HomeMy WebLinkAbout03-01-13 (2)J Lsos61a1as
REV-1500 Ex`°~ "' l"' `
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes ~""°~"`" ~ County Code Year File Number
PO BOx z8o6ox INHERITANCE TAX RETURN
Harrisburg PA x7128-0601 RESIDENT DECEDENT ~~ I ~`~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDVVYY Date of Birth MMDDYYYY
04/18/2010 04/02/1942
Decedent's Last Name Suffix Decedent's First Name MI
ORLOWSKY JAMES M
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
O 1. Original Return ~ 2. Supplemental Return (~ 3. Remainder Return (Date of Death
Prior to 12-13-82)
O 4. Limited Estate C~ 4a. Future Interest Compromise (date of O 5. Fetleral Estate Taz Return Required
death after 12-12-82)
O 6. Decetlent Died Testate C7 7. Decedent Maintained a Living Trust ~ S. Total Number of Safe Deposit Boxes
(Attach Copy of WIII) (Attach Copy of Trust.)
O 9. Litigation Proceeds Received O t0. Spousal Poverty Credit (Gate of Death t~ 11. Election to Taz under Sec. 9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
Jac ueline M. Verne Es -~
9 Y. 4 (717) 24390 w ~ ~
r O fr1
First Line of Atldress
44 S. Hanover Street
Second Line of Address
City or Post Office
Carlisle
Correspondent's a-mail address: jnlVemey@a01.C0111
State ZIP Code
PA 17013
REGIS~'R tjfj WILLS U~NLW ~
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DATE FILEEI ~? ~
Under penalties of perjury, I tleclare Inat I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, wrtect and complete. Declaration or preparar other than the parsonai representative is based on all information o1 which preparer has any knowletlge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE
L 1505610105
Side 1
1505610105 J
Ca'
15g56102g5
REV-1500 EX (Fij
Decedents Social Security Number
oeceae~rs Name: James M. Orlowsk
RECAPRUTATION
1. Real Estate (Schedule A) ..................................... ....... 1.
2. Stocks and Bonds {Schedule B) ........................... ........... 2
3. Closely Held Corporetion, Partnership or Sole-Proprietorship (Schedule C) .... 3.
4. Mortgages and Notes Receivable (Schedule D) .... ................... .. 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)..... .. 5. 20,673.19
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6.
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested...... .. 7.
8. Total Gross Assets (total Lines 1 through 7) ........ ... . .. 8. 20,873.19
9. Funeral Expenses and Administrative Costs (Schedule H)..... _ ......... ... 9. 500.00
10. Debts of Decedent, Mortgage Liabilities antl liens (Schedule I). _ _ .. _ .. 10.
11. Total Deductions (total Lines 8 and 10) ................................. 11.
12. Net Value of Estate (Line 8 minus Line 11) ....... ......... .... ..... .. 12.
13. Charitable and Governmental Bequests/Sec 9f 73 Trusts for which
an election to tax has not been made (Schedule J) ........ ......... .. 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) ............. ........ .. 14.
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
a[the spousal [ax rate, or
transfers under Sec. 9116
(a)(1.2) X .0_ 15.
16. Amount of Line 14 taxable
at lineal rate X .0 45 20,173.19 16.
17. Amount of Line 14 taxable
at sibling rate X .72 17.
i6. Amount of Line 74 taxable
at collateral rate X .15 1 B.
19. TAX DUE ......................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
1505610205
Side 2
20,173.19
907.80
907.80
C7
1505610205 J
REV-15o0 EX (FI) Page 3
Decedent's Complete Address:
File Number
James M. Orlowsky
STREET ADDRESS
55 West View
CITY __ _. _. - STATE
Carlisle
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
8. Discount
3. Interest
4. It Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
fill in oval on Page 2, Line 20 to request a refund.
(3)
(4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the 7AX DUE. (5)
Make check payable to: REGISTER OF WILLS, AGENT.
