HomeMy WebLinkAbout13-1445 OF TH E P R 0 T H 0 t%'O"I'A 17,%'
50
R.J.MARZELLA&ASSOCIATES, P.C. CUMBERLAND COUNTY
BY:Charles W.Marsar,Jr., Esq. PENNSYLVANIA
PA SUPREME COURT I.D.No.86702
3513 North Front Street Attorney for
Harrisburg, PA 17110 Cynthia Ray, Individually
Telephone: (717)234-7828 and as Administratrix of
Facsimile: (717) 234-6883 the Estate of Klesha Maclin
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CYNTHIA RAY,INDIVIDUALLY AND AS DOCKET NO.
ADMINISTRATRIX OF THE ESTATE OF KIESHA
MACLIN;
PLAINTIFFS, PROFESSIONAL MEDICAL
NEGLIGENCE
V.
PINNACLE HEALTH SYSTEMS,
DEFENDANTS JURY TRIAL DEMANDED
PRAECIPE FOR WRIT OF SUMMONS
TO THE PROTHONOTARY OF SAID COURT:
Please issue Writ of Summons in the above-captioned action.
The addresses of all Parties:
Plaintiff: Cynthia Ray,Individually and as Administratix of the Estate of Klesha
Maclin
58 Lee Park Ave,Apt. E
Hanover Township,PA 187o6
Defendants: Pinnacle Health Systems
2015 Technology Parkway
Mechanicsburg,PA 17050
-Z0;.3%
2 Writ of Summons shall be issued and forwarded to (X)Attorney( )Sheriff
Charles W. Marsar,Esquire A x
3513 North Front Street ' na re of A o ey
Harrisburg, PA 17110
(717)234-7828 Supreme Coln N6. 86072
Names/Address/Telephone No. Date: llg
of Attorney
WRIT OF SUMMONS
TO THE ABOVE NAMED DEFENDANTS:
YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF HAS COMMENCED
AN ACTION AGAINST YOU.
Prothonotary
Date:
Deputy
:( j10wk here-if reverse is used for additional information.
CERTIFICATE OF SERVICE
I, Katie L. Adam, hereby certify that a true and correct copy of the foregoing
document was served upon counsel of record this 18th day of
March , 2013, by depositing said copy in the United States Mail at Harrisburg,
Pennsylvania, postage prepaid,first class delivery, and addressed as follows:
Michael Badowski, Esq.
Margolis Edelstein
Post Office Box 932
Camp Hill, PA 17011
Counsel for Defendant, Pinnacle Health Systems
R.J.MARZELLA&ASSocIATES,P.C.
BY:
KATIE L.ADAM,LAW CLERK
R.J.MARZELLA&ASSOCIATES,P.C.
BY: CHARLES W.MARSAR,JR.,ESQUIRE
PA SUPREME COURT I.D.N0.86702
3513 NORTH FRONT STREET ATTORNEYS FOR PLAINTIFF
HARRISBURG,PA 17110-1438 CYNTHIA RAY,As ADMINISTRATRIX
TELEPHONE: (717)234-7828 OF THE ESTATE OF KIESHA MACLIN
FACSIMILE: (717)234-6883
FMAIL' CMARSARkH MA A A ON
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA, ORPHAN"S COURT DIVISION
CYNTHIA RAY,ADMINISTRATRIX OF THE DOCKET NUMBER: I
ESTATE OF KIESHA MACLIN
ra
PLAINTIFF
=M r"
CO C ) ,
PINNACLE HEALTH SYSTEMS <�
DEFENDANTS
C n
PETITION TO APPROVE SETTLEMENT
TO THE HONORABLE, THE JUDGE OF THE SAID COURT:
The Petition of Cynthia Ray, Administratrix of the Estate of Kiesha Maclin,
Deceased, by her attorney, Charles W. Marsar, Jr. Esquire, respectfully avers as follows:
1. Petitioner is Cynthia Ray who was appointed Administratrix of the Estate
of Keisha Maclin, Deceased, on August 26, 2011, by the Register of Wills of Dauphin
County. A copy of the Grant of Letters is attached as Exhibit A.
2. The decedent died on March 22, 2011.
3. The Administratrix of the Estate launched a negligence claim against
Pinnacle Health.
