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HomeMy WebLinkAbout13-3034 IN THE COURT OF COMMON PLEAS OF DOCKET #J/'.-b3 ((/( CUMBERLAND COUNTY, PENNSYLVANIA DATE ENTERED CERTIFIED COPY OF LIEN COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY TO THE PROTHONOTARY OF SAID COURT: UNINSURED EMPLOYERS GUARANTY FUND Pursuant to Section 1605 of the Pennsylvania Workers' Compensation Law, 77 P.S. § 2705, this is a Certified Proof of vs. CD Payment for the balance of payments made by the Fund on behalf of the uninsured employer to be entered of record by MICHAEL TIBBENS D /B /A MIKE'S4 DINtR you and indexed as judgments are indexed. 411 BRICK CHURCH ROAD mM � te r. ENOLA, PA 17050 BUREAU OF WORKERS' COMPENSATION <r r C � CLAIM NUMBER: 3794864 UNINSURED EMPLOYER GUARANTY CLAIMNUMBER: UEG1 -10079 ACCOUNT NUMBER: DISBURSEMENTS -" BALANCE DUE AMT PAID CREDIT Total $ 4.80 -0- $ 4.80 Expenses Total $ -0- $ Indemnit Legal $ -0- $ Fees ACS $ 601.88 -0- $ 601.88 Adjusting Costs Total $ 733.42 -0- $ 733.42 Medical TOTAL: $ 1 ,340.10 FILING FEE(S): $ 21.50 ADDITIONAL -0- COSTS: SATISFACTION $ 1 ,361.60 AMOUNT: The undersigned, Director, Bureau of Workers' Compensation, Department of Labor & Industry certifies that the above balance is due and payable by the above named defendant under the provisions of the Pennsylvania Workers' Compensation Law. Pursuant to section 1605 of said law, 77 P.S. § 2705, the above balance is a judgment and statutory lien upon the flan hises and property, both real and personal, including after acquired property, of the above named defendant and attach thereto from the date f entry this Certified C y of Lien. ephen ireoved Date irector, Bureau orkers' Compensation r --JF �l Prothonotary IN THE RLANDOCOUNTY, O CLIMB PENNSYLVANIA DOCKET # DATE ENTERED COMMONWE M T OF L INDUSTRY UNINSURED DE LABOR & DUSTRY UNINSURED EMPLOYERS GUARANTY FUND NOTICE TO DEFENDANT OF ENTRY OF LIE V MICHAEL TIBBENS This is a copy of the Certified Copy of Lien which has been filed with the Prothonotary of the Court D /B /A MIKE'S FAMILY DINER designated on the reverse side of this notice. 411 BRICK CHURCH ROAD ENOLA, PA 17050 The Department of Labor & Industry of the Commonwealth of Pennsylvania, at the expiration often This (10) days after the receipt of this U to the extent ne essary to this ens that your property may, be levied upon, attached and CERTIFIED COPY OF LIEN UNDER Execution will not occur if this lien is satisfied. PENNSYLVANIA WORKERS' COMPENSATION Order made payable to the LAW payment should be ma de by a Cashers Check, Certified Check or Money Commonwealth of Pennsylvania. ThAcc f the remittance and mailed to the address belol�, document should be affixed to the lower left co Pennsylvania Uninsured Employers Guaranty Fund Post Office Box 1774 Harrisburg, PA 17105 -177 red Employers Guaranty Fund Any questions concerning this Lien should be ad dressed on the to th Unmsu o ffice at the address or telephone number show i Y IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF LABOR & INDUSTRY • UNINSURED EMPLOYERS GUARANTY FUND, • Civil Action - Law Plaintiff • • Docket#: 13-3034 vs. • • MICHAEL TIBBENS • Lien n,� D/B/A MIKE'S FAMILY DINER • 411 BRICK CHURCH ROAD • " ",' ENOLA, PA 17050 • Plaintiff's Interrogatories Directed to Defendant(s) Pursuant to Rule 3117 of the Pennsylvania Rules of Civil Procedure Discovery In Aid of Execution Plaintiff hereby makes demand that the Defendant(s) answer the following Interrogatories pursuant to the Pennsylvania Rules of Civil Procedure 3117 and 4001 et seq. These Interrogatories must be answered as provided in Pa. R.C.P. 4006 and the Answers must be served on all other parties within thirty (30) days after the Interrogatories are deemed served. These Interrogatories are deemed to be continuing as to require the filing of Supplemental Answers promptly in the event Defendant or their representatives (including counsel) learn additional facts not set forth in its original Answers or discover that information provided in the Answers is erroneous. Such supplemental Answers may be filed from time to time, but not later than 30 days after such further information is received, pursuant to Pa.R.C.P. 4007.4. These Interrogatories are addressed to you as a party to this action; your answers shall be based upon information known to you or in the possession, custody or control of you, your attorney or other representative acting on your behalf whether in preparation for litigation or otherwise. These Interrogatories must be answered completely and specifically by you in writing and must be 1 verified. The fact that investigation is continuing or that discovery is not complete shall not be used as an excuse for failure to answer each interrogatory as completely as possible. The omission of any name, fact, or other item of information from the Answers shall be deemed a representation that such name, fact, or other item was not known to Defendant, their counsel, or other representatives at the time of service of the Answers. 