907.80
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred .._ ........................................................................._,,... ...... ^
b, retain the right to designate who shall use the properly transferred or its income ...._ ................................ ...... ^
c. retain a reversionary interest ......................................._........_....,..........................,........_............_....._...... ...... ^
d, receive the promise for life of either payments, benefits or care?........._............_........._...........__ ............. ...... ^
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................._......................._............_........_.................................... ...... ^
3. Did decedent own an "intrust for" or payable-upon-death bank account or security at his or her death?......._ ..... ^
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? _. ..........._... _........_._ .. ................. . ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN
For dates of death on or after July 1,1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for lbe use of the surviving spouse
is 3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dales of death on or after Jan. 1, 1995, the taz rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only benefciary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(aj(i.2j].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4,5 percent, except as noted in [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
ZIP
PA 17013
(1) 907.80
Total Credits (A + 8) (2)
FEVn5o8 EX+ (o6-a)
pennsylvania
iiT DEPARTMENTOF REVENUE
INHERITANCE TA% RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS & MISC.
PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
James M. Orlowsky 21-10-0503
If more space is needed, use additional sheets of paper of the same size.
REV-1511 ER+ (10-09)
Pennsylvania SCHEDULE H
oEaanrmervr or sEVervuE FUNERAL EXPENSES AND
INHERttANCE TAx RETURN ADMINISTRATIVE COSTS
RESlDFNT DECEDENT
ESTATE OF FILE NUMBER
James M. Orlowsky 21-10-0503
Decedent's debts must be reported on Schetlule i.
A. I FUNERAL EXPENSES:
1,
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
C1tY _.. .State
Year(s) Commission Paid:
2. Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State
Relationship of Claimant to Decedent
4. Probate Fees:
5. Accountant Fees:
6. Tax Return Preparer fees:
7.
ZIP
ZIP
500.00
TOTAL (Also enter on Line 9, Recapitulation) I; 500.00
If more space is needed, use additional sheets of paper of the same size.
' W E I T Z
L U X E N B E R G
A P R O F E S S I O N A L C O R P O R A T I O N
• L A W O F F I C E S.
700 BROADWAY • NEW YORK, NY 10003-9576
TEL. 212-558-5500 FAX 212-344-54b1
W W W.W EITZLUXCOM
PERRY VvEITZ
ARTHUR M. LUXENBERG
ROBERT J. GORDON }t
EDWARD S. BO6EK
EDWARD BRANIFF TT
JOHN M. BROAODUS E
DANIEL C. BURKE
PATTI BURBHTYN ti
LISA 'MTHANSON BU6LH
BRIAN BUTCHER i
DAVID A. CHANDLER
VINCENT CHENG
EILEEN CLARNE
TIOMAS COMERFORD T}
ADAM R. COOPER
BENJAMIN DARCNE
CHARLES M. FERGUfiON
STUART R. FRIEDMAN
STE4EN J. GERMAN Tf§
UWRENCE GOLOHIRSCH ^
ROBIN L.OgEENWALO'
EDWARD J. W1HN'
CATHERINE MEACOX }}
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JOSHUA VITOW
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JOSEPH PATRICK PoLLIAMS
NILHOUB WSE
ALUN 2ELIKOVIC
GLENN ZUCKERMAN
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Jacqueline M Verney Esq.
44 South Hanover Street
Carlisle, PA 17013
Dear Sir:
RE: Jim Orlowsky #206368
11/30/2012
Enclosed please find a settlement check in the sum of $15,047.05 which represents the above-
referenced client's net share from defendant, MANVILLE TRUST. Please refer to the enclosed
balance sheet for details concerning this settlement payment.
Please note that this Estate has either full Letters of Administration or full Letters Testamentary.
In as much as your firm is the attorney for the estate of this client, it is your responsibility to ensure that
these funds are properly distributed.
If all necessary filings have been completed for this estate and you wish to have future checks
made payable to the estate representative, please notify us in writing of such request.
Should you have any questions concerning the above, please feel free to contact the undersigned
at your convenience.
Very Truly Yours,
WEITZ &LUXENBERG, P.C.
210 LAKE DRIVE EAST, SUITE 101 • CHERRY HILL, NJ 08002 • TEL 856-755..1115 • FAX 856755-1995
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Jacqueline M Verney Esq.
