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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
STATE FARM FIRE & CASUALTY
Plaintiff No: 13- Do210 Cj~~1 ~°fl~
vs.
COMPLAINT IN CIVIL ACTION
MANUEL ROMERO-MONDRAGO
Defendant FILED ON BEHALF OF
Plaintiff
COUNSEL OF RECORD OF
THIS PARTY:
Benjamin W. Lawrence,209032
WELTMAN, WEINBERG & REIS CO., L.P.A.
325 CHESTNUT STREET SUITE 501
PHILADELPHIA, PA 19106-2614
215-599-1500
FAX: 215-599-1505
09788679 C Y Jer DKM
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
STATE FARM FIRE & CASUALTY
Plaintiff
vs. Civil Action No
MANUEL ROMERO-MONDRAGO
Defendant
COMPLAINT AND NOTICE TO DEFEND
You have been sued in court. If you wish to defend against the
claims set forth in the following pages, you must take action within
twenty (20) days after this complaint and notice are served, by entering
a written appearance personally or by an attorney and filing in writing
with the court your defenses or objections to the claims set forth
against you. You are warned that if you fail to do so the case may
proceed without you and a judgment may be entered against you by the
court without further notice for any money claimed in the complaint or
for any other claim or relief requested by the plaintiff. You may lose
money or property or other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET
FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE
TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL
SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
LAWYER REFERRAL SERVICE
CUMBERLAND COUNTY BAR ASSOCIATION
32 SOUTH BEDFORD STREET
CARLISLE, PA 17013
(717) 249-3166
WELTMAN, WEINBERG & REIS CO., L.P.A.
BY: Benjamin W. Lawrence, Esquire Attorney for Plaintiff(s)
Pa. Identification No.209032
325 Chestnut Street, Suite 501
Philadelphia, PA 19106
Phone: 215.599.1500
Fax: 215.599.1505
File #09788679
STATE FARM f 1 iZ c ~ ' ~.~~!,0 LT }
(; y } Court of Common Pleas
} Cumberland County
}
}
vs. }
}
MANUEL ROMERO-MONDRAGO } NO.
CIVIL ACTION -COMPLAINT
Plaintiff is a business organization licensed and authorized to conduct
business in the State of Illinois with a place of business located at P. O. Box 2371,
Bloomington, Illinois 61702.
2. Defendant is an adult individual who at all time pertinent hereto resided at
3417 Northside Drive, Atlanta, Georgia 30354.
3. State Farm issued a policy of motor vehicle insurance whereby State
Farm agreed to insure the motor vehicle involved in this incident ("Insured Vehicle"),
owned by Plaintiffs insured.
4. On or about January 11, 2012 Defendant was the operator of a motor
vehicle which vehicle did negligently, recklessly and/or carelessly collide with the Plaintiff
Insured's vehicle at or near Noble Boulevard and West Street, Carlisle, Pennsylvania.
5. The negligence and/or carelessness of the Defendant consisted of the
following:
a. Failing to have his motor vehicle under such control as the situation
warranted;
b. Operating his motor vehicle in complete disregard of the point and
position of Plaintiffs vehicle;
c. Failing to keep a proper lookout;
d. Traveling too fast for conditions;
e. Disregarding traffic control devices;
f. Failing to abide by the Rules of the Road and the Motor Vehicle Code of
Pennsylvania;
g. Being otherwise negligent under the circumstances; and,
h. Being negligent as a matter of law as may be relevant through discovery
and/or at the time of trial.
6. As a direct and proximate result of Defendant's negligence, the State
Farm Insured's vehicle sustained property damage and/or incurred rental charges in the
total amount of $8,007.64. See attached as Exhibit "1" a copy of the damage
documentation which documents Plaintiff further intends to introduce at the arbitration in
this matter.
7. Pursuant to the insurance policy issued by State Farm and as a result of
the aforesaid payment, State Farm became subrogated to the claim of its Insured
against Defendant.
WHEREFORE, Plaintiff demands Judgment against Defendant in the amount of
$8,007.64 plus interest and costs.
WELTMAN, WEINBERG & REIS, CO., L.P.A.
Benjamin W. wren, Esquire
PA I.D. # 032
325 Ch ~ ut Street
Suite
Philad Iphia, PA 19106
(215) 599-1500
EXHIBIT 1
01/16/12 09:40 AUTOSOURCE VEHICLE RECORDS Page 1
Via: Multiple AS Request: 30254336
Vehicle Inspection Report Pa
Claim No: 38-OP59-25901 Rep: Claim Unit:
Owner: JOHNSON Rep Phone: Rep Fax:
Insured: JOHNSON, ALIKIA Loss Code: Date of Loss: Ol/11 12
Date Report.: 01/16/12
Location Address: Phone: Storage: S /day
N/A, Towing S
Cause of Loss: Stock #
*Collision Theft Flood Vandalism Hail Fire Other:
----------------------------------------------------------------------------
VEHICLE DESCRIPTION
2006 Nissan Maxima SE 4D Sedan Lic. P1t:HFK-4051 Exp.:
VIN: 1N4BA41E16C809785 Color: Ext. WHITE PRL Int.TAN CLOTH St:PA
Engine Disp. 3.5 No. Cyl. 6 *Gas -Diesel -Turbo/Supercharged -Electric
Trans: *Auto Manual Speeds: _3 _4 *5 _6 _7 _8 9 _10
Mileage: Tires Mfg: oWear: LF 75o LR 45o SP _a
158,130 Size: RF 75o RR 45a
----------------------------------------------------------------------------
Cab Type:_Reg Cab _Ext.Cab Crew Cab Load/Rating: _1/2 Ton _3/4 Ton _1 Ton
Box Size: Box Type: _Styleside _Stepside
Van Type -Passenger -Cargo -Regular -Extended Conversion Name:
VEHICLE EQUIPMENT
-----------------
ACCESSORIES
*Pwr Steer
*Pwr Brakes
*Pwr Windows
*Pwr Locks
*Pwr Mirrors
*Cruise Ctrl
*Tilt Wheel
*Air Cond.
-Dual Air
*AntiLck Brk
4WH Dsc Brk
_4 Wh Str'g
*Air Bg Drvr
*Air Bg Pass
*Air Bg Othr
_Pwr Antenna
_Rear Wiper
_Rear Spoilr
*Remote Trun',
OTHER ACC.
_AM Radio
*AM/FM Stro
_AM/FM Cass
*AM/FM CS/CD
CD Player
CD Changer
-Equalizer
*Alarm Sys.
-Rem. Startr
*Keyless
Navigation
DVD Player
GPS
-VCR
*Center Cons
*Overhd Cons
{
SEATS
*Power Seat
Du Pwr Seat
Heated Seat
Lumbar Adj.
