 83776
60 West Pomfret Street
Carlisle, PA 17013
(717) 249-2353
Attorney for Rio Costa
ORRSTOWN
BANK
Teller #/Transaction # Amount
Time/Date Account #
9R-36A ~'° Please be sure to enter this transaction in your records.
JAN-80-2004 FRI 02:04 PM
ORRST~ HANOVER ST
FAX No, 2412004
1/30/04
RIO ASHLEY COSTA
Deposit Account
Alert Messages
C023740
This account should have been set up as a Trust AcoounZ. NO
withdraws are to be authorized on this account without a
court order. Any questions, please contact Hanover Branch.
P, O02
13:59:42
706001708 S
Expire Off
Date Code
XXX
XXX
XXX
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