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Home My WebLink About10-09-14 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: . THE ESTATE OF CHERYL A. . WISNER-GARDNER, a/k/a CHERYL A. WISNER DeAea9ea . No. 21-11-1126 Late of the Township : of Southhampton . PRAECIPE TO WITHDRAW/DISMISS CLAIM To The Register of Wills/ Clerk of the Orphans' Court: Please withdraw the claim that was filed on my behalf(resulting from of a Complaint filed in the General Court of Justice, Superior Court Division, Beaufort County,North Carolina (12 CVS 114)) in the above-referenced estate as it has been settled and satisfied. Respectfully submitted, f �� JE ETTE BE S, Pro Se �v �-, � s C O _S � C�'1 Date: � �� ; "''_ o CiJ 't7 ---1 � .�"'.1.. � f'l —;- C'� __.� CJ _� �:za ��. r— ;�, a T i _._ . cn . � � � , � � �.., � -v ;, -n ,. , � -r� � _ ;y - � . ►--► ,--.= rn , % N �, , , ; r,'1 G� G� � � i NORTH CAROLINA BEAUFORT COUNTY RELEASE OF ALL CLAIMS WITNESSETH,that for and in consideration of the sum of ONE HIINDRED THOUSAND AND 00/100 DOLLARS ($100,000.00), the receipt and legal sufficiency of which is hereby acknowledged, the undersigned hereby releases and forever discharges PAUL M. GARDNER, CHERYL A.WISNER-GARDNER,the Estate of CHERYL A. WISNER-GARDNER and STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, and any other person, firm or corporation, charged or chargeable with responsibility or liability, their heirs, representatives and assigns, from any and all claims, demands, damages, costs, expenses, loss of services, actions, and causes of action of any nature whatsoever, arising from any act or occurrence up to the present time and particularly on account of all personal injury,disability,property damage,loss or damages of any kind already sustained or that the undersigned may hereafter sustain as a consequence of an automobile accident which occurred on or about the 24th day of September,2011,in or near the City . of Vanceboro, Craven County, North Carolina. It is understood that this settlement is the compromise of a doubtful and disputed claim and that the payment made is not to be construed as an admission of liability on the part of PAUL M. GARDNER,CHERYL A. WISNER-GARDNER,the Estate of CHERYL A.WISNER-GARDNER and STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY(or any of its insureds, agents, or employees)and that this settlement shall apply to all unknown and unanticipated injuries and damages resulting from the accident, casualty or event, as well as to those now known or disclosed. It is also expressly understood that the undersigned has represented to the parties released that there are no other related claims (including, but not limited to, claims for mental and/or emotional distress) now asserted, or to be asserted, arising out of the accident or event described above,and the parties released have relied upon such representation. In the event such related claim shall be hereafter asserted,the undersigned promises to indemnify and repay the parties released for any and all damages,judgments, expenses and costs (including interest) of any nature whatsoever paid or incurred as a result of such related claim. To procure payment of the sum,the undersigned hereby declares: that I am more than eighteen (18) years of age; that no representations about the nature and extent of the injuries, disabilities or damages made by any physician, attorney or agent of an y party hereby released, nor any representations regarding the nature and extent of legal liability or financial responsibility of any of the parties hereby released,have induced me to make this settlement;that in determining the value of this claim and settlement, I have considered not only the ascertained injuries, disabilities and damages, but also the possibility that the injuries sustained may be permanent and progressive and that recovery may be uncertain and indefinite, so that consequences not now anticipated may result from the accident. The undersigned hereby agrees,as a further consideration and inducement for this compromise settlement, that this settlement shall apply to all unknown and unanticipated injuries and damages resulting from the accident, casualty or event, as well as to those now disclosed and known. The undersigned understands that the parties hereby released admit no liability of any sort by reason of the accident and that this compromise payment and settlement is made to terminate further controversy respecting all claims for damages heretofore asserted or that might hereafter be asserted because of the accident. The undersigned further understands that such liability as I may or shall have incurred,directly or indirectly, in connection with or for damages arising out of the accident, to each person or organization released and discharged of liability,and to any other person or organization,is expressly reserved as to each