_Splt 60/40
*Bucket
*Cloth/Velr
Leather
-Vinyl
_Cpt'n Chair
2 _4 _6
GLASS
HeadsUp Dsp
_Heated W/S
*Heated B/G1
*Tinted Gls
-Privacy Gls
ROOF
Vinyl Top
Luggage Rck
Roll/LteBar
Convertible
Sun-Power
_Sun-Manual
_Sun-Pop-Up
TRUCKS/VANS
Television
Sliding Rr
Window
Power Rear
Window
DRIVETRAIN
*2 WD
_4 WD
_AutoLckHubs
_ManuLckHubs
BUMPERS
Rear Step
Tube
-Chrome
_Chr. Step
WHEELS
Cust. Whl
_Whl Cvr
*Alum./Alloy
Chrome
-Sty. Stl
-Dual Rear
Wheels
SUSPENSION
Trl Tow Pkg
-Off. Rd Pkg
_Cmp. Spl
OTHER
Grille Grd
*Fog Lights
Winch
Camp.Shell
-Bed Liner
_Sp-in Bed
Liner
-Tool Box
-Aux Tank
_Hyd.Lft Gt
Lift Kit
Gr Eff Pkg
Trlr Hitch
Run.Boards
PAINT
2-Tone
Custom
-Graphics
----------------------------------------------------------------------------
Use this space to explain or describe Equipment/Accessories listed above
and/or list and describe additional Equipment/Accessories
Automatic Dimming Mirror, Dual Airbags, Dual Zone Auto A/C, Cargo/Trunk Net,
Floor Mats, Garage Door Opener, Intermittent Wipers, Lighted Entry System,
Split Folding Rear Seat, Skyview Glass Roof, Sport Suspension, Strg Wheel Ra
dio Control, Leather Steering Wheel, Tachometer, Trip Computer, Traction Con
9788679
trol System, Theft Deterrent System
RADIO: *OEM Non--OEM Brand: Model No.
CELLULAR
PHONE: OEM _Non-OEM Brand: Model No.
CB: OEM Non--OEM Brand: Model No.
PAINT: *Orig. Repaint(+/- S
PRE-LOSS CONDITION
Explain if other than average condition for year, make and model vehicle:
+ Avg -
INTERIOR: ________
Seats: Minor Wear _ X _
Carpet: Minor Wear _ X
Glass: Good _ X _
Dash: Minor Damage _ X _
Headln: Good _ X _
EXTERIOR:
Sht.Mt: Minor Damage _ X
Paint: Minor Wear X _
Trim: Good _
_ X _
MECHANICAL:
Engine: Minor Wear X
Trans.: Minor Wear _
X
PRIOR DAMAGE:
No Est. Written: _Yes _No Amount: S
Yes _
_
_
_
OVERALL CONDITION: Above Avg. _Avg. _Below Avg_
OVERALL CONDITION DESCRIPTION:
SELECT SERVICE ADVISOR DAN COONSESTIMATE AMOUNT 57895.31TOWBILL 5396.50
TIRE TREAD DEPTHFRONT -4/32° (PLUG IN RT. FRONT TIRE)REAR - 5/32"
Inspected by:
Date:
Report Generated by Audatex, a Solera Company
(C) 2012 Audatex North America, Inc. All Rights Reserved.
9788679
FAULKNER COLLISION CENTER OF Workfile ID: 737875da
Federal ID: 232611806
CARLISLE_CF
"To Be Sure"
2 ROADWAY DR, CARLISLE, PA 17013
Phone: (717)254-0041
FAX: (717) 254-0046
Estimate of Record
Customer: 70HNSON, ALIKIA A
Insured: JOHNSON, ALIKIA A
Type of Loss: COLL-Collision
Point of Impact: 15 Total Loss
Owner:
JOHNSON, ALIKIA A
170 VIRGINIA AVE
CARLISLE, PA 17013-1067
(717) 960-8210 Evening
(717)448-3379 Day
Written By: Shawn Feaser, 564867, 1/16/2012 12:47:53 PM
Policy #:
Date of Loss: 1/11/2012 8:00:00 PM
Claim #: 38-OP59-25901
Days to Repair: 0
Inspection Location:
FAULKNER COLLISION CENTER OF
CARLISLE_CF
2 ROADWAY DR
CARLISLE, PA 17013
Repair Facility
(717} 2540041 Business
Insurance Company:
STATE FARM INSURANCE COMPANIES
COC FSTIMATICS
ONE STATE FARM DRIVE
CONCORDVILLE, PA 19339
VEHICLE
Year: 2006 Body Style: 4D SED VIN: SN4BA41E16C809785 Mileage In: 158130
Make: NISS Engine: 6-3.5L-FI License: HFK-4051 Mileage Out:
Model: MAXIMA SE Production Date: 9/2005 State: PA Vehicle Out:
Color: WHITE PRL Int: TAN Condition: Job #:
4 Wheel Disc Brakes CD Player Front Side Impact Air Bags Power Trunk/Tailgate
6 Speed Transmission Clear Coat Paint Intermittent Wipers Power Windows
Air Conditioning Cloth Seats Keyless Entry Rear Defogger
Alarm Console/Storage Overdrive Search/Seek
Aluminum/Alloy Wheels Cruise Control Passenger Air Bag Steering Wheel Controls
AM Radio Digital Clock Power Brakes Stereo
Anti-Lock Brakes (4) Driver Air Bag Power Driver Seat Telescopic Wheel
Body Side Moldings Dual Mirrors Power Locks Tilt Wheel
Bucket Seats FM Radio Power Mirrors Traction Control
Cassette Fog Lamps Power Steering
9788679
1/16/2012 12:47:54 PM 079599 Page 1
Estimate of Record
Customer: 70HNSON, ALIKIA A
Vehicle: 2006 NISS MAXIMA SE 4D SED 6-3.5L-FI WHITE PRL
Line Operation Description Qty Extended
Price ~ Labor Paint
1 # *** VIR REPORTED 1/16/12 *** 1
2 FROtYT BUMPER
N 3 # Repl Qual Recy Parts LKQ LT 3/4 FRONT ASSY. 1 4,375.00
+25%
4 # Rpr DISSASEMBLE LKQ CLIP 2.0
N 5 # Rpr CUT /SPLICE TRIM 1.0
6 0/H front bumper 2.2
N 7 * <> Repl Qual Recy Parts bumper assy +25% 1 ncl. Incl. 2.6
g Add for Clear Coat 1.0
N 9 * Repl Qual Recy Parts Top cover 1 Incl. Incl.
N 10 * Repl Qual Recy Parts Energy absort~er 1 Incl. Incl.
N 11 * Repl Qual Recy Parts Reinforcement (HSS} 1 Incl. Incl.
N 12 * Repl Qual Recy Parts RT Stay 1 Incl.
N 13 * Repl Qual Recy Parts LT Stay 1 j,Q„rl. Q,~
14 GRILLE
N 15 * Repl Qual Recy Parts Grille 1 ul Incl.
16 FRONT LAMPS
N 17 * Repl Qual Recy Parts RT Headlamp assy 1 ncl. Incl.
N 18 * Repl Qual Recy Parts LT Headlamp assy 1 Incl. jncl.
19 Aim headlamps 0.5
2p R&I RT Cornering lamp 0.3
N 21 * Repl Qual Recy Parts LT Cornering lamp 1 Incl. 0_3
22 RADIATOR SUPPORT
N 23 * Repl Qual Recy Parts Radiator support 1 Incl. s 4.$
24 R&I Lower cover Incl.
25 COOLING
N 26 * Repl Qual Recy Parts Radiator assy SE 1 Incl. m Incl.
27 # Repl COOLANT 1 8.50
2g R&I Reservoir assy 0.4
N 29 * Repl Qual Recy Parts Fan assy 1 Inc1, m n~ls
30 AIR CONDITIONER & HEATER
N 31 * Repl Qual ReCy Parts Condenser 1 Incl. m Incl.
32 Evacuate & recharge m 1.4
33 Refrigerant recovery m 0.4
N 34 # Repl R-134 Freon $6.00/per lb. 1 6.00
35 HOOD
N 36 * Qual Recy Parts hood +25% 1 Incl. 0.6 2.8
37 Overlap Major Non-Adj. Panel -0.2
38 Add for Clear Coat 0.5
39 Refi underside 1.4
40 R&I Insulator 0.3
N 41 * Repl Qual Recy Parts Lock 1 Incl. Incl.