1. State: (a) All of the names under which you, Michael Tibbens, currently conduct, or have previously conducted, business, or those businesses in which you hold, or previously held, an ownership interest, including, but not limited to Mike's Family Diner, and any predecessors, successors, assigns or affiliated entities of said businesses. Include any alternate spellings of the business names. (b) For each entity identified in Question 1(a), identify the: (1) official business name; (2) business structure (i.e. sole proprietorship, corporation, limited liability company, etc.); (3) type of business; (4) principal place of business; (5) registered address for service of process; 2 (6) business telephone number(s); (7) dates the business was in operation; (8) FEIN number; and (9) the name and address of any individual(s)/business(es) that have, and/or have ever had, an ownership interest in the business. (c) For each business identified in Question 1(a) identify whether business is currently conducted under that name, and if not identify the year in which business was last conducted under that name. (d) For each business identified in Question 1(a) provide copies of all relevant documents executed to form and commence operation of said business. This includes, but is not limited to, fictitious or associated name registrations, partnership agreements, articles of incorporation, certificates of organization, and/or any documents filed with the Pennsylvania Department of State. (e) For each business identified in Question 1(a) identify how much capital was allocated to start the business and identify whether that capital was in a separate business account or held in an individual's account. 3 In each case provide the name of the financial institution, account number, name on the account, and name of all individuals, or entities, who had access to said account. (f) For each business identified in Question 1(a) provide the most recent tax filings for the last five years that entity was in operation. For any entity in operation less than five years provide the tax filings for each year the entity was in operation. This request is deemed to include all applicable tax filings for the specific business including, but not limited to, both Federal and State tax returns, and the applicable corporate, partnership, or individual tax returns filed by the entity or its agents or principals. (g) Identify the bookkeeping methods employed by Mike's Family Diner, and any other entities identified in Question 1(a), including any software programs or external accounting services used. (1) If an individual or servicer is employed or used for the purposes listed above, provide their name, address and telephone number. (h) Identify how Mike's Family Diner, any other entities identified in Question 1(a), run their payroll, including any software programs or external or third-party vendors used. 4 • (1) If an external or third-party vendor is used for the purposes listed above, provide their name, address, and telephone number. (i) Identify all Accounts Receivable for all entities identified in Question 1(a), including but not limited to Mike's Family Diner. In doing so, identify from whom the account is receivable and include the name, address and telephone number of that individual or entity; the amount due; the date due; any discounts to be applied to the amount due; whether the payment is to be made in a lump sum or in increments; how the payment is to be made (i.e., cash, check, electronic transfer, etc.); and the financial institution's name and the account number of any and all accounts into which said payments are to be made. (j) State whether each business identified in Question 1(a) has ever changed, or currently plans on changing, its name and/or entity structure? If yes, list all business names, entity structures, date of the change or proposed change, and all owners of, or individuals with an interest in, the resulting business entity. (k) State whether you, Michael Tibbens, are currently employed? If Yes, state: (1) The name and address of your employer; 5 (2) Your salary or wages; (3) How you are paid, i.e. cash, check, direct deposit, etc; (4) Where your pay is deposited or cashed, including the institution's name and address as well as the account number; (5) How long you have been working for this employer; and (6) Your job title and duties. (I) List all sources of income, including, but not limited to, self- employment, government