44 South Hanover Street
Carlisle, PA 17013
RE: Jim Orlowsky #206368
Dear Sir:
Enclosed please find a settlement check in the sum of $5,626.14 which represents the above-
referenced client's net share from defendant, NATIONAL GYPSUM CO. TRUST. Please refer to the
enclosed balance sheet for details concerning this settlement payment.
Please note that this Estate has either full Letters of Administration or full Letters Testamentary.
In as much as your firm is the attorney for the estate of this client, it is your responsibility to ensure that
these funds are properly distributed.
If all necessary filings have been completed for this estate and you wish to have future checks
made payable to the estate representative, please notify us in writing of such request.
Should you have any questions concerning the above, please feel free to contact the undersigned
at your convenience.
Very Truly Yours,
WEPIZ & LUXENBERG, P.C.
20U L1ilCE DRNE EAST, SUCLF,:OS • CHHER,RRY HILL, Nl 08002 • TEL 856-955-L1 LS
I RRO Cfl1NT[JRY PARK FAST. Si:ITE 700 • LOS ANGELES, CA 90067 • T13L.310-2d7-p921
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~• ~s r '.' 'WJURED~PARTY. NAME: Jim Orlowsky ~ -
.CLAIM # ,, .1483563
• .' _'~ ~IAW FiRM.' •' ~.. WEITZ & LUXENBERG ~ ~` , '. ~ .
LIQUIDATED'VALUE: $350,000.00 ~ ~ ~, ~"
°~ ~~!~ .SETTLEMENT,VAL•UE: $26,250:00 : ` :~ ,
' ,; 'DEFINITIONS
;, I understand-that certain words used in this Release will be considered to Have the ,
`~ `meanings, defined below: ~ ~~
A TRUST is [he Manville Personal-Injury Settlement Trust. PLAN is'the Manville '•
;, z - -
~Coiporation's'Second, Amended and Restated Plan or Reorganization:•;REL'EASED',
-` ' " , ;PARTIES are the~people and organizations that I agree to discharge froimactual or.i ~ .
'potential legal'duties,:claims or liabilities, and.include the Trust, Manville Corporation "':
.'wand,subsidiaries;;al'I`Settling'Insurance Companies as defined~in the;Plan, the distribufor•• .
`~_ < Pacor"their trustors =trdstees directors officers agents servants employees attocne_ys -• -
=,- "successors. and assrggs; heirs and executors, and anyand all other persons or.' ; • . ' `
: ~ ;. _ „ ; ' o>•gamzations wh'o were entitled to benefit from the injunction entered on: November"28, ~~ '
''1988 in~dieArdar Confnning the Plan, and subsequent Orders issued by, the U.S. ;;~
' - ~ !Bankruptcy;court forthe Southern District of New York or the U.S: Districf Courts•fdr.•~
~'~ihe Eastern•and'Southern Districts of New York, all of whom are collectively referred,to
`' ~ `as the"'Trust".: PAYMENT PLAN is the compensation program described in the Trust , .
r :'~~ • ~ Drstnbufion Process (';TDP") attached.to the,Stipulation of Settlement'in the Class Action
~.
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B. '','fhis•documentiis aRELEASE or covenant not to sue releasing any and.all claims o
-; ;(except'as noted in the last sentence of Paragraph 3) including, but not,limited to'personal .
;;-,~ itiJury arid:wrongful~death claims asserted against the Trust andaose'persons or; : , ~ .
~.orgariizations-defined•as the Released Parties: SETTLEMENT~I'AYMENT(S)-,are the
,' amounts of money I wilt actually receive under the Payment Plan: The total°atnount I
`will receive, from. the Trust' is uncertain and will depend on the number of claims filed :.. '
' ~ ,~~ 'with aril the rncome received by the Trust. If is likely I will never•receive any;settlement .
gayments other than "rrry.first settlement payment. LIQUIDATED VALUE ~s the;.. .