42 * R&I Release cable (PARTIAL R&I}
9788679
1/16/2012 12:47:54 PM 079599 Page 2
Estimate of Record
Customer: JOHNSON, ALIKIA A
Vehicle: 2006 NISS MAXIMA SE 4D SED 6-3.5C-FI WHITE PRL
43 R&I RT Support cylinder 0.2
N q4 * Repl Qual Recy Parts LT Support cylinder 1 Incl. 0_2
N 45 * Repl Qual Recy Parts RT Hinge 1 Incl. 0_8 0_3
q6 Add for Clear Coat 0.1
N 47 * Repl Qual Recy Parts LT Hinge 1 Incl. 0_8 0_3
qg Add for Gear Coat 0.1
49 FENDER
N 50 R8cI RT R&I fender assy i•8
51 Deduct for Overlap -0.4
52 Deduct for Overlap -0.6
N 53 * Rpr RT Fender 4..~ 2.0
54 Overlap Major Adj. Panel -0.4
55 Add for Clear Coat 0.3
56 # Refn DEDUCT FOR PARTIAL REFINISH -0.3
N 57 * Repl Qual Recy Parts RT Fender liner +25% 1 56 5 0_4
N 58 * Qual Recy Parts LT fender assy +25% 1 Incl. 1.8 2.0
59 Overlap Major Adj. Panel -0.4
60 Add for Gear Coat 0.3
61 Deduct for Overlap -0.4
62 Deduct for Overlap -0.6
63 Refi edges 0.5
N 64 * Repl Qual Recy Parts LT Fender liner 1 Incl. 0_4
65 Refinish Components
N 66 * Rpr LT Apron panel s 2_0 Incl.
N 67 * Repl Qual Recy Parts LT Hook 1 Incl.
N 68 * Rpr LT Sidemember all (HSS) s ~.0 0_3
69 ELECTRICAL
70 R&I Battery m 0.3
71 R&I Battery tray 0.2
72 * Rept Qual Recy Parts Horn high note 1 jam, m Q,,~
73 ENGINE / T'RANSAXLE
74 * Repl Qual Recy Parts Air cleaner assy 1 Incl. m 0_6
75 R&I Intake duct m Incl.
76 R&I Resonator assy #1 m 0.3
77 WHEELS
78 * R&I RT/Front R&I wheel m Incl.
79 # Rpr CHECK BALANCE 0.3
N 80 * Subl RC-CON RT/Front Wheel +25% 1 156.25 m
81 COWL
82 * R&I RT Side cover
83 * R&I LT Side cover
84 PILLARS, ROCKER & FLOOR
N 85 R&I RT Raker molding 0.7
N 86 R&I LT Rocker molding 0.7
87 FRONT DOOR
9788679
1/16/2012 12:47:54 PM 079599 Page 3
Estimate of Record
Customer: 70HNSON, ALIKIA A
Vehicle: 2006 NISS MAXIMA SE 4D SED 6-3.5L-FI WHITE PRL
88 Blnd LT Outer panel
89 R8cI LT Belt w'strip
90 * R8cI LT Bodv side mldg
91 * R8cI LT Mirror assv
92 R&I LT Handle, outside frost
93 R8d LT R&I trim panel
94 # MISC. 1
95 # Subl Two wheel alignment 1 49.95 T
96 # Rpr SETUP AND MEASURE
97 # Rpr PULL TIME
98 # Repl FLEX ADDITIVE 1 4.00
99 # Repl SEAM SEALER 1 5.00
100 # Refn RESTORE CORROSION PROTECTION
101 # Subl REPLACE PINSTRIPES TAPE 1 25.00
102 # Repl CAR COVER 1 5.00
103 # Subl HAZARDOUS WASTE REMOVAL 1 3.00
0.3
0.3
0.3
0.4
0.5
1.0
2.0
0.2
1.1
0.1
104 OTHER CHARGES
105 # Towing 1 396.50
SUBTOTALS 5,090.45 32.5 14.4
NOTES
Line 3: AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 5: REMOVE LT RAIL END
Line 7: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 9: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 J KEYSTONE QUOTE #7955408
Line 10: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 11: INCLUDED W/ LKQ FRONT CUP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 12: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 13: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 J KEYSTONE QUOTE #7955408
Line 15: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 17: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 18: INCLUDED W/ LKQ FRONT CLIP AS PER ].C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 21: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 23: INCLUDED W/ LKQ FRONT CLIP AS PER ].C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 26: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 29: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 31: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 34: REFRIGERANT CAPACITY
R134 0408 1.1 +- .055 LBS
Line 36: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 41: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 44: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 45: INCLUDED W/ LKQ FROfYT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 47: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 50: R&I FENDER TO REPLACE HOOD HINGE
Line 53: TIME IS TO REPAIR DEFLECTION DAMAGE ALONG REAR EDGE FROM IMPACT WITH HOOD HINGE
Line 57: AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 58: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 64: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 /KEYSTONE QUOTE #7955408
Line 66: REPAIR DAMAGE @ FRONT OF APRON PANEL W/ PARTIAL REFINISH
9788679
1/16/2012 12:47:54 PM 079599 Page 4
Estimate of Record
Customer: 70HNSON, ALIKIA A
Vehicle: 2006 NISS MAXIMA SE 4D SED 6-3.5L-FI WHITE PRL
Line 67: INCLUDED W/ LKQ FRONT CLIP AS PER J.C. @ LKQ250 J KEYSTONE QUOTE #7955408
Line 68: REPLACE LT RAIL END CAP
Line 80: AS PER NICK @ ALLOY WHEEL REPAIR
Line 85: R8d TO REMOVE FENDERS
Line 86: R8cI TO REMOVE FENDERS
Estimate Notes:
*** VIR REPORTED 1/16/12 ***
PARTS SEARCH
SPOKE TO J.C. @ LKQ250 /KEYSTONE 1-800-334-9811 EXT-4819
SPOKE TO JOE @ STOYSTOWN 1-877-729-8770 EXT-6608
SPOKE TO BILL @ NEWCUMBERLAND 717-774-1190
ESTIMATE TOTALS
Category Basis Rate Cost #
Parts
Body Labor
Paint Labor
Paint Supplies
Miscellaneous
Other Charges
32.5 hrs
14.4 hrs
14.4 hrs
@
@
@
$44.00 /hr
$44.00 /hr
$ 22.00 jhr 4,644.00
1,430.00
633.60
316.80
49.95
396.50
Subtotal 7,470.85
Sales Tax $ 7,074.35 @ 6.0000 % 424.46
Grand Total 7,895.31
Deductible 250.00
CUSTOMER PAY 250.00
INSURANCE PAY 7,645.31
9788679
1/16/2012 12:47:54 PM 079599 Page 5
Estimate of Record
Customer: ]OHNSON, ALIKIA A
Vehicle: 2006 NISS MAXIMA SE 4D SED 6-3.SL-FI WHITE PRL
THE ABOVE IS AN ESTIMATE BASED ON OUR INSPECTION AND DOES NOT INCLUDE ADDITIONAL PARTS OR LABOR
WHICH MAY BE REQUIRED AFTER THE REPAIR IS STARTED. OCCASIONALLY AFTER THE REPAIR HAS BEGUN, WORN
OR DAMAGED PARTS ARE DISCOVERED. BECAUSE OF THIS THE ABOVE PRICES ARE NOT GUARANTEED. PRICES
SUBJECT TO CHANGE AFTER 30 DAYS.