benefits, retirement benefits, structured or lump sum settlements, etc., for Michael Tibbens for the past five years. For each source of income, state: (1) From whom, or what, income is received; (2) The amount of income received; (3) Why income was received from each source; 6 (4) How the income was received, i.e. cash, check, direct deposit, etc.; (5) When income was last received from each source. (m)Does Michael Tibbens receive any form of public assistance? If so, identify: (1) The type of assistance received; (2) The amount of assistance received; (3) When assistance was first received; and (4) When assistance was last received. (n) Provide Michael Tibbens' most recent tax filings for the last five years. If you have not filed taxes for the last five years, provide the fillings for each year you did file taxes. This request is deemed to include all tax filings for Michael Tibbens, including, but not limited to, Federal, State, and Local tax returns, filed individually or jointly with another. 2. Business Assets: 7 (a) For each business identified in Question 1(a) that is no longer in operation state the following: (1) The name of the business; (2) The date upon which the business ceased to operate; (3) The manner in which the business ended operations (i.e. asset sale, stock transfer, etc.) and provide any documentation evidencing the same; (4) The name and address of the successor(s) to the business; (5) The name and address of all individuals having an ownership interest in the successor(s). (b) To the extent that any business identified in Question 1(a) was sold or transferred, provide the name and address of the person(s), or entity(ies), to whom it was sold or transferred and attach a copy of the agreement(s) evidencing that transfer. (c) To the extent that any business identified in Question 1(a) has sold or transferred assets to another entity(ies) or successor(s), identify the assets transferred, value of those assets, the consideration received, 8 who received the consideration, and a copy of the agreements evidencing those transactions. (d) Does any business identified in Question 1(a) have any account or investment in any type of financial institution, individually or with another or in the name of another, including checking accounts, savings accounts, certificates of deposit and money market accounts? If so, with regard to each such account or investment, state the following: (1) The type of account or investment; (2) The name and address of the financial institution; (3) The name and address of each person in whose name the account is held or has been held; (4) The account number; and (5) All transactions or transfers of funds out of the identified account during the last 180 days. For each transaction provide the amount of the transfer, date of transfer, name of the person, institution, account, and/or account number to which the funds were transferred, and the reason for the transfer. (e) Does any business identified in Question 1(a) own any interest in real estate? If so, with regard to each such interest state the following: 9 (1) The size and description of the parcel of real estate, including improvements thereon; (2) The name, address and interest of each person who has or claims to have an ownership interest in the parcel of real estate; (3) The date the entity acquired its interest in the parcel of real estate; (4) The consideration transferred or paid for the interest in the parcel of real estate: (5) An estimate of the current fair market value of the parcel of real estate; (6) The amount of any indebtedness owed on the parcel of real estate and to whom that indebtedness is owed; and (7) The name of the insurance company, and policy number, for each insurance policy covering the parcel of real estate or any improvements thereon. 10 (f) Does any business identified in Question 1(a) hold a mortgage on or other security interest in any real estate? If so, as to each such mortgage or other security interest state: (1) The description of the real estate; (2) The date when the mortgage or other security interest was acquired; (3) The identity of the assignor of the mortgage or other security interest, if any; (4) The outstanding balance due on the note or obligation which the mortgage or other security interest secures; (5) The identities of the mortgagor(s), or party(ies) granting the security interest, and the real owner(s); (6) The identity of any documents which relate to the mortgage or other security interest; and (7) The priority of the mortgage or other security interest. (g) State the year, make, and model of each motor or motorized vehicle in which any business identified in Question 1(a) has an ownership 11 interest or claim of