• "'payment amount ~l would receive if the Trust could fully pay mY claim. 13ecause•the
~• `~ _ ,Trir'sf cannot fully, pay my claim, my Settlement Payments wit[ total less tlian'the~ +•
- Liquidated~Value:ofiriy claim: ~ ~ ~ '
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RELEASE FILE #:206368
1. I accept payment of the Settlement Payments as full settlement of my Trust
Claims. I understand it is very unlikely I will receive any additional Settlement
Payments after the initial payment described in the next paragraph. T intend my
Release to be effective not only on behalf of myself but also my spouse, heirs,
representatives, successors or assigns. I further agree that this Release extends to
all my rights and claims of any kind against the Released Parties, whether based in
tort, contract, fraud or any other legal or equitable theory, and whether I possess
them now or may possess them in the future, including but not limited to all claims
far my asbestos related personal injury or wrongful death arising from my present
injury.
2. I accept payment of my Settlement Payments as follows: An initial 7.5% of
the Liquidated Value shall be paid now. Remaining Settlement Payments, if any,
shall be paid as provided in the TDP. As previously agreed to at the time I
understand the payments and payment terms described herein are and shall remain
subject to the availability of Trust funding.
3. In consideration of the payment of the Settlement Payments, except as noted
in the next sentence, I fully release, waive and discharge all rights or claims of any
kind against the Released Parties allegedly resulting from my exposure to asbestos
and/or Released Parties, including claims I now possess or may later possess
because of any matter or thing done, omitted or suffered to be done by the
Released Parties prior to and including today and particularly on account of all
known and unknown personal injuries, disease, disorders andJor death having
already resulted or that may result at any time in the future from my present injury,
whether presently contemplated or not and regardless of whether they arise
following execution of this Release including but not limited toasbestos-related
injuries, disease, mental conditions, disorders, and/or death, and all spousal claims
for loss of services or consortium. I understand that if the Settlement Payments
described herein are for the settlement of anon-malignant claim which has not
resulted in death, I may file a second Trust claim when and if I have a malignant
disease caused by my exposure to Manville asbestos. .
4. This release does not release claims for asbestos-related injuries allegedly
suffered by my spouse, heirs, representatives, successors or assigns, or children
because of their personal exposure to asbestos. This Release does not release
claims for asbestos related property damage claims. I understand and agree that
this settlement is not an admission of liability on the part of the Trust.
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>e and-this~Release cbntains•the entire agreement between meland:the, ~.!
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~ed;Piiities;°and that the. terms of this. Release are not a mere recital. but are ~ , ti ..,~.
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wisionsofahe TDP. I also understand that all disputes relating;to or arising:
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Releaseshall be heard bythe courts of the State of New York or in'tlie
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~I understand and agreeahat as further consideration for payment of the`' a
merit`Payments;_I-will take whatever steps are necessary.to dismiss any: ~ ~;~~
igaawsuits'orappeals regarding my Trust.claim. ~'{„
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~I'understand and agree that this Release has been entered'into in~good-faith
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atI and~my attorneys will cooperate with the Trust in any proceedings to• , ,
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nme the, good faith of this' settlement. I understand that no change or :-.~ . ,..: Y..