Written Warranty
Faulkner Collision Center of Carlisle
THIS CERTIFICATE assures the repairs to which you and Faulkner Collision Center of Carlisle have agreed on Repair
Order No. have been completed. We guarantee the work performed at Faulkner Collision Center of Carlisle
so long as said vehicle shall remain under the present ownership. Items on the repair order, such as Sublet Work or
Sublet Labor are subject to the guarantee of those suppliers. This warranty shall only apply if the defects occurred
under normal driving conditions and not where any vehicle has been subjected to accidents, negligence, abuse or
misuse. Specifically excluded from this limited warranty is rust coming through the metal, scratches and gravel marks
acquired from driving conditions. This is a fragmented two part Written Warranty, and specific additional stipulations
pertaining to each fragmented part are stated hereafter:
1. WORKMANSHIP: Faulkner Collision Center of Carlisle provides a Lifetime Warranty against defective workmanship to
include welding and the application of materials utilized in making collision repairs against cracking, flaking, pitting or
deterioration. The Shop will at its sole option, repair and or re-repair any metal work warranted hereby.
2. PAINTING, STRIPES AND DECALS: Faulkner Collision Center of Carlisle provides a ~fetime Warranty on paint-related
priming and paint work against solvent blistering, peeling, hazing and excessive bss of pigmentation, and a Lifetime
Written Warranty on the application and adhesion of decorative stripes and decals, excluding defects which are caused
by extreme environmental conditions to which the vehicle may be exposed. The Shop will, at it's sole option, re-prime,
re-paint, re-stripe or re-decal the specific section or sections of the vehicle warranted hereby. Paint Warranty is valid
only when paint is applied over anginal factory finishes that are free of defects.
SPECIFICALLY EXCLUDED are incidental costs, such as towing fees, car rental charges, travel expenses or assemblies
and components which are not specif'~cally covered by this WRITTEN WARRANTY, nor as consequential damages such as
damage to other assemblies and components resulting from a defective part or installation of such part installed or
repaired during the repair included in the WRITTEN WARRANTY.
This WRITTEN WARRANTY shall not be varied, supplemented, qualified or interpreted by any prior course of dealings.
PRESENTED TO:
Name
Address
City/State/Zip Repair Order No.
Vehicle Date of Completion
Authorized by Tammy Gossard Date:
THIS WRITTEN WARRANTY shall be null and void if the repair is altered, adjusted or tampered with by any person not
authorize by the above named shop. This warranty is not transferable.
9788679
1/16/2012 12:47:54 PM 079599 Page 6
Estimate of Record
Customer: IOHNSON, ALIKIA A
Vehicle: 2006 HISS MAXIMA SE 4D SED 6-3.5L-FI WHITE PRL
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 CNIL PENALTIES.THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO
DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED:D=DISCONTINUED PART A=APPROXIMATE
PRICE B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR
S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS ADJ=ADJACENT ALGN=ALIGN
A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTNE PARTS ASSOCIATION D&R=DISCONNECT AND
RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED
MISC=MISCELLANEOUS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER
QTY=QUANTITY QUAL RELY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL
PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE
AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT
W/O=WITHOUT W/_=WITH/_ #=MANUAL LINE ENTRY *=OTHER [IE..MOTORS DATABASE INFORMATION WAS
CHANGED]. **=DATABASE LINE WIf}i AFTERMARKET N=NOTES ATTACHED TO LINE NAGS=NATIONAL AUTO GLASS
SPECIFICATIONS. MQVP=MANUFACTURER'S QUALITY AND VALIDATION PROGRAM.OPT OEM=ORIGINAL EQUIPMENT
MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR
DISCOUNT. NWCPP=NATIONWIDE CRASH PARTS PROGRAM.THE ATTACHED ESTIMATE REPRESENTS AN APPRAISAL
OF THE COST OF REPAIR FOR THE VISIBLE DAMAGE TO THE VEHICLE NOTED AT THE TIME OF INSPECTION
NECESSARY TO RETURN THE VEHICLE TO ITS PREDAMAGED CONDITION. COSTS ABOVE THE APPRAISED AMOUNT
MAY BE THE RESPONSIBILITY OF THE VEHICLE OWNER. THERE IS NO REQUIREMENT THAT THE VEHICLE OWNER
USE ANY SPECIFIED REPAIR SHOP. INFORMATION REGARDING REPAIR FACILITIES WHICH WILL BE ABLE TO REPAIR
THE VEHICLE FOR THE APPRAISED AMOUNT IS AVAILABLE FROM THE INSURANCE COMPANY. IF USED PARTS ARE
SPECIFIED, THEY ARE REQUIRED TO BE OF LIKE KIND AND QUALITY TO THOSE BEING REPLACED. INCIDENTAL
CHARGES SUCH AS TOWING, PROTECTNE CARE, CUSTODY, STORAGE, DEPRECIATION, BATTERY AND TIRE
REPLACEMENT ARE NOTED WHEN APPLICABLE.
9788679
1/16/2012 12:47:54 PM 079599 Page 7
Estimate of Record
Customer: ]OHNSON, ALIKIA A
Vehicle: 2006 NISS MAXIMA SE 4D SED 6-3.5L-FI WHI1E PRL
Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide
ARF3750, CCC Data Date 1/10/2012, and the parts selected are OEM-parts manufactured by the vehicles Original
Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM
(Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle
dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or
ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or
Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or
may have come from an alternate data source. Tilde sign (~) items indicate MOTOR Not-Included Labor operations.
The symbol (<>) indicates the refinish operation WILL NOT be performed as a separate procedure from the other
panels in the estimate. Non-0riginal Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or
Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts,
RCY, or USED. Reconditioned parts are described as Recond. Recored parts are described as Recore. NAGS Part
Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed on the
line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not
included. Pound sign (#) items indicate manual entries. Some 2010 vehicles contain minor changes from the
previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data
from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers
and prices should be confirmed with the local dealership.
CCC Pathways - A product of CCC Information Services Inc.
9788679
1/16/2012 12:47:54 PM 079599 Page 8
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Gower C~# Attorney
with Odometer Disclosure
Claim # 38-0P59-259
1N48N41E16C8097$5
Vehicle lderttifit:artion Ntmtber
Year 20U6 Make Nissan Model_Mexima SE_
Attorneyan-1~act {individual of organizatiors you wish to act far you in this matter}
Insurance Auto Auctions
Federal and State law require that lfic transferor/seller states the mileage upon transfer of ownership. ProviderE a false statement may result in
fines andJor imprisonment. The Transeror/Seller appoints the Attorney-In-Fact above to sign all papers and documents required to secure the
tide, and farther grants the aulttorityto endorse and transfer tide therein, and to disdose the mileage, for the vehicle described above, exactly
as stated in the following disclosure.
Odometer Reading {no tentfis}
Miles IGlometers
Ngleage in excess of the odometer mechanical limits.
NOT Actual Mileage. WARNING -0DOMETER D15CREPANCY
Any person who latowing}y and with intent to defraud any insurance company or other person files an application for insurance or a statement
of claim containing any materially false information or conceals for the purpose e~f misleadlrt6, infomtation concerning anyfad malarial thereto
commits a fraudulent insurance act, whid+ is a crime and subjects such person to u'indnal and tivll penalties.