interest, whether individually or with another, and with regard to each item state the following: (1) The date the vehicle was acquired; (2) The license plate number of the vehicle; (3) The consideration paid for the vehicle; (4) The name and address of each other person or entity who has a right, title, claim, or interest in or to the vehicle; (5) The approximate fair market value of the vehicle; (6) The amount of any indebtedness on the vehicle and the name and address of the creditor; (7) The registration information for each vehicle, including the VIN number; and (8) The name of the insurance company and the policy number for all insurance policies covering each vehicle. (h) Does any business identified in Question 1(a) have any safe deposit box or other similar storage facility in its name (either individually or 12 jointly with another individual or entity), in the name of any entity in which it has any ownership or other involvement (either alone or jointly with another entity or individual) or in which it has contained personal property with a value in excess of$100? If so, as to each such box or facility state: (1) The identity of the institution in which the safe deposit box or facility is rented or maintained; (2) The number under which such safe deposit box or facility is rented; (3) The name under which such safe deposit box or facility is rented; and (4) The contents of such safe deposit box or facility. (i) Does any business identified in Question 1(a) have a credit card, prepaid debit card, money card, or similar card? If so, with regard to each card identify: (1) The type of card; (2) The financial or other institution that provides the card; (3) The name on the card; and 13 (4) The card number. (j) Does any business identified in Question 1(a) have a line of credit with any financial or other institution. If so, identify: (1) The name, address, and telephone number of the institution or individual providing the line of credit; (2) The total amount of the line of credit; (3) The current amount available; (4) The current amount owed on the line of credit; (5) The name in which the line of credit is issued; and (6) Any account or identifying numbers associated with the line of credit. (k) Does any business identified in Question 1(a) have any outstanding indebtedness or financial obligations, including mortgages, promissory notes, or other oral or written contracts? If so, with regard to each obligation state the following: (1) The name and address of the creditor; (2) The form of the obligation; 14 (3) The date the obligation was initially incurred; (4) The amount of the original obligation; (5) The purpose or consideration for which the obligation was incurred; (6) A description of any security connected with the obligation; (7) The rate of interest on the obligation; (8) The present unpaid balance of the obligation; (9) The dates and amounts of installment payments; and (10) The date of maturity of the obligation. (I) Is any business identified in Question 1(a) owed any money or property? If so, state: (1) The name, address, and telephone number of the debtor; (2) The form of the obligation; 15 (3) The date the obligation was initially incurred; (4) The amount of the original obligation; (5) The purpose or consideration for which the obligation was incurred; (6) The description of any security connected with the obligation; (7) The rate of interest on the obligation; (8) The present unpaid balance of the obligation; (9) The dates and amounts of installment payments; and (10) The date of maturity of the obligation. (m) Is any business identified in Question 1(a) the beneficiary under an insurance policy on the life of any person? If so, identify the policy, including policy number, the issuer, the insured, the amount of the policy, the current value of the policy, and any other beneficiaries. 16 (n) For every business identified in Question 1(a) identify all insurance policies, including workers' compensation, general liability and health that the business currently maintains or has ever maintained. For each policy, include: (1) The name of the insurer; (2) The policy number(s); and (3) The type of insurance. 3. Personal Assets — Michael Tibbens: (a) List all other aliases of Michael Tibbens. (b) Provide Michael Tibbens' social security number, alien registration number, and/or tax identification number. (c) Identify any other social security numbers, alien registration numbers, and/or tax identification numbers used, or previously used by Michael Tibbens and identify the years in which these numbers were used, why they were used, and why they are no longer used. (d) Identify your home address and telephone number(s), including direct line and any mobile or cellular number(s). 