4. All parties have reached a mutually agreeable global resolution to which
the Administratrix hereby requests this Court to approve.
5. Notice of the institution of the action, as required by Pa.R.C.P. 2205, was
given on March 15, 2013 to the Cynthia Ray, mother of Kiesha Maclin, and guardian of
Kieyah White, the decedent's minor daughter, born July 23, 2004.
6. Pursuant to 20 Pa.C.S. §2101 et seq., Petitioner has served a copy of this
Petition on Cynthia Ray, mother of Kiesha Maclin, and guardian of Kieyah White, the
decedent's minor daughter, intestate heirs of plaintiff decedent
7. The decedent did not have a will.
8. The decedent died leaving behind one minor child, Kieyah White.
9. Pursuant to Dauphin County Order dated April 13, 2011, Petitioner,
Cynthia Ray is the primary legal guardian and custodial guardian of Kieyah White. (See
Court Order dates April 13, 2011 attached hereto as Exhibit B.
8. A global settlement of$500,000.00 has been proposed. In order to resolve
all potential claims, the parties have agreed that the $500,000.00 will be divided as
follows:
• $300,000.00 to resolve minor-plaintiff, Kieyah White's, claims; which
will be invested in an annuity as described in paragraph 10 and further
detailed in Exhibit C.
• $200,000.00 to resolve plaintiff, Cynthia Ray's, claims (including but not
limited to Negligent Infliction of Emotional Distress).
A copy of the proposed Release is attached as Exhibit C.
t �
10. $220,000.00 of the settlement is to be paid into a structured settlement for
the benefit of the minor child. This settlement would provide Kieyah with tax free
payments of$25,000.00 a year for four (4) years from age 18 to age 22. Kieyah would
then be paid a $50,000.00 lump sum at age 25 and a $250,000.00 lump sum at age 30.
The funds would be placed with Berkshire Hathaway Life Insurance Company of NE, an
company rated A++ by A.M. Best. A copy of the proposed structured settlement plan is
attached as Exhibit D.
11. Counsel is of professional opinion that the proposed settlement is
reasonable.
12. Petitioner is of the opinion that the proposed settlement is reasonable.
13. Petitioner entered into a Contingency Fee Agreement with R.J. Marzella&
Associates agreeing to 40% attorney's fees and reimbursement of expenses in the event
of a recovery
14. Counsel requests counsel fees and costs in the following amounts:
a. 25% from the minor's portion of the settlement ($300,000.00),
which amounts to $75,000.00. (Counsel agrees to reduce the attorney's fees from 40% to
25%because the Petitioner is a minor).
b. 40% from the adult's portion of the settlement ($200,000.00),
which amounts to $80,000.00.
C. Counsel further requests reimbursement of costs in the amount of
$471.49. A list of costs is attached as Exhibit E.
15. The Department of Revenue has agreed to allocate the entire portion of the
minor's settlement to the wrongful death claim. A copy of the correspondence is
attached as Exhibit F.
16. The Department of Public Welfare provided payment for the medical
services that were provided to Ms. Maclin. They are asserting a lien of$8,500.00. After
expenses, costs and attorney's fees are deducted, the lien will be reduced to
approximately $4,500.00 or less. Accordingly, $4,528.51 will be maintained in an
interest bearing escrow account until such time as any potential lien is completely
resolved. Any remaining sum of money after full satisfaction of the lien will be
distributed to the plaintiff, Cynthia Ray for the benefit of the minor child. It will be
deposited in an interest bearing restricted account until the minor reaches her 181h
birthday. Proof of deposit will be filed with this Court.
WHEREFORE, Petitioner requests that he/she be permitted to enter into
the settlement recited above, and that the Court enter an Order approving the settlement
as proposed.
Respectfully submitted,
R..T. EL &ASSOCIATES,P.C.
B '
HARLE W. ARS R,JR., ESQUIRE
ID No. 607
DATED: } 11q)13
y
VERIFICATION
I, Cynthia Ray, Administratrix of the Estate of Kiesha Maclin, do hereby swear
and affirm that the facts and matters set forth in the foregoing Petition are true and correct
to the best of my knowledge, information and belief.