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ion of theaanguage of this Release is effective unless expressly•agreed~to
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wtedged~in'writing by both the Trust and me or my attorney. _
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I state and1I have carefully read the foregoing Release and lmow'the:co`ntents i. 7`
If+and;Isign thesame as my own free act. ~ ~ - ~ Y-
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Shaine Capone as dministratnx CTA;of the'
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Claim: NG~050918 Injured Party: Jtm Orjatasky ~ SSN:, 3834fH1538
NGC Bodily Injury Trust
RELEASE AND INDEMNITY AGREEMENT
WHEREAS, the undersigned, wlw is either the "Injured Party,' or'Claimam Representative" of an Injured Party, Injured Party's
estate w Injured Parly'c helrc (either being refened M herein as the'ClaimanC), has filed a dawn (tha'Gaim') with the NGC
Bodily Injury Trust (°NGCSIT') ptxsmnt to the Claims Resolution Procedures for the NGC81T (the'CRP') approved by the United
States District Court for the Northam Districl of Texas -Dallas Division in In Re Asbestos Claims Managerrxnt Corporaton, Case
Pb. 02.37124SAF-i t, and such Claim is an Asbestos Chaim (as defined in the Third Amended Plan of Reorganiz~at Under
Chapter 11 of fhe United States Bankwptcy Cade for Asbestos Gaims Management Corporation ({the °Plan"}) (all c~italized
terms not defined herein shall have their respeclive meanings as defined in the Plan); and
WHEREAS, Claimant has agreed to settle and compromise the Injured Party's Asbestos Claim, for and inconsideration of the
allowance of the Asbestos Claim by the Trust and its payment pursuant to the CRP;
NOW, THEREFORE, Claimant hereby agrees as follows
Claimant hereby fully and finalty RELEASES, ACQUITS end FOREVER DISCHARGES the Nt;CBIT and the Pmteded Parties
(including, but rrot limited to, ACMC, the NGC Settlement Trust, and New NC,C) (collectively, tlre'Releasees'), hom any Asbestos
Gleim asserted, now or in the future, by or on behalf of the Injured Party, the Injured Party's estate, the Injured Party's heirs and/or
anyone else claiming rights thrargh the Injured Party; prov[dad, haweves, that if the Claim Ss for anon-malignant, astreatosrelated
cwrdition, the Clarrrent shall retain the right to file, in arx:ordartce wtlh the CRP only, a new asbestos bodily injury claFrr with the
NGCBIT for a more serrous non-rnefigrrent condition or an asbestos-related malignancy that is not diagnosed as of the date
hereof.
Claimant expressly covenants and agrees forever to refrain from bringing any suit or proceeding at law or in equity, against arty of
the Releasees with respectto airy Asbestos Claim released herein.
Gaimant intends this Release and tndemniry Agreement to be as broad and Iwmpmhensive as possible so that the Releasees
shall never be liable, directly or Imtimdly to the Injtaed Parry or the Injured Party's hairs, legal represenhrtives, txtceossors or
assigns, or any other Entity cfainting by, through, trader or on behalf of the Injured Party, for or on account nt arty Asbestos Claim,
whether the same is now known or unknown or may nav tre lafeht a may in gee future appear to develop, except as expessty
provkted herein. g CFaiment is a repr~entatlve of an Injured Party wta held an Asbestos Gaim against arty of the Relaasees,
Gaimant represents and warrants that Gaimant has ail requisite legal authority to ad for, tHnd and accept payment on behag of
the Injured Pany and all other hairs oI the tnjurod Party art account of arty Asbestos Claim against the Releasees and hereby
agrees to irxfemrtiry and hoW harm~ss the Releasees from any loss, cost, damage or expense arising out of a n owrnection with
the rightful claim of arty other Entity to payments with respect ro the Injured Party's Asbestos Claim agalrist the Releasees.
This Release and Indemnity Agreement is not intended to bar any cause of aclion, right, lien or claim which Claimant may have
against arty alleged torlfeasor, or any other person or entlry, not specifically named herein or enoompassad within. the definition of
the °Protsctad Parties° contained within the Third Amended Plan of Reorganizatan Under Chapter 11 of the United Stabs
Bankruptcy Code for Asbestos Gaims Management Corporation, Arficle 1, Defiritrona and Interpretagon, paregr~rh 1.1.143. The
Claimant hereby expressly reserves ail his or her dphts against such parsons or engties. If Gaimard is a Claimant Representative
of a parson who hakt an Asbestos Gaim against any of the Releacces, this Rokase and Indemnity Agreement is not intended to
relesae or discharge any Asbestos Claim or potential Asbestos Claim that the Claimam Raprosanfativa or the Claimant
Representatve s heirs (other than the Injured Parry, or those claiming through the Injured Party) may have as a resutl of the their
awn exposure to asbestos orasbestos-containing praducls.
t SpadfioeYy, ff are Asbssbs claim reiresed herein h a NonMallprtetd III darn, the Clldmam reWrs ga right b fits a rrw W1m wfih Me
tJfCBR, al esowdartoe wlal the CRP arty, Por a Nm.sMBRram II or Non~igrrM 1 cgWleorr that Is rte dargrmed as d grs date IrmaW. It the
Asbalo+ C(dm retesged ttetdn k s NorNaetgrem II dorm, em Geinwx retetm eie did b fik ^ new Warr wxh ors NGCBR, M aormdanw vAtlr
tlts CRP only. for s Non~WhrreM t eondftlon that b rwl dlsanosed as of the dale hereof.