Print Name of Owner :- ~ Signature of Owner r"
Print Name of Co-Owner~ Signature of Co-Owner
Form Must be Signed by all Registered Owners
Form Must be Notarized
tip a-C7 (,}-
In Witness Whereof, I/We have here unto set MyJOur hands} and seals} this ~~ day of ~~(Jiti~' ,
Subscribed and swan to itefore me this ~ ~` day of ~0.~.f ~ i }
SEAL N~rul Sad
r it>tla,aal E Shope. Notary F'udk
My Commission Expires + ~ ~ I ~ 1 I ~ ~ wyC..~ xi F~nlor. tie. z~otz
-- tNenber, Perrmyhrania Assxiation of Notaries
Notary Signature
9~~8679 re of the above odometer certification made bythe seller
Buyer Name (printed) Buyer Signature
01/16/12 09:41 AUTOSOURCE VALUATION Page 1
Via: Multiple AS Request: 30254339 Version: 1
ADMINISTRATIVE DATA
Faulkner Coll of Carlis
State Farm Insurance
Concordville Branch
1 State Farm Drive
Concordville PA 19339
Appraiser License:
Owner Name:
Owner City:
Owner State:
Owner Zip:
Estimator Name:
Estimator License:
Primary Impact:
ALUATION SUMMARY
2006 NISSAN MAXIMA SE 4D SEDAN
Claimant:
Insured:Johnson, Alikia
Claim:38-OP59-25901
Loss Date:01/11/2012
Loss Type:Collision
Policy:
Other:
JOHNSON
Carlisle
PA
17013-
SHAWN FEASER
564867
11
2006 NISSAN MAXIMA SE 4D SEDAN
See N.A.D.A See Valuation Autosource/
Value Section Detail Section N.A.D.A.
N.A.D.A. Retail Autosource Average
--------
Base Price: ---------
512,625 ---------------
512-486 ----------
512,556
Engine:
Transmission:
Odometer: -3,475 -2,875 -3,175
Equipment:
-------- 0
--------- 0
---
- 0
--------
Value Before Adjustments:
---------
59,150 --
----------
----------------
59,611 ---------
---------
59.381
Value Before Condition Adjs.: --
-- ----------------
----------------
59-611 ---------
---------
59,381
Suggested Total Condition Adj.: -50
Total Condition Adjusted Mkt Val: 59,331
General Sales Tax: 6.000$ 559.86
Title Fee:
Transfer Fee:
Deductible: -250.00
Net Adjusted Value:
Salvage/Other: -
NSOURCE ANALYSIS 2006 NISSAN MAXIMA SE 4D SEDAN
978~67~9
O1 16 12 09:41 AUTOSOURCE VALUATION Page 2
Via: Multiple AS Request: 30254339 Version: 1
VINSOURCE ANALYSIS (continued)
2006 NISSAN MAXIMA SE 4D SEDAN
VIN: 1N4BA41E16C809785
Decodes as: 2006 Nissan Maxima SE 4D Sedan
Accuracy: Decodes Correctly
History: No activity was reported
N.A.D.A. VALUE** 2006 NISSAN MAXIMA SE 4D SEDAN
**N.A.D.A. Vehicle Description: 2006 NISSAN Maxima-V6 Sedan 4D SE
N.A.D.A. values are as of January, 2012 from the Eastern Edition.
-----------Base Value----------- 512,625
-----------Mechanical-----------
Engine: SO
Transmission: SO
-----------Equipment------------
-------Equipment Subtotal------- SO
------Mileage: 158,130 Mi------- S -3,475
Adjusted Total 59,150
These current N.A.D.A. values are furnished under license from NADASC. All
values Copyright (C) NADASC 2012.
The values in the N.A.D.A. guide assume a vehicle in clean condition.
Appropriate deductions should be made to put a vehicle in salable condition.
SPECIAL NOTE ON OLDER VEHICLES: N.A.D.A.'s editors believe that most
optional equipment has little or no value on older vehicles. This is
especially true of options that cost relatively little to begin with and
which deteriorate with age or use.
LOSS VEHICLE VALUATION 2006 NISSAN MAXIMA SE 4D SEDAN
The Autosource database contains inspected dealer inventories, dealer
advertisements, phone verified vehicles, and private party advertisements
from thousands of sources including automotive publications, newspapers and
Web sites. Autosource uses vehicles comparable in year, make and model
within the specified market area, expanding as necessary, to determine the
loss vehicle's local market value. This valuation includes a representative
sample of the vehicles used to calculate the typical starting price.
The market search originated from Zip Code 17013, as determined by the
vehicle owner`s principally garaged area. Autosource located 32, 2006
Nissan Maxima vehicles which were used to determine the typical vehicle
price. Adjustments have been made to the comparable vehicles for value
differences in vehicle description as indicated in the "Veh Adj" field. The
sum of the 32 comparable vehicles is $425,069 for an average price of
513,283.
01/16/12 09:41 AUTOSOURCE VALUATION Page 3
~~~ltiple AS Request: 30254339 Version: 1
LOSS VEHICLE VALUATION (continued) 2006 NISSAN MAXIMA SE 4D SEDAN
The asking or actual sale price is displayed for each vehicle. If a vehicle
has been sold, the sold price is displayed with an (S) indicator. The
selling price may be substantially less than the asking price. In the case
of this 2006 Nissan Maxima, the difference between the asking price and
selling price is generally 60. This selling price adjustment has been
applied to the typical price. Additional adjustments have been made to the
typical vehicle price taking into consideration the loss vehicles mileage,
equipment and condition. All adjustments are vehicle specific and reflect
driving habits and condition for the vehicles market. A mileage adjustment
of 3.50 cents per mile has been applied.
Taking into consideration the vehicle specifics, the fair market value is
59,331.
VEHICLE VALUATION DETAIL 2006 NISSAN MAXIMA SE 4D SEDAN
Typical Vehicle Loss Vehicle Adjustment
City/State:Carlisle, PA Carlisle, PA
Price:512,486 512,48&
----Description-----
Year:2006
Make:Nissan
Model:Maxima
Edition:SE
Door:4D
Body:Sedan
Drive:2WD
Engine:6 Cylinder 3.5 Engine
Transmission:5 Speed Automatic
Color:Not Applicable
Odometer:76,050 Mi(Typical)
-----Equipment------
Convenience Options:Automatic Dimming
Air Conditioning
Telescopic Steering Whl
Strg Wheel Radio
Rem Trunk-L/Gate
Dual Zone Auto A/C
Cruise Control
Cargo/Trunk Net
Rear Window Defroster
Floor Mats
Tilt Steering Wheel
Garage Door Opener
2006
Nissan
Maxima
SE
4D
Sedan
2WD
6 Cylinder 3.5 Engine
5 Speed Automatic
Not Specified
158,130 Mi(Actual)
Automatic Dimming
Air Conditioning
Telescopic Steering
Strg Wheel Radio
Rem Trunk-L/Gate
Dual Zone Auto A/C
Cruise Control
Cargo/Trunk Net
Rear Window Defroster
Floor Mats
Tilt Steering Wheel
Garage Door Opener
-2,875
Other Optional:Center Console Center Console
Tinted Glass Tinted Glass
Head Airbags Head Airbags
01/16/12 09:41 AUTOSOURCE VALUATION Page 4
Via: Multiple AS Request: 30254339 Version: 1
VEHICLE VALUATION DETAIL (continued) 2006 NISSAN MAXIMA SE 4D SEDAN
9788679
Typical Vehicle Loss Vehicle Adjustment
Intermittent Wipers
Keyless Entry System
Lighted Entry System
Leather Steering Wheel
Overhead Console
Skyview Glass Roof
Side Airbags
Anti-lock Brakes
Sport Suspension
Fog Lights
Dual Airbags
Traction Control System
Trip Computer
Tachometer
Power Accessories:Power Drivers Seat
Power Steering
Power Windows
Power Mirrors
Power Brakes
Power Door Locks
Radio/Phone/Alarm:Alarm System
Theft Deterrent System
Compact Disc W/Tape
Seat Options:Velour/Cloth Seats
Split Folding Rear Seat
Bucket Seats
Wheel Options:Aluminum/Alloy Wheels
Autosource Value Before
------Interior-------
Seats:Minor
Carpets:Minor
Int Trim:Minor
G1ass:Good
Headliner:Good
------Exterior------
Body:Minor
Paint:Minor
Ext Trim:Good
-----Mechanical-----
Engine:Minor
Transmission:Minor
-------Tires--------
Front Tires:Good
Rear Tires:Good
01/16/12 09:41
Via: Multiple
VEHICLE VALUATION DETAIL
9788679
Intermittent Wipers
Keyless Entry System
Lighted Entry System
Leather Steering
Overhead Console
Skyview Glass Roof
Side Airbags
Anti-lock Brakes
Sport Suspension
Fog Lights
Dual Airbags
Traction Control
Trip Computer
Tachometer
Power Drivers Seat
Power Steering
Power Windows
Power Mirrors
Power Brakes
Power Door Locks
Alarm System
Theft Deterrent
Compact Disc W/Tape
Velour/Cloth Seats
Split Folding Rear
Bucket Seats
Aluminum/Alloy Wheels
Condition Adjustments:
Wear Minor Wear
Wear Minor Wear
Damage Minor Damage
Good
Good
Damage Minor Damage
Wear Minor Wear
Good
Wear Minor Wear
Wear Minor Wear
Replace
Good
9 611
-50
Total Condition Adjustments: -50
AUTOSOURCE VALUATION Page 5
AS Request: 30254339 Version: 1
(continued) 2006 NISSAN MAXIMA SE 4D SEDAN
Typical Vehicle Loss Vehicle Adjustment
Prior Damage:
Condition Adjustment: -50
Net Condition Adjustment: -50
Total Condition Adjusted Market Value: 59,561
VALUATION NOTES
o Adjustments of Special Note
2006 NISSAN MAXIMA SE 4D SEDAN
- A mileage adjustment of 3.50 cents per mile/kilometer has been applied.