I understand that the statements made therein are made subject to the penalties of
18 Pa. C.S. § 4904 relating to unworn falsification to authorities.
Dated: - " ak4ji� ��)
Cyn Ray,Administratrix o e
Estate of Kiesha Maclin
i • i
EXHIBIT
y
Register Of Wills Of Dauphin County,Pennsylvania
Certificate of Grant of LETTERS OF ADMINISTRATION
File No.: 2211-0905 !
Estate Of: KIESHA MACLIN
Social Security No: 166-66-2369
WHEREAS,KIESHA MACLIN late of HARRISBURG CITY,died on the 22nd
day of March,2011 and !
I
WHEREAS,the grant of letters of administration is required for the
administration of the estate.
THEREFORE,I, Sandra C. Snyder,Register of Wills in and for the County of
Dauphin,in the Commonwealth of Pennsylvania,have this day granted LETTERS OF j
ADMINISTRA.TION*to'CYNTHIA RAY whir has duly qualified as Personal
Representative(s)of the estate of the above named decedent and.has agreed to administer
the estate according to law, all of which fully appears of record in my Office at Dauphin
County Court House,Harrisburg,Pennsylvania.
IN TESTIMONY''WHEREOF,I have hereunto set my hand and affixed the seal
of my Office on August 26,2011.
r4u&'T 0. 'Iful4fu
egister of Wills
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EXHIBIT
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• . uj'�.t..l.rt'T,11Y i.eV tJl♦t 1 1 ut�t4v t ae T t
In the Interest Of __.... . . .. . .. . .
I
KIEYAH WHITE,a Minor DOCKET NO: DP-9-2011
STATUS CONFERENCE ORDER
AND NOW, '` ,2011
based upon due consideration o e recommendations of the Master.in the above captioned matter,
based. upon clear and convincing evidence presented at a hearing on APRIL 13, 2011 the Court
finds that the minor child, KTEYAH WHITE is no longer dependent pursuant to 42 Pa. C.S. §
6302.
THE COURT FURTHER FINDS that Dauphin County Social Services for Children and
Youth pursued reasonable efforts to finalize the permanency plan in effect,and
IT IS ORDERED AND DECREED that the minor child be released from the legal and
physical care and custody of Dauphin County Social Services for Children and Youth and placed
into the care and custody of her Grandmother, Cynthia Ray, and that the plan, as proposed, be
incorporated.
Br' Perry Master
BY THE COURT:
Todd A.Hoover Judge
V N3
A' L1 i=- _:`t~u :` Cmfied. A Tine Copy
6S :C Wd 91 8dV 116Z APR 2 0 Z011
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EXHIBIT
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FULL AND FINAL GENERAL RELEASE
1. FOR AND IN CONSIDERATION of the sum of$500,000 paid to the undersigned, as
set forth in the attached Addendum, receipt of which is hereby acknowledged; the
undersigned does fully release and discharge Pinnacle Health System, Pinnacle Health at
Harrisburg Hospital; Harrisburg Hospital and all of its actual or ostensible agents and
employees and all other persons, government entities, associations and corporations
whether or not herein named and all of their heirs, executors, administrators, attorneys,
successors, assigns and insurers as well as any and all of their respective agents, servants
and employees (hereafter referred to collectively as "Releasees"), from any or all causes
of action, claims and demands of whatsoever kind on account of all known and unknown
injuries, losses and damages allegedly sustained by the undersigned and, specifically,
from any claims or joinders for sole liability, contribution, indemnity or otherwise as a
result of, arising from, or in any way connected with all medical professional health care
services rendered to Kiesha Maclin or in any way related to the death of Keisha Maclin
and on account of which legal action was instituted by the undersigned in the Court of
Common Pleas of Cumberland County, PA, at Docket No. 13' /qq� The
undersigned does understand, and agrees, that the acceptance of said sum is in full accord
and satisfaction of a disputed claim and that the payment of said sum is not an admission
of liability by any party herein named.
2. It is expressly understood and agreed that this release and settlement is intended to cover
and does cover not only all now known injuries, losses and damages, but any further or
future injuries, losses and damages which may arise from, or which in anyway may be
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connected to the death of Keisha Maclin and any and all professional health care Keisha
Maclin received prior to her death.
