HomeMy WebLinkAbout12-7544/d - ~5`~~ ~ iv v l T l'!y1
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
DOCKET #
DATE EN"fERED
CERTIFIED COPY OF LIEN
TO THE PROTHONOTARY OF SAID COURT:
Pursuant to Section 1605 of the Pennsylvania Workers'
Compensation Law, 77 P.S. § 2705 this is a Certified Proof of
Payment for the balance of payments made by the Fund on
behalf of the uninsured employer to be entered of record by
you and indexed as judgments are indexed.
BUREAU OF WORKERS' COMPENSATION
CLAIM NUMBER: 3673471
UNINSURED EMPLOYER GUARANTY
CLAIM NUMBER: UEG1-9291,UEG1-9292
ACCOUNT NUMBER:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR & INDUSTRY ~ , r.-.,
UNINSURED EMPLOYERS GUARANTY FU3~D ~'-='
r^ i cz~ ;--~ '_
vs. --. ~~ , ,,t
ON THE RUN MART, INC. `~='''
.
- ^-~ `-`
--
1 1 NORTH WALNUT STREET - .,
r
~ ~
~
MECHANICSBURG, PA 17055 ~ `~
.~_~ ,`- =? -
°
. i- 'ti
-.... ~.
._.~;
DATE DISBURSEMENTS BALANCE DUE
~ AMT PAID CREDIT
Total
Ex enses
$ 1,561.79
-0- _
$ 1,561.79
Total
Indemni $ 767.72
_ -0- $ 767.72
Legal
Fees $ -0- -0- $ -0-
ACS
Adjusting
Costs $ 2,621.50 -0- $ 2,621.50
Total
Medical $ 3,941.92 -0- $ 3,941.92
^
TOTAL: $ $,$92.93
FILING FEE(S): $ 21.50
ADDITIONAL
COSTS: _0_
SATISFACTION
AMOUNT: $ $,914.43
The undersigned, Director, Bureau of Workers' Compensation, Department of Labor & Industry, certifies that the above balance is due and payable by the above lamed
defendant under the provisions ofthe Pennsylvania Workers' Compensation Law. Pursuant to section 1605 of said law, 77 P.S. § 2705, the above balance is a judgment
and statutory lien upon the franchi es and property, both real and personal, including after acquired property, of the above named defendant and attach thereto from the
date of e try this Certified Copy f Lien.
7
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
DOCKET #
DATE ENTERED
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR & INDUSTRY
UNINSURED EMPLOYERS GUARANTY FUND
v.
ON THE RUN MART, INC.
11 NORTH WALNUT STREET
MECHANICSBURG, PA 17055
CERTIFIED COPY OF LIEN UNDER
PENNSYLVANIA WORKERS' COMPENSATION
LA W
Prothonotary
NOTICE TO DEFENDANT OF ENTRY OF LIEN
This is a copy of the Certified Copy of Lien which has been filed with the Prothonotary of the Court
designated on the reverse side of this notice.
The Department of Labor & Industry of the Commonwealth of Pennsylvania, at the expiration often
(10) days after the receipt of this notice, is authorized by law to execute upon this lien. This means
that your property may be levied upon, attached and sold to the extent necessary to satisfy this lien.
Execution will not occur if this lien is satisfied.
Payment should be made by a Cashers Check, Certified Check or Money Order made payable to the
Commonwealth of Pennsylvania. The Account Number shown on the reverse side of this document
should be affixed to the lower left corner of the remittance and mailed to the address below:
Pennsylvania Uninsured Employers Guaranty Fund
Post Office Box 1774
Harrisburg, PA 171 OS-1774
Any questions concerning this Lien should be addressed to the Uninsured Employers Guaranty Fund
office at the address or telephone number shown on the enclosure.
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR & INDUSTRY
UNINSURED EMPLOYERS GUARANTY FUND
vs.
ON THE RUN MART, INC.
11 NORTH WALNUT STREET
MECHANICSBURG, PA 17055
Defendant
PRAECIPE TO MARK LIEN SATISFIED
TO THE PROTHONOTARY OF SAID COURT:
Kindly mark the lien in the matter captioned above as satisfied in full as to all named
parties. Your assistance in this issue is most appreciated.
No. 12-7544
Dated: November 5, 2014
Respectfully submitted,
C)-71
richi ehl (Attorney I.D. #40388)
Assistant Counsel
Office of Chief Counsel
Workers' Compensation Division
1171 South Cameron Street
Harrisburg, PA 17104
Attorney for the Plaintiff
CERTIFICATE OF SERVICE
I, Erich M. Diehl, attorney for the Plaintiff, hereby certify that on this date I
served a copy of the foregoing Praecipe to Mark Lien Satisfied on the following
individuals, by mailing same to them by regular first class United States Mail, postage
prepaid, at the following addresses:
ON THE RUN MART, INC.
11 NORTH WALNUT STREET
MECHANICSBURG, PA 17055
�
Date: »V�`�x�x�'
v '
Erich M.Diehl (Attorney iD.#4OS88\
Assistant Counsel
Office of Chief Counsel
Workers' Compensation Division
1171 South Cameron Street
Harrisburg, PA 17104
Attorney for the Plaintiff