17 (e) Do you hold, or have you ever held, an ownership interest in any business identified in Question 1(a)? If yes, identify that ownership interest and describe the amount of and value of that ownership interest. (f) Does any other individual hold an ownership interest in any business identified in Question 1(a)? If yes, identify that individual, provide their home address, and identify their ownership interest and describe the amount of and value of that ownership interest. (g) Do you, Michael Tibbens, have any account or investment in any type of financial institution, individually or with another or in the name of another, including checking accounts, savings accounts, certificates of deposit and money market accounts? If so, with regard to each such account or investment, state the following: (1) The type of account or investment; (2) The name and address of the financial institution; (3) The name and address of each person in whose name the account is held; (4) The account number; and 18 (5) All transactions or transfers of funds out of the identified account during the last 180 days. For each transaction provide the amount of the transfer, date of transfer, name of the person, institution, account, and/or account number to which the funds were transferred, and the reason for the transfer. (h) Do you, Michael Tibbens, own any stocks, bonds, securities, or other investments, including savings bonds? If so, with regard to each such stock, bond, security or investment state: (1) A description of the stock, bond, security or investment; (2) The name and address of the entity issuing the stock, bond, security or investment; (3) The date of acquisition of the stock, bond, security or investment; (4) The name and address of any other owner or owners in such stock, bond security, or investment. 19 (i) Do you, Michael Tibbens, own any interest in real estate? If so, with regard to each such interest state the following: (1) The size and description of the parcel of real estate, including improvements thereon; (2) The name, address and interest of each person who has or claims to have an ownership interest in the parcel of real estate; (3) The date the interest in the parcel of real estate was acquired; (4) The consideration transferred or paid for the interest in the parcel of real estate: (5) An estimate of the current fair market value of the parcel of real estate; (6) The amount of any indebtedness owed on the parcel of real estate and to whom that indebtedness is owed; and (7) The name of the insurance company, and policy number, for each insurance policy covering the parcel of real estate or any improvements thereon. 20 (j) Do you, Michael Tibbens, hold a mortgage on or other security interest in any real estate? If so, as to each such mortgage or other security interest state: (1) The description of the real estate; (2) The date when the mortgage or other security interest was acquired; (3) The identity of the assignor of the mortgage or other security interest, if any; (4) The outstanding balance due on the note or obligation which the mortgage or other security interest secures; (5) The identities of the mortgagor(s), or party(ies) granting the security interest, and the real owner(s); (6) The identity of any documents which relate to the mortgage or other security interest; and (7) The priority of the mortgage or other security interest. 21 (k) State the year, make, and model of each motor or motorized vehicle in which you, Michael Tibbens, have an ownership interest or claim of interest, whether individually or with another, and with regard to each item state the following: (1) The date the vehicle was acquired; (2) The license plate number of the vehicle; (3) The consideration paid for the vehicle; (4) The name and address of each other person who has a right, title, claim, or interest in or to the vehicle; (5) The approximate fair market value of the vehicle; (6) The amount of any indebtedness on the vehicle and the name and address of the creditor; (7) The registration information for each vehicle, including the VIN number; and (8) The name of the insurance company and the policy number for all insurance policies covering each vehicle. 