3. The undersigned hereby agrees, on her behalf and on behalf of her heirs, executors,
successors and/or assigns, to satisfy any and all valid liens that have been asserted and/or
which could be or may be asserted for reimbursement of any medical benefits or other
benefits provided to the undersigned or Keisha Maclin by a third party as a result of the
injuries claimed in the legal action referenced above. Further, the undersigned shall
satisfy, by way of payment,reduction, and/or compromise, any and all Commonwealth of
Pennsylvania Department of Public Welfare and/or Medicare and/or other statutory liens
and conditional payments that have been, or which may be, asserted against the proceeds
of this settlement. Additionally, the undersigned hereby agrees, on her behalf and on
behalf of her heirs, executors, successors and/or assigns, to indemnify and save forever
harmless the Releasees named in this document from and against any and all claims,
demands or actions, known or unknown, made against the Releasees by any person or
entity on account of, or in any way or manner related to or arising from, the legal action
noted above.
4. In the event court approval is required for the settlement, compromise or resolution of
this claim, this settlement is conditioned upon plaintiff promptly undertaking any and all
necessary action to obtain same. It is further understood and agreed that if court approval
is required for any aspect of the settlement of this claim the undersigned hereby agrees to
waive any and all provisions of Pa. R.C.P. 229.1, with respect to entitlement claims of
interests.
5. If this settlement is determined by any court to be without effect because some necessary
court approval was not obtained, or if the released parties are subjected to further legal
action or claim which could not have been instituted or presented had proper court
approval been obtained by the undersigned, then the undersigned will indemnify the
released parties for any future loss, cost, or expense, including but not limited to,
reasonable attorney's fees for defending, litigating and settling any such claims or action,
and for any judgment resulting from any such claim or action.
6. It is further understood and agreed that this is a complete general release agreement, and
that there are no written or oral understandings or agreements, directly or indirectly,
connected with this release and settlement, that are not herein incorporated. This
agreement shall be binding upon and inure to the successors, assigns, heirs, executors,
administrators, and legal representatives of the respective parties hereto.
7. It is further understood and agreed and made part hereof, that the undersigned, her family
and representatives and her attorney(s) shall not comment, either directly or indirectly, on
any aspect of this case or settlement to any member of the news media, or in any way
publicize or cause to be publicized in any news or communications media, including but
not limited to newspapers, magazines, journals, radio, television, on-line computer
systems and law-related publications, the facts of this case, the existence of this
settlement and the terms and conditions of this settlement. This paragraph is intended to
become part of the consideration for settlement of this claim.
8. THE UNDERSIGNED HEREBY DECLARES that the terms of this settlement have
been completely read; and that she has discussed the terms of this settlement with legal
counsel of her choice; and said terms are fully understood and voluntarily accepted for
the purpose of making a full and final compromise adjustment and settlement of any and
all claims on account of the injuries and damages above-mentioned, and for the express
purpose of precluding forever any further or additional suits or claims which in any way
relates to the death of Keisha Maclin.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of
February, 2013.
(SEAL)
Cynthia Ray, individually and as
Administratrix of the Estate of Keisha
Maclin, Deceased
Social Security Number
SWORN to and subscribed before me this
Day of 2013.
NOTARY PUBLIC
ADDENDUM TO THE FULL AND FINAL GENERAL RELEASE
1.0 Definitions
"Claimant" herein shall mean Cynthia Ray, individually, and as Administratrix
of the Estate of Keisha Maclin, Deceased
"Releasees"herein shall mean Pinnacle Health System, Pinnacle Health at
Harrisburg Hospital; Harrisburg Hospital and all of its actual or ostensible agents
and employees and all other persons, government entities, associations and
corporations whether or not herein named and all of their heirs, executors,
administrators, attorneys, successors, assigns and insurers as well as any and all of
their respective agents, servants and employees
"Annuity Issuer" herein shall mean Berkshire Hathaway Life Insurance
Company of Nebraska(BHLN).
"Assignee" herein shall mean BHG Structured Settlements, Inc. (BHGSS).
2.0 Payments
In consideration of the release set forth above, Releasees agree to pay to the individual
named below the sums outlined in this Section 2 below:
2.1 Payments due at the time of settlement as follows:
$275,000.00 up-front cash, inclusive of attorney fees and expenses
2.2 Periodic payments made to Kieyah White ("Payee") according to the schedule as
follows (the "Periodic Payments"):
$25,000.00, annually, guaranteed for four(4)years only, beginning July 23, 2022.