This adjustment is based on the vehicle year, vehicle category and
market area. Mileage adjustments are capped at 40% of the vehicle`s
starting value.
- No special adjustments were made for this vehicle.
o Information provided by State Farm Insurance
- Loss vehicle description was provided by State Farm Insurance
- All values are in U.S. dollars.
o Autosource Valuation Process
- Over 3,800,000 vehicles are entered weekly into the database used for
researching this value. This database includes dealer inspected, dealer
inventory, dealer advertised, phone verified and advertised private
party vehicles.
- The originating search area for this valuation was Carlisle,
Pennsylvania.
o Other Adjustments or Comments
- SELECT SERVICE ADVISOR DAN COONS ESTIMATE AMOUNT 57895.31 TOWBILL
5396.50
- TIRE TREAD DEPTH FRONT -4/32" (PLUG IN RT. FRONT TIRE) REAR - 5/32"
- The tax was calculated based on a date of loss of 01/11/2012 using zip
17013, in CARLISLE, Cumberland County, Pennsylvania. The city may vary
from search area to reflect correct tax location.
o Conditioning Notes
01/16/12 09:41 AUTOSOURCE VALUATION Page 6
Via: Multiple AS Request: 30254339 Version: 1
VALUATION NOTES (continued) 2006 NISSAN MAXIMA SE 4D SEDAN
- TIRES
* FRONT TIRES: 4/32" TREAD DEPTH PLUG IN RT FRONT TIRE
97886~'l9REAR TIRES: 5/32" TREAD DEPTH
ORIGINAL EQUIPMENT GUIDE 2006 NISSAN MAXIMA SE 4D SEDAN
----------Engine Options-----------
* 6 Cylinder 3.5 Engine STD
- ----Other Optional Equipment ------
* Anti-lock Brakes STD
* Center Console STD
* Dual Airbags STD
* Fog Lights STD
* Head Airbags STD
Heated Steering Wheel
* Intermittent Wipers STD
* Keyless Entry System STD
* Lighted Entry System STD
* Leather Steering Wheel STD
Navigation System 51,800
* Overhead Console STD
* Side Airbags STD
Stability Cntrl Suspensn 5600
* Skyview Glass Roof STD
Rear Spoiler 5260
* Sport Suspension STD
* Tachometer STD
* Trip Computer STD
* Traction Control System STD
* Tinted Glass STD
Xenon Headlamps
- ----Radio/Phone/Alarm Option s-----
* Alarm System STD
Bose Sound System
In-Dash CD Changer &Tape
* Compact Disc W/Tape STD
Sirius Satellite Radio 5350
* Theft Deterrent System STD
XM Satellite Radio 5350
- ----------Wheel Options----- ------
* Aluminum/Alloy Wheels STD
Chromed Alloy Wheels 51,550
- ----------Roof Options------ ------
Power Moonroof 5900
- ------Transmission Options-- ------
6 Speed Manual SO
* 5 Speed Automatic STD
- -------Convenience Options-- ------
* Air Conditioning STD
* Automatic Dimming Mirror STD
Cargo/Trunk Mat S60
* Cruise Control STD
* Cargo/Trunk Net STD
* Rear Window Defroster STD
* Dual Zone Auto A/C STD
* Floor Mats 5100
* Garage Door Opener STD
Mud/Splash Guards 5130
Reverse Sensing System
* Rem Trunk-L/Gate Release STD
* Strg Wheel Radio Control STD
* Telescopic Steering Whl STD
* Tilt Steering Wheel STD
- --------Power Accessories--- ------
Heated Power Mirrors
* Power Drivers Seat STD
Dual Power Seats
* Power Brakes STD
Pwr Driver Lumbar Supp
* Power Door Locks STD
* Power Mirrors STD
* Power Steering STD
Pwr Tilt/Tele. Str Wheel
* Power Windows STD
- ----------Seat Options------ ------
* Bucket Seats STD
Driver Seat Memory
Heated Front Seats
Leather Seats
* Split Folding Rear Seat STD
* Velour/Cloth Seats STD
------------------------------Option Packages-------------------------------
Hands-Free Communication 5300
01/16/12 09:41 AUTOSOURCE VALUATION Page 7
Via: Multiple AS Request: 30254339 Version: 1
ORIGINAL EQUIPMENT GUIDE (continued) 2006 NISSAN MAXIMA SE 4D SEDAN
Preferred Package 53,650
9788679
Includes Power Passenger Seat;
Heated Front Seats; Compass; Heated
Mirrors; Heated Power
Tilt/Telescopic Steering Wheel;
Driver Power Lumbar Support; Rear
Spoiler; Xenon Headlights; Driver
Seat Memory; Bose Sound System;
Leather Seating.
Premium Audio Package 51,000 Includes Bose Audio System; In-Dash
6 Disc Changer With Cassette; 8
Speakers.
Sensory Package 52,350 Includes Power Passenger Seat;
Heated Front Seats; Heated Outside
Mirrors; Compass; Bose Sound System;
Leather Seating.
Base retail price: 528,665
Loss Vehicle manufacturer s suggested retail price as reported: 528,765
Editions available for the same body style (in order of original cost,
increasing): *SE, SL, SE Elite
* Indicates loss vehicle equipment.
VEHICLE LOCATOR SERVICE 2006 NISSAN MAXIMA SE 4D SEDAN
After your claim is settled Autosource provides free assistance in locating
your next vehicle. Your request can be submitted online 24hrs. per day at
https://autosource.audatex.us. Under Additional Services click the
Autosource Vehicle Locator Service Form link to complete the VLS form. Or
you can call us Monday through Friday, between 8:00 AM and 5:00 PM,
Pacific time at (800)351-3133, ext 7428. Our specialists will work with
you to find a new or used vehicle in your area.
PENNSYLVANIA REGULATORY STATEMENT 2006 NISSAN MAXIMA SE 4D SEDAN
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 such person to
criminal and civil penalties.
Any person who knowingly and with intent to injure or defraud any insurer
files an application or claim containing any false, incomplete or misleading
information shall, upon conviction, be subject to imprisonment for up to
seven years and the payment of a fine of up to 515,000.