of them,such liability not being waived,agreed upon,discharged,compromised or settled. The undersigned does hereby acknowledge that if any payment has been received by her in any capacity from any governmental entity,that she has an independent legal obligation under 42 C.F.R. Section 411.24, as is currently in effect or as may be hereinafter modified; and that such governmental lien or interest is the distinct sole and separate obligation of the undersigned. Further, the undersigned recognizes that any refusal to provide future benefits on the part of Medicare, Medicaid or other similar governmental entity as a result of this settlement shall in no way impact, effect, disturb, alter, or modify the terms of this agreement. The undersigned agrees to save and hold harmless the released parties for any failure to comply with payments requirements for any and all medical, hospital or other treatment liens required by State or Federal law to be paid. In the alternative, the undersigned expressly covenants and warrants that all Medicare, Medicaid, and other medical liens, subrogation rights, rights of reimbursement and claims of any nature whatsoever arising as a result of health care services provided to the undersigned have been or will be satisfied, settled,compromised or paid by express agreement with each health care provider prior to disbursement of the settlement proceeds. The undersigned further expressly covenants and warrants that no assignment of the proceeds of this settlement or recovery have been made to any health care provider,insurance company,agency,organization ar entity for the purpose of creating a lien, claim or right of reimbursement or subrogation against the settlement proceeds. The undersigned covenants and warrants that all such claims,liens and assignments have been disclosed in writing to the parties released prior to settlement. The undersigned agrees to indemnify and hold harmless the parties released for any and all damages, judgments, expenses or costs (including interest)of any nature whatsoever paid or incurred as a result of any breach of these warranties and covenants. The undersigned understands and agrees that the parties released have relied on these representations as part of the consideration and inducement for this settlement. The undersigned further releases, extinguishes,withdraws and/or deems satisfied any and all claims or liens made upon the Estate of Cheryl A. Wisner-Garnder, alk/a Cheryl A. Wisner, filed in the Court of Common Pleas of Cumberland County,Pennsylvania,Orphans Court Division(No.21- 11-1126) as a result of the accident described herein, against the decedent, Cheryl A. Wisner- Garnder, a/k/a Cheryl A. Wisner, last known residence, 35 Cleversburg Road, Shippensburg, Cumberland County, Pennsylvania. The undersigned agrees to assist the parties released herein in whatever method necessary to assure that said claim(s)or lien(s)made upon the Estate of Cheryl A. Wisner-Garnder, a/k/a Cheryl A. Wisner, filed in the Court of Common Pleas of Cumberland County, Pennsylvania, Orphans Court Division (No. 21-11-1126) are release, extinguished, withdrawn and/or deemed satisfied. The parties acknowledge that by the execution of this document that certain representations have been made by the undersigned to the parties released herein,and such parties have relied upon same. If any party herein released shall incur any expense, cost, fees, loss, damages, interest, payment or sustain any monetary damage whatsoever as a result of any representation, or other warranty,promise, guarantee, or statement made by the undersigned to the parties herein released, the undersigned,both in their individual and representative capacities, do hereby agree to save and hold harmless such released parties from any and all expense, cost, fees, loss, damages, interest, payment, or any monetary damage of any nature whatsoever that they may incur or be compelled to pay as a result of such representations, warranty,promise, guarantee, or statement. This Release of All Claims contains the entire agreement between the parties, and the terms are contractual and not mere recital. The undersigned has carefully read this document, knows its contents, and signs the same freely and voluntarily. All of the terms and provisions of this Release of All Claims shall be binding upon the undersigned and the undersigned's heirs, personal representatives, successors and assigns. SIGNED AND SEALED this the o�`�'day of c�¢�-�I� , 2014. CAUTION-READ BEFORE SIGNING (SEAL) ETT BEAKES WITNESSED BY: NORTH CAROLINA COUNTY OF �aw-��-�- On this Zb'� day of,�e,o�p,,�bp,r , 2014, befare me personally appeared JEANNETTE BEAKES,to me known to be the person who executed the foregoing instrument,and acknowledged that he/she executed the same as his/her free act and deed. ��l� � .�J� _ NOTARY PUBLIC My commission expires -�k�. a �j/(� --� _