$50,000.00 guaranteed lump sum payable July 23, 2029.
$250,000.00 guaranteed lump sum payable July 23,2034.
Any payments to be made after the death of Kieyah White pursuant to the ternis
of this Addendum shall be made to the Estate of Kieyah White or to such person or entity as
shall be designated in writing to the Releasees or the Assignee by the guardian of Kieyah White
with court approval or from Kieyah White upon attaining the age of majority. If no person or
entity is so designated by Kieyah White, or if the person designated is not living at the time of
said Payee's death, such payments shall be made to the Estate of said Payee. No such
designation, nor any revocation thereof, shall be effective unless it is in writing and delivered to
the Insurer or the Assignee. The designation must be in a form acceptable to the Insurer or the
Assignee before such payments are made.
All sums set forth herein constitute damages on account of personal physical
injuries or physical sickness, within the meaning of Section 104(a)(2) of the Internal Revenue
Code of 1986, as amended.
3.0 Claimant's Rights to Payments
Claimant acknowledges that the Periodic Payments cannot be accelerated,
deferred, increased or decreased by the Claimant; nor shall the Claimant have the power to sell,
mortgage, encumber, or anticipate the Periodic Payments, or any part thereof, by assignment or
otherwise.
4.0 Consent to Qualified Assignment
4.1 Claimant acknowledges and agree that the Releasees may make a "qualified
assignment", within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as
amended, of the Releasees' liability to make the Periodic Payments set forth in Section 2.2 to
BHG Structured Settlements, Inc. (BHGSS) ("the Assignee"). The Assignee's obligation for
payment of the Periodic Payments shall be no greater than that of Releasees (whether by
judgment or agreement) irmnediately preceding the assignment of the Periodic Payments
obligation.
4.2 Any such assignment shall be accepted by the Claimant without right of rejection
and shall completely release and discharge the Releasees from the Periodic Payments obligation
assigned to the Assignee. The Claimant recognizes that the Assignee shall be the sole obligor
with respect to the Periodic Payments obligation, and that all other releases with respect to the
Periodic Payments obligation that pertain to the liability of the Releasees shall thereupon become
final, irrevocable and absolute.
5.0 Right to Purchase an Annuity
The Releasees, themselves or through the Assignee, reserve the right to fund the
liability to make the Periodic Payments through the purchase of an annuity policy from Berkshire
Hathaway Life Insurance Company of Nebraska (BHLN). The Releasees or the Assignee shall
be the sole owner of the annuity policy and shall have all rights of ownership. The Releasees or
the Assignee may have BHLN mail payments directly to the Payee. The Claimant shall be
responsible for maintaining a current mailing address with BHLN.
6.0 Discharge of Obligation
The obligation of the Releasees and/or Assignee to make each Periodic Payment
shall be discharged upon the mailing of a valid check in the amount of such payment to the
designated address of the Payee named in Section 2 of this Settlement Agreement, or the deposit
by electronic funds transfer in the amount of such payment to an account designated by the
Payee identified in Section 2.
(SEAL)
Cynthia Ray, individually and as
Administratrix of the Estate of Keisha
Maclin, Deceased
-7-
NFP -, - ,
Accepted Plan
Individually Designed Settlement
Kieyah White
DATE OF BIRTH: July 23, 2004
GUARANTEED
BENEFIT COST YIELD
Guaranteed Tax-Free Payments
$25,000 per year, guaranteed for 4 S 100,000.00
years (4 payments). Payments
beginning 07/23/2022(Age 18).
Guaranteed Lump Sums
$50,000.00 At Age 25 $50,000.00
250,000.00 At Age 30 $250,000,00
Grand Total $220,000.00 $400,000.00
Benefits provided by:
Be,,kshire Hathaway Life Insurance Company of NE, Rated A++ By A.M. Best
Company
r,
EXHIBIT
ONFPStructured
Settlements
Accepted Plan
Individually Designed Settlement
IGeyoh White
DATE OF BIRTH: July 23, 2004
GUARANTEED
BENEFIT COST YIELD
Guaranteed Tax-Free Payments
$25,00 per year, guaranteed for 4 $100,000.00
years(4 payments). Payments
beginning 07/23/2022(Age 18).