~~
Page 1 of 5
Claim: NG-4050918 Injured Party: Jim oriowsky SSN: 383400536
Claimant fuller agrees to indemnity, defend and hold trarmless the Releaseas from any acct atl eleklta, demands, damages,
debts, obligations, liabil"i 'bee, liens or charges of any character by reason of any daims asserts by arty Entity against the
Rekasees br erderratiry, contribution w suprogation as a result of any claim, demand, cause of action, judgment w payment
made by or th Claimant, or Gatmant's he'ss, legal representatives, successors or assigns, arising out of arty Asbestos Gaim
released herein and any and all expenses (including, without limitation, reasonable fees end expenses of oaunsel for arty of the
Releasees) incurred by or on behalf of any of the Releasees in connection therewith.
It is turthar agreed and untlersfood that if Clalmant has filed a civil aetian against any of the Releasees for or on account of any
Asbestos Claim released herein, the Gaimant shall dismiss such duct action antl ebtatn (he entry r# an Ordei of Dismissal with
Prejudice of such Asbestos Gaim against the Releasees.
The Claimant understands that the Claim has been allowed by the NGCBIT, and an Allowed Uquidated Value has been
established forthe Claim. The Claimant acknowledges that the NGCBIT will only be able to pay the Claimant a percentage (the
NGC Bodily Injury Payment Percentage) of the Allowed Liquidated Value of the Claim. The Claimant fitnher acknowbdgas that
the NGC Bodily Injury Payment Percentage Is based on estimates chat change over Ume, and that dher daimarrh may have in
the past rscaived, or may ih the future receive, a smaller w larger percentage of tl+e value of their daims than the Claimant The
Gaimant fuAher acknowledges that, ether than as specifically set forth in the CRP, the fact that Barger or later claimants were
paid, or may in the fuW re be paid, a smaller err larger percentage of the value of their claims shaft not entitle the Claimant to any
additional compensation from the NGCBIT.
Claimant understands, represents and warrants this Release and Indemnity Agreement to be a full compromise of a disputed
claim and not an admission of liability by, w on the part of, the Releasees. Nekher this Release and f ndemnily Agreement, the
compromise and settlement widenced hereby, nor any widenca relating thereto, will war be admasible as evidence against Me
Releasees in arty suit, claim w proceeding of any nature except to enforce this tielease and prdemniry Agreement. However, this
Release and Indemnity Agreement is and may be asserted by the Releasees es an absdute and final bar to any dakn w
proceeding now pending or hereafter brought by Claimant, except as~expressly provided heroin.
Gaimant represents that he w she understands this Release and Indemnity Agreement constitutes a final and complete release
of the Releasees with respect to the Injured Party's Asbestos Claim, except es expressly provided herein. Claimant has relied
solery upon his w fier own knowledge and intomtation, and the advice of his w her attorneys, es to the nature, exthM and duration
of his w her injuries, damages, acrd legal rights, es well as the alleged liability of the Refeasees and the legal cwnequerr0as of
this Release and Indemnity Agreement, and not on arty statement w representatlon made by or on behaH M the Releasees.
This Release and Indemnity Agreement contains the entire agreement between the parties and supersedes alt prior a
contemporrareous, scat or writthn agreements or understandings rotating to the subject matDer hereof bolwaen w among any of
the parties hereto.
This Release and indemnity Agreement shall be governed by, and construed and enforced N accoMance with, tl>a laws of the
State of Texas, without gluing effect is the prindples of cenfiids of law thereof and shell be binding on the Injuretl Party and his or
her heirs, Isgal representatives, successors and assigns.