01/16/12 09:41 AUTOSOURCE VALUATION Page 8
Via: Multiple AS Request: 30254339 Version: 1
ABOUT YOUR VALUATION 2006 NISSAN MAXIMA SE 4D SEDAN
This report contains proprietary information of Audatex and shall not be
disclosed to any third party (other than the insured or claimant) without
Audatex~s prior written consent. If you are the insured or claimant and
have questions regarding the description of your vehicle, please contact the
insurance company that is handling your claim. Information within
~~•ce/NICB is provided solely to identify potential duplicative claims
activity- User agrees to use such information solely for lawful purposes.
Tax rates contained herein are based on general sales tax data provided by
Vertex Inc. Excise, use, registration, licensing and other taxes and fees
that may be applicable are not included- Audatex makes no representations
or warranties concerning the applicability or accuracy of such tax data.
Report Generated by Audatex, a Solera Company
US Pat. No 7912740B2
(C) 2012 Audatex North America, Inc. All Rights Reserved.
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INSiIRA1V[•F
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Insurance Auto Auctions,lnc.
Attn: Settlement Group
100 Industrial Way
Conshohocken, PA 19428-1058
Phone: (610) 277-0894
Fax: (610) 27T-9276
E-mail: IAA ASAP_Philadelphia(d3iaai.com
Tax I D #: 954455113
Salvage Info
Stock #: rmation
000-09245091
Branch: Harrisburg
Insured: ALiKIA JOHNSON
Owner: ALIKIA JOHNSON
Claim #: 380P59259
Year: 2006
MakeJModel: NISSAN/MAXIMA
V1 N: 1 N4BA41 E 160809785
ACV: $9331
Plck UQ Information
FAULKNER COLLISION CENTER OF CARLISLE
2 Roadway. Dr
Carlisle, PA 17013
Seller DiracdBuv~r Information
Resale Cert#: VD030050 (PA}
IMS Auto Sales LLC
2810 Paxton Street Suite B
Harrisburg, PA 17111
Date of Events
Loss Date
01!11!2012
Assigned 01/18/2012
Released 01/20/2012
Pickup 01/20/2012
Title Received 02/22/2012
Sale Doc. Received 02/23/2012
Auction Date 05/02/2012
~r~~f~+nent Date 05/03/2012
Reported to NICB 05/07/2012
REMITTANCE: 9328109
DATE: 05107/2012
Remittance Payable To
State Farm Mutual Automobile Ins Co - PA ACH
State Farm Claims
PO Box 106117
Atlanta, GA 30348117
Attn: Salvage Dept
Check Amount
High Bid
$2,381.50
$2,900.00
Pool Charges
Poot Fee $122.00
Total 6122.00
Advance Charges
Tow
$396.50
Total 6396.50
Payment Amount 62,3s1.5o
IAA Doc. RP002_SF.rpt
VERIFICATION
I, Benjamin W. Lawrence, Esquire, attorney for the Plaintiff(s) do hereby swear
and affirm that the averments in the attached Complaint are true and correct to the best
of my knowledge, information and/or belief. These averments are made subject to the
penalties of 18 Pa.C.S.A. §4904 relating to unsworn jal+~ification to authorities.
amin W. Lawrence
Date "~~~~~ ~ ,
e
C.J �
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jypl.wc�
jvpl
IN THE COURT OF COMMON PLEAS --
CUMBERLAND COUNTY, PENNSYLVANIA -�
CIVIL DIVISION
STATE FARM FIRE & CASUALTY
Plaintiff No: 13-0210
VS.
PRAECIPE FOR DEFAULT JUDGMENT
MANUEL ROMERO-MONDRAGO
Defendant FILED ON BEHALF OF
Plaintiff
COUNSEL OF RECORD OF
THIS PARTY:
Benjamin W. Lawrence, 209032
WELTMAN, WEINBERG & REIS CO. , L.P.A.
325 CHESTNUT STREET SUI'T'E 501
PHILADELPHIA, PA 19106-2614
215-599-1500
FAX: 215-599-1505
09788679 C Y Jer DKM
Judgment Amount $8007. 64
Q
so�� a
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
STATE FARM FIRE & CASUALTY
Plaintiff
VS. Civil Action No. 13-0210
MANUEL ROMERO-MONDRAGO
NOTICE OF JUDGMENT OR ORDER
TO: ( ) Plaintiff
(xx) Defendant
( ) Garnishee
You are hereby notified that the 1 owing Order of Judgment
was entered against you on
(xx) Assumpsit Judgment in the amount of $8007. 64 plus costs.
( ) Trespass Judgment in the amount of $ plus costs.
( ) If not satisfied within sixty (60) days, your motor vehicle
operator' s license and/or registration will be suspended
by the Department of Transportation, Bureau of Traffic Safety,
Harrisburg, PA.
(xx) Entry of Judgment of
( ) Court Order
( ) Non-Pros
( ) Confession
(xx) Default
( ) Verdict
( ) Arbitration ftard
Prothonotary
By: - 4%
PROTHONOTAR DEP
MANUEL ROMERO-MONDRAGO
3417 NORTHSIDE DR
ATLANTA, GA 30354
Plaintiff 's address is:
c/o WELTMAN, WEINBERG & REIS CO. , L.P.A. ,
325 CHESTNUT STREET SUITE 501
PHILADELPHIA, PA 19106-2614
215-599-1500
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
STATE FARM FIRE & CASUALTY
Plaintiff
VS. Civil Action No. 13-0210
MANUEL ROMERO-MONDRAGO
PRAECIPE FOR DEFAULT JUDGMENT
TO THE PROTHONTARY:
Kindly enter Judgment against the Defendant MANUEL ROMERO-MONDRAGO above
named, in the default of an Answer, in the amount of $8007.64 computed as
follows:
Amount claimed in Complaint $8007 . 64
Less payments / adjustments made $0 . 00
Attorney' s fees $0 . 00
TOTAL $8007. 64
I hereby certify that appropriate Notices of Default, as attached have
been mailed in accordance with PA R.C.P. 237 .1 on the dates indicated on the
Notices .
WELTMAN, WEINBERG & REIS CO. , L.P.A.
By:
Ben ami Lawrence, 209032
09788679 C Y Jer DKM
Plaintiff ' s address is:
c/o WELTMAN, WEINBERG & REIS CO. , L.P.A. ,
325 CHESTNUT STREET SUITE 501 PHILADELPHIA, PA 19106-2614
And that the last known address of the Defendant is
MANUEL ROMERO-MONDRAGO
3417 NORTHSIDE DR
ATLANTA, GA 30354
IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
STATE FARM FIRE &CASUALTY
Plaintiff
Case No. 13-0210
vs.
MANUEL ROMERO-MONDRAGO
Defendant
IMPORTANT NOTICE
TO:
MANUEL ROMERO-MONDRAGO
3417 NORTHSIDE DR FS S 5 2013
ATLANTA, GA 30354
Date of Notice:
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE
PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS
TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS
NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR
PROPERTY OR OTHER IMPORTANT RIGHTS.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER, GO
TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION
ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU
WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS
AT A REDUCED FEE OR NO FEE.
CUMBERLAND COUNTY BAR ASSOCIATION
32 SOUTH BEDFORD STREET
CARLISLE, PA. 17013
(717)249-3166
WELTMAN, WEINBERG& REIS CO., L.P.A.
By: —
Michael D ughe
P.A.I.R
WELTMAN,WEINBERG & REIS CO., L.P.A.