Guarant"d Lures Sums
$50,000.00 At Age 25 $50,000.00
$250,000.00 At Age 30 $250,000.00
Grand Total $220,000.00 $400,000.00'
Benefits provided by:
Berkshire Hathaway Life Insurance Company of NE. Rated A++ By A.M. Best
Company
Ttie enctomi figures are for illustrative ourpoSeS only aild Should not be construed aS a contract,All figures are subbed to avoroval by we life insurance carrier
prtor to Contract rssuan.�e.Please contact our office to vertfy tigttreS Prior to court approval as the figures are time-sensitive ano va+-/LOO funding Oat'S.
www.nfpstructures.com
800-229-2228
EXHIBIT
"Ell
1:58 PM R.J.MARZELLA,ESQUIRE AND ASSOCIATES,P.C.
03/14/13 Account QuickReport
Accrual Basis All Transactions
Type Date Num Name Memo Split Amount Balance
Client Prepaids
CWM'S
Maclin,Est Kiesha
Check 8/25/2011 19204 Register of Wills VOID: Bank(M&T)... 0.00 0.00
Check 8/26/2011 19205 Register of Wills Open Estate Bank(M&T)... 79.50 79.50
Check 12/8/2011 19572 Star Med PA-51-112209 Bank(M&T)... 193.55 273.05
Check 8/29/2012 20039 Register of Wills D... 2210-0162 Bank(M&T)... 18.00 291.05
Check 10/29/2012 20177 Hamilton Health C... Bank(M&T)... 35.91 326.96
Check 11115/2012 20277 Hamilton Health C... Bank(M&T)... 48.43 375.39
Check 3/14/2013 Jacqulyn Harris Bank(M&T)... 96.10 471.49
Total Maclin, Est Kiesha 471.49 471.49
Total CWM'S 471.49 471.49
Total Client Prepaids 471.49 471.49
TOTAL 471.49 471.49
Page 1
EXHIBIT
p ennsylvania
DEPARTMENT OF REVENUE
March 13,2013
Robin J.Marzella,Esquire
RJMarzella&Associates
3513 North Front Street
Harrisburg,PA 19110
Re: Estate of Keisha Maclin
File Number 2211-0905
Court of Common Pleas Cumberland County
Dear Ms.Marzella:
The Department of Revenue has received the Petition for Approval of Settlement Claim to be
filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has
been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to
settle the actions.
Pursuant to the Petition,the 25 year old decedent died as a result of medical negligence.
Decedent is survived by her minor child.
Please be advised that,based upon these facts and under the special circumstances specific to this
estate, and for inheritance tax purposes only,this Department has no objection to the proposed allocation
of the net proceeds of this action, $220,000.00 to the wrongful death claim and$0 to the survival claim.
Proceeds of a survival action are an asset included in the decedent's estate and are subject to the
imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302; 72 P.S. §9106, 9107. Costs and fees
must be deducted in the same percentages as the proceeds are allocated. In re Estate of Meer-y�man, 669
A.2d 1059(Pa. Cmwlth. 1995).
I trust that this letter is a sufficient representation of the Department's position on this matter. As
the Department has no objections to the Petition,an attorney from the Department of Revenue will not be
attending any hearing regarding it. Please contact me if you or the Court has any questions or requires
anything additional from this Bureau.
I on,
E.Baker
Trust Valuation Specialist
Inheritance Tax Division
Bureau of Individual Taxes I PO Box 280601 1 Harrisburg, PA 17128 1717.783.5824 1 shabaker @pa.gov
CERTIFICATE OF SERVICE
I, Katie L. Adam, hereby certify that a true and correct copy of the foregoing
document was served upon counsel of record this 18th day of
March , 2013, by depositing said copy in the United States Mail at Harrisburg,
Pennsylvania, postage prepaid,first class delivery, and addressed as follows:
Michael Badowski, Esq.
Margolis Edelstein
Post Office Box 932
Camp Hill, PA 17011
Counsel for Defendant, Pinnacle Health Systems
R.J.MARZELLA&ASSOCIATES,P.C.