To the extent applicable, Claimant hereby vreives all rights under Section 1542 of the Califamia Clvll Code, and em simihr laws
of any dher state. talifomie ChM Coda Section 1542 states_
A general release does not axterd to Gaims which the creditor dace not know err suspect to exert in his favor at the time of
executing the release, wfiidr if known by him must have matsrially aRaeted his settlement with the debtor:
Claimant understands and acknowledges that because ad Claimant's waiver of Section 1542 of the California Civil Code, wen if
Claimant slwWtl wentually salter addtonal damages, Claimant will not be able th make any claim for chose damages, except as
expressly ptwlded trerein. Gaimant acknowedges that he w she intends these eonsequances.
Page 2015
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Claim: NG-0050918 Injured Party: Jim Orlowsky SSN: 3834110536
By executing'this Release and Indemnity Agreement Below; in addition to agreeing to the terms set kith herein, I; thaCtaimant;:
herab}i certify; under panaltyof perjury. that
(1) I.gave rtiyattomey cortect and acarirata.infonnatioh abaft the Injured Party's exposure Wasbestos-cont~ning piptluct's;.
(2) 1 eutlrorized,my attomay to usa.that information to fik a claim with ttie.NGCBIT on my behaN;
(3j The Injured Parry was exposed to NationafGypsum Company.asbestos-cantainingpradua(s}; and
(4)The Injured:Parly has Eden diagnosed as having Mesothelioma
EXE ~ under perrelty~f perjury'this ~, day of ~ t~ : 20 (?
Sign(cal~utlIeotGaitnant
17N0(.n~ COl ~0Y1L
Pnnted Name of,Claimant
Capacity of Claimem:
(, ]Injured Party j)U Exewtor }Administrator /Trustee [ ].Guardian'
[~ 1Algomey-tn•Fact(PowerotAttwney) -O1har
(Oiie,oi the following tvro.yerifications must bb completed. In addition, tiie Attorney Certification end Release appeadnfl beliipii
must also be completed:)
NOTARY
STAre of GMG~ ~,
couNrroF,~ (~'~~
BEFOREme, \U~Gn a!;I rtt. , a rwtarypublic, on this day personally appeared
known to me to be the parson whose name is subscribed to tliataagoirrg insltument
:eatted the wme for the~puLLrpose and comideiation theiein'ezpiessed.
this~daYOf (kid~r ,fro r2.
;tC~~~,}};,,
t2-2i-ZDt-Z
Name: ~ ~ (~ ['Pit Z
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3ignature~ '"
Name: t
Page 4 of 5'
Claim: NG-4050918 knjured Party: Jim Orlowsky SSN: 383400536
AND
Law Firms may clwose to execute the Attorney Cerfification and Release below or they may file the Annual Attorney CeBficalion
and Release Fonn (on the. NGCBIT website, www.NGC81Tn+storg , or provided by request), annualry (calendar year), for ag the
Fan's NGC elanns.
Q'~ ( Annual Aitomay Cedifiesfion and Release on file.
OR
ATTORNEY CERTIFICATION AND RELEASE
[May De provided by separate letter or dowmerd]
f cerfiry that Ne undersigned fine is attorney of record for Claimant The I~al effect of the Release end Indemnity Agreement
was fully explained to Claimant by the firm, in person or in writing, prior to its execution. For adequate eonsi~retien, the
suffidency of wNch is hereby acknowledged, the undersigned firm releases any daims orotl~ interests of the fimr or its
individual aGomeya related to the matters released hereto. I further cerfiy, under penalty of perjury, as follows: I was auCroraed
to file the Claim Form in support of this claim; I, or other trained personnel within my flnn, reviewed the infomfatidt submitted on
such Gaim Form and all documents submitted in support of this daim; and fo the hest of my knowledge, based on pdides and
protedraes adopted and implemented by my firn concerning claims processing, the intlwrrralion submitted is trtfe, accurate and.
wmplete, andfor the intomwUon is irxluded within the daimant's file and is derived from infornation provided by the caiment, one
or more of the claimant's co-worker: or the claimant's matlical experts.
Signature
Pdnted name of attorney:
CaPapb~
Page 5 of 5