22 (I) Have you, Michael Tibbens, filed for bankruptcy protection, or intend to file for bankruptcy protection in the future? If so, state the court in which the bankruptcy petition was filed, the docket number, and the current status of the bankruptcy action. (m) Are you, Michael Tibbens, the beneficiary of any trust? If so, identify the name, address and telephone number of the trustee, the duration of the trust and his interest therein, the amount of income he receives from the trust annually, the amount of principal to which he is entitled upon distribution, the date of distribution, and the identity of all documents relating to the creation of the trust. (n) Do you, Michael Tibbens, have any safe deposit box or other similar storage facility in your name (either individually or jointly with another individual or entity), in the name of any entity in which you have any ownership or other involvement (either alone or jointly with another entity or individual) or in which you have personal property with a value in excess of$100? If so, as to each such box or facility state: (1) The identity of the institution in which such safe deposit box or facility is rented or maintained; (2) The number under which such safe deposit box or facility is rented; (3) The name under which such safe deposit box or facility is rented; and 23 (4) The contents of such safe deposit box or facility. (o) Are you, Michael Tibbens, the beneficiary under an insurance policy on the life of any other person? If so, identify the policy, the issuer, the insured, the amount of the policy, the current value of the policy, and any other beneficiaries. (p) Identify all insurance policies you, Michael Tibbens, currently hold, including workers' compensation, general liability, health, homeowner's and automobile. For each policy, include: (1) The name and address of the insurer; (2) The policy number; (3) The type of insurance. 4. State the name and address of the person answering these Interrogatories and their relationship with the Defendant(s). 24 Date: October 24, 2013 By: i• �r ! .,!d I ;-- • •rah J. Sch , Assistan 'ounsel Supreme Court I.D7 70557 Attorney for Plaintiff Bureau of Workers' Compensation Legal Division — Room 327 1171 South Cameron Street Harrisburg, PA 17104 (717) 783-4467 (Phone) (717) 783-4469 (Fax) 25 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA • COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF LABOR & INDUSTRY UNINSURED EMPLOYERS GUARANTY FUND, • Civil Action - Law • Plaintiff • Docket#: 13-3034 vs. • MICHAEL TIBBENS • Lien • D/B/A MIKE'S FAMILY DINER • 411 BRICK CHURCH ROAD ENOLA, PA 17050 VERIFICATION I being subject to the penalties of 18 Pa.C.S.A. § 4904, relating to unsworn falsification to authorities, state that the attached answers and/or documents are submitted in response to the foregoing Interrogatories and that to the best of my knowledge, information and belief they are true and complete. Date: By: 26 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA : DEPARTMENT OF LABOR & INDUSTRY . UNINSURED EMPLOYERS GUARANTY FUND, • Civil Action - Law • Plaintiff . • Docket#: 13-3034 vs. . MICHAEL TIBBENS • Lien D/B/A MIKE'S FAMILY DINER : 411 BRICK CHURCH ROAD . ENOLA, PA 17050 . CERTIFICATE OF SERVICE I, DEBORAH J. SCHWARTZ, Esquire, do hereby certify that on this date I served the foregoing Interrogatories on the following individuals by mailing it to them by United States First Class Mail and/or by Certified Mail, United States Postal Service, postage prepaid, addressed as follows: Michael Tibbens David D. Buell, Prothonotary d/b/a Mike's Family Diner 1 Courthouse Square 411 Brick Church Road Suite 100 Enola, PA 17050 Carlisle, PA 17013 (first class & certified) (original) 100,106‘1041111 1 caff>‘ eborah J. Schwa 41Esq. Assistant Counsel Bureau of Workers' Compensation Legal Division — Room 327 1171 South Cameron Street Harrisburg, PA 17104 Date: October 24, 2013 (717) 783-4467 27 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY UNINSURED EMPLOYERS GUARANTY FUND vs. MICHAEL TIBBENS D/B /A MIKE'S FAMILY DINER 411 BRICK CHURCH ROAD ENOLA, PA 17050 1510 ORRS BRIDGE ROAD ENOLA, PA 17025 Defendant PRAECIPE TO AMEND LIEN TO THE PROTHONOTARY OF SAID COURT: Kindly amend the lien in the matter docketed at 13 -3034 to add the 1510 Orrs Bridge Road, Enola, PA, 17025 address, as captioned above. Your assistance in this issue is most appreciated. Docket #13 -3034 C) Crt Respectfully submitted, Leah M. Lewis (Attorney I.D. #207045) Assistant Counsel Office of Chief Counsel Workers' Compensation Division 1171 South Cameron Street Harrisburg, PA 17104 Attorney for the Plaintiff Dated: April 1, 2014 CERTIFICATE OF SERVICE I, Leah M. Lewis, attorney for the Plaintiff, hereby certify that on this date I served a copy of the foregoing Praecipe to Amend Lien on the following individuals, by mailing same to them by regular first class United States Mail, postage prepaid, at the following addresses: MICHAEL TIBBENS D/B/A MIKE'S FAMILY DINER 411 BRICK CHURCH ROAD ENOLA, PA 17050 1510 ORRS BRIDGE ROAD ENOLA, PA 17025 Date: 4 /dly By: Leah M. Lewis (Attorney I.D. #207045) Assistant Counsel Office of Chief Counsel Workers' Compensation Division 1171 South Cameron Street Harrisburg, PA 17104 Attorney for the Plaintiff