325 Chestnut Street, Suite 501
Philadelphia, PA 19106
(215)599-1500
(215) 599-1505
9788679 Y PHI
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
STATE FARM FIRE & CASUALTY
Plaintiff
VS. Civil Action No. 13-0210
N
MANUEL ROMERO-MONDRAGO ON-MILITARY AFFIDAVIT
The undersigned is the duly authorized agent and/or attorney for the
Plaintiff in the within matter and states as follows:
Affiant states that the within Affidavit is made pursuant to and in
accordance with the Servicemembers ' Civil Relief Act (SCRA) , 50 U.S.C. App.
521 .
Affiant further states that based upon investigation it is the affiant ' s
belief that the Defendant, MANUEL ROMERO-MONDRAGO is not in military
service.
Affiant further states that this belief is supported by the attached
certificate from the Defense Manpower Data Center (DMDC) , which states that
the DMDC does not possess any information indicating that the below
individual is in the military service:
MANUEL ROMERO-MONDRAGO
3417 NORTHSIDE DR
ATLANTA, GA 30354
Affiant further states that the averments contained herein are true and
correct to the best of Affiant 's knowledge, information and belief and that
these averments are made subject to the penalties of 18 Pa C.S.A. Section
4904 relating to unsworn falsification to authorities.
AFFI
as of:Mar-12-2013 05:13:22
Department of Defense Manpower Data Center Resets
SCRA 3.0
Sate R
PINUAW to S —T' n Civil Relief Act
Last Name: ROMERO-MONDRAGO
First Name: MANUEL
Middle Name:
Active Duty Status As Of: Mar-12-2013
On Active Duty On AW"D*Ste"Mo
Active Dtty&AI Deft Active *End 0" SGtRa servitors Comporlar t
NA NA NO NA
TNs resporm reflectstoksiWduals active duty sWA bwd an tlm A" Vitus Date
Lolt Active Duty MW 397 Days of AWAPra Duty OMs
Active Duty Start Date Active D*End DMa am" service Compo"W
NA NA No NA
TNs response reflects where aM WX W W left activa da4r.+t a wIpW1:367 days precsdirp the Acpw OLO StaWs Data
The Mer*w or HislHer tk*,Wens Wftod of*Fsdwa 0e1W*to AcN*O*anAa"Ouly auras 046
order N cn b'W Doss Ord N001005M Est!fortis swo Servos cWgw pt
NA NA Na NA
TNs response ra0ac#wfWW fffe lg Mitt p ltiedtN urvt tai rwytyW� to report for adve duty
Upon searching the data banks of the Department of Defense Manpower Deta Centlrr,based on the information that you provided,the above is the status of
the individual on the active duty status date as to all branches of the Uniformed Services(Army,Navy,Marine Corps,Air Force,NOAH,Public Health,and
Coast Guard). This status includes information on a Servic:emmember or his/her unit receiving notification of future orders to report for Active Duty.
HOWEVER,WITHOUT A SOCIAL SECURITY NUMBER,THE DEPARTMENT OF DEFENSE MANPOWER DATA CENTER CANNOT AUTHORITATIVELY
ASSERT THAT THIS IS THE SAME INDIVIDUAL THAT YOUR QUERY REFERS TO.NAME AND DATE OF BIRTH ALONE DO NOT UNIQUELY
IDENTIFY AN INDIVIDUAL.
Jt�]1 s
a. erg
Mary M.Snavely-Dixon,Director
Department of Defense-Manpower Data Center
4800 Mark Center Drive,Suite 04E25
Arlington,VA 22350
The Defense Manpower Data Center(DMDC)is an organization of the Department of Defense(DoD)that maintains the Defense Enrollment and Eligibility
Reporting System(DEERS)database which is the official source of data on eligibility for military medical care and other eligibility systems.
The DoD strongly supports the enforcement of the Servicemembers Civil Relief Act(50 USC App.§501 at seq,as amended)(SCRA)(formerly known as
the Soldiers'and Sailors'Civil Relief Act of 1940). DMDC has issued hundreds of thousands of"does not possess any information indicating that the
individual is currently on active duty"responses,and has experienced only a small error rate. In the event the individual referenced above,or any family
member,friend,or representative asserts in any manner that the individual was on active duty for the active duty status date,or is otherwise entitled to the
protections of the SCRA,your are strongly encouraged to obtain further verification of the person's status by contacting that person's Service via the
"defenselink.mil"URL:http://www.defenselink.m!Vfaq/pis/PCOgSLDR.html, If you have evidence the person was on active duty for the active duty status
date and you fail to obtain this additional Service verification,punitive provisions of the SCRA may be invoked against you. See 50 USC App.§521(c).
This response reflects the following information: (1)The individual's Active Duty status on the Active Duty Status Date(2)Whether the individual left Active
Duty status within 367 days preceding the Active Duty Status Date(3)Whether the individual or his/her unit received early notification to report for active
duty on the Active Duty Status Date.
More information on"Active Duty Status"
Active duty status as reported in this certificate is defined in accordance with 10 USG§101(d)(1). Prior to 2010 only some of the active duty periods less
than 30 consecutive days in length were available. In the case of a member of the National Guard,this includes service under a call to active service
authorized by the President or the Secretary of Defense under 32 USC§502(f)for purposes of responding to a national emergency declared by the
President and supported by Federal funds. All Active Guard Reserve(AGR)members must be assigned against an authorized mobilization positions in the
unit they support. This includes Navy Training and Administration of the Reserves(TARs),Marine Corps Active Reserve(ARs)and Coast Guard Reserve
Program Administrator(RDAs). Active Duty status also applies to a Uniformed Service member who is an active duty commissioned officer of the U.S.
Public Health Service or the National Oceanic and Atmospheric Administration(NOAA Commissioned Corps).
Coverage Under the SCRA is Broader in Some Cases
Coverage under the SCRA is broader in some cases and includes some categories of persons on active duty for purposes of the SCRA who would not be
reported as on Active Duty under this certificate. SCRA protections are for Title 10 and Title 14 active duty records for all the Uniformed Services periods.
Title 32 periods of Active Duty are not covered by SCRA,as defined in accordance with 10 USC§101(d)(1).
Many times orders are amended to extend the period of active duty,which would extend SCRA protections.Persons seeking to rely on this website
certification should check to make sure the orders on which SCRA protections are based have not been amended to extend the inclusive dates of service.
Furthermore,some protections of the SCRA may extend to persons who have received orders to report for active duty or to be inducted,but who have not
actually begun active duty or actually reported for induction. The Last Date on Active Duty entry is important because a number of protections of the SCRA
extend beyond the last dates of active duty.
Those who could rely on this certificate are urged to seek qualified legal counsel to ensure that all rights guaranteed to Service members under the SCRA
are protected
WARNING: This certificate was provided based on a last name,SSN/date of birth,and active duty status date provided by the requester. Providing
erroneous information will cause an erroneous certificate to be provided.
Certificate ID: J24BNE80FOC3P80
WELTMAN, WEINBERG & REIS, CO. , L. P.A.
BY: Michael J. Dougherty, 76046 Attorney for Plaintiff (s)
I .D. No. 76046
323 W. Lakeside Ave 2nd Fl
Cleveland, Oh 44113
216-739-5080
FAX: 216-739-5115
File # 09788679 C Y Bro TWI
STATE FARM FIRE & CASUALTY
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
vs .
MANUEL ROMERO-MONDRAGO
CASE NO. 13-0210
C) r+
4
rr W
3�+ 3:m:—
PRAECIPE TO SATISFY =73 zz
.<> co
X Q c3
TO THE PROTHONTARY:
Kindly mark the case and judgment entered against Defendant
MANUEL ROMERO-MONDRAGO as satisfied.
WELTMAN, WEINBERG & REIS CO. , L. P.A.
By
Michael J. o gherty
Attorney f r Plaintiff
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