BY;
KATIE L. AM A LAW CLERK
R.J.MARZELLA&ASSOCIATES,P.C.
BY: CHARLES W.MARSAR,JR.,ESQUIRE
PA SUPREME COURT I.D.No.86702
3513 NORTH FRONT STREET ATTORNEYS FOR PLAINTIFF
HARRISBURG,PA 17110-1438 CYNTHIA RAY,AS ADMINISTRATRIX
TELEPHONE: (717)234-7828 OF THE ESTATE OF KIESHA MACLIN
FACSIMILE: (717)234-6883
EMAIL: CNIAR ARr�?iRJ,MARZELLA.COM
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA,
CYNTHIA RAY,ADMINISTRATRIX OF THE DOCKET NUMBER: z—L
ESTATE OF KIESHA MACLIN
PLAINTIFF
PINNACLE HEALTH SYSTEMS
DEFENDANTS
ORDER
AND NOW,this2eaY of , 2013 the Petition to Approve Settlement
is GRANTED and Distribution is ordered as follows:
R.J. Marzella &Associates $ 155,471.49
Escrow for Pa. Department of Public Welfare $ 4,528.51
Payment to Cynthia Ray $ 120,000.00
For the Benefit of Kieyah White $ 220,0000
IT IS FURTHER ORDERED that the sum of$220,000.00 will be utilized to fund a
structured settlement annuity underwritten by Berkshire Hathaway Life Insurance
Company of Nebraska (BHLN)(rated A++ Superior by A.M. Best Company)for the
benefit of the minor, Kieyah White. Said annuity will provide the following periodic
payments:
$ 25,000.00, annually, guaranteed for four(4)years only, beginning July 23, 2022
$ 50,000.00 guaranteed lump sum payable July 23, 2029
$ 250, 0000.00 guaranteed lump sum payable July 23, 2034
Pinnacle Health Systems shall issue a check in the amount Of$ 220,000.00 made
payable to BHG Structured Settlements, Inc. (BHGSS). BHGSS shall fund the "periodic
payments" by purchasing a "qualified funding asset" within the meaning of Section
13o(d)of the Internal Revenue Code of 1986 in the form of an annuity contract issued
by BHLN. The parties to this settlement shall cooperate fully and execute any and all
supplementary documents, including the Qualified Assignment document, and to
take all additional actions which may be necessary or appropriate to give full force
and effect to the basic terms and i tent of this settlement.
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R.J.MARZELLA&ASSOCIATES,P.C.
BY: CHARLES W.MARSAR,JR.,ESQUIRE
PA SUPREME COURT I.D.No.86702
3513 NORTH FRONT STREET ATTORNEYS FOR PLAINTIFF
HARRISBURG,PA 17110-1438 CYNTHIA RAY,AS ADMINISTRATRIX
TELEPHONE: (717)234-7828 OF THE ESTATE OF KIESHA MACLIN
FACSIMILE: (717)234-6883
EMAIL: CMARSARaRJMAR2;ELLA.com
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CYNTHIA RAY,ADMINISTRATRIX OF THE DOCKET NUMBER: 13-"
ESTATE OF KIESHA MACLIN
PLAINTIFF f— =
vs.
PINNACLE HEALTH SYSTEMS
DEFENDANTS
PRAECIPE TO DISCONTINUE PURSUANT TO PA.R.C.P. 229
TO THE PROTHONOTARY, CUMBERLAND COUNTY:
Please mark the above-referenced action settled and discontinued,
with prejudice as to all Defendants.
Respectfaff bmitted,
R.J. arzell & s oclates, P.C.
B
C. arle . Ma ar, E quire
Dated:
�2� 3 Supreme Co _LD No. 86072
CERTIFICATE OF SERVICE
I, Katie L. Adam, hereby certify that a true and correct copy of the foregoing
document was served upon counsel of record this z7th day of
March, 2013, by depositing said copy in the United States Mail at Harrisburg,
Pennsylvania, postage prepaid,first class delivery, and addressed as follows:
Michael Badowski, Esq.
Margolis Edelstein
Post Office Box 932
Camp Hill, PA 17011
Counsel for Defendant, Pinnacle Health Systems
R.J.MARZELLA&ASSOCIATES,P.C.
BY:
TIE L.A M, LAW CLERK