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HomeMy WebLinkAbout10-10-14 ti n _� IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, P `1�SYLVA�IIV' � "a — o i O :Zj ro IN RE: Estate of Orphan's Court Madison J. Perry, Deceased _ ^� Register of Wills File # 2013-01019 r-- c-n 9 PETITION FOR COURT APPROVAL OF SETTLEMENT OF A DEATH CASE INVOLVING WRONGFUL DEATH AND SURVIVAL CLAIMS 1. Petitioner is Chris P. Perry, an adult individual who resides at 35 Montgomery Avenue, Shippensburg, PA 17257. 2. On September 30, 2013, the Register of Wills of Cumberland County, Pennsylvania granted letters of Administration of the estate of Madison J. Perry, who died January 10, 2013 to the Petitioner, who was the father of the Decedent. Attached hereto and marked "Exhibit A" is a true and correct copy of the Short Certificate issued by the Register of Wills. 3. Petitioner's Decedent died on January 10, 2013 as a result of injuries sustained in a motor vehicle accident which occurred about 12:16 a.m. on December 31, 2012 at the intersection of McKinley Street and Cleveland Avenue in Chambersburg, Franklin County, Pennsylvania. Attached hereto and marked"Exhibit B," is a true and correct Certificate of Death of the Petitioner's Decedent,who was 24 years old at the time of his death. 4. At the time of the aforesaid motor vehicle collision, the Petitioner's Decedent, Madison J. Perry, was a passenger in an automobile which was owned by Heather Marie Coble, who was riding in the front passenger seat of an automobile which was being driven by Nicholas Fortenberry. 557111-1 5. The aforesaid motor vehicle collision occurred when the 1998 Ford Expedition owned by Gerardo Garcia and operated by Agustin Macias-Marquez, which was headed north on Cleveland Avenue, proceeded through the stop sign at the intersection of Cleveland Avenue and McKinley Street and crashed into the passenger side of the vehicle in which the Decedent was a passenger, which vehicle was proceeding east on McKinley Street through the intersection and which had the right-of-way. Attached hereto and marked "Exhibit C," is a true and correct copy of the initial Police Crash Report from the aforesaid motor vehicle collision. 6. As a result of the aforesaid motor vehicle collision, the driver Agustin Macias- Marquez was prosecuted at Franklin County, Pennsylvania Criminal Action No. 282 of 2013, and entered a guilty plea to Homicide by Motor Vehicle while Driving Under the Influence, receiving a prison sentence of 42 months to 84 months at a State Correctional Institution. 7. The Petitioner is advised through counsel, that the other passenger with him in the vehicle, Heather Marie Coble, died on December 31, 2012 as a result of injuries sustained in the motor vehicle collision. 8. Attached hereto and marked "Exhibit D," is a letter dated May 8, 2014 from counsel for Nicholas Fortenberry summarizing his severe injuries and substantial losses sustained in the motor vehicle collision. 9. It is the Petitioner's understanding that the only liability insurance coverage available for the claims of his Decedent's estate and survivors, the estate and survivors of Heather Marie Coble, and Nicholas Fortenberry is a per accident limit of $100,000.00 through coverage with Travelers Personal Security Insurance Company which had been purchased by Gerardo Garcia, owner of the vehicle which Agustin Macias-Marquez was driving at the time of the accident. 557111-1 10. The per accident $100,000.00 limit of liability insurance coverage has been offered by Travelers Personal Security Insurance Company in settlement of all claims of the estates and survivors of Heather Coble and Madison Perry, and of Nicholas Fortenberry. See the letter from Michael V. Farrell dated August 16, 2013, with attachment, a true copy of which is attached hereto and marked"Exhibit E." 11. The Petitioner's Decedent was unmarried and is survived by one minor child, Elisa J. Perry, born April 10, 2012. Elisa J. Perry resides with her mother, Cheyenne Carbaugh at 415 Penn Street, Shippensburg, Cumberland County, Pennsylvania 17257. 12. The Petitioner is advised, through counsel, that Heather Marie Coble was unmarried and is survived by two minor children. 13. The Petitioner, on behalf of the estate and survivors of Decedent, the estate and survivors of Heather Marie Coble, and Nicholas Fortenberry have all tentatively agreed to an equal division of the $100,000.00 in insurance coverage which has been tendered, with one-third of that amount allocated to the estate and survivors of each Decedent, and one-third allocated to Mr. Fortenberry, subject to Court approval of the settlements of each of the death cases. 14. The Petitioner believes that the settlement of the claims of the estate and survivors of his Decedent, in exchange for the proposed one-third allocation of the $100,000.00 in available liability insurance proceeds, is in the best interest of the estate and survivors of Madison J. Perry. 15. The Decedent, Madison J. Perry, was qualified to receive medical assistance through the Department of Public Welfare who was responsible for and did pay medical bills incurred by Madison J. Perry as a result of the injuries he sustained in the accident up to the time of his death ten days later. 557111-1 16. Pursuant to the policy of the Pennsylvania Department of Public Welfare, the Department of Public Welfare has agreed to accept fifty percent of the net amount of the recovery, after deduction of attorney's fees and costs, as indicated by the letter of October 23, 2013 from the Department of Public Welfare attached hereto and marked "Exhibit F." 17. Department of Public Welfare's agreement to accept the amount indicated in "Exhibit F" of$10,901.59 was based upon attorney's fees of one-third of the gross settlement of $33,333.33. The fee agreement between the Petitioner and the law firm, Metzger, Wickersham, Knauss & Erb, P.C. is attached hereto and marked "Exhibit G." However, the law firm has agreed to reduce its fee to twenty-five percent in view of the fact that the beneficiary in this case entitled to the wrongful death proceeds is the minor child of the Decedent. Therefore, the amount of the settlement proceeds going to both the Department of Public Welfare and to those entitled to the wrongful death proceeds will increase. 18. All costs incurred in this case, including any costs for the administration of the estate, are itemized on"Exhibit H" attached hereto. No additional costs or attorney's fees will be incurred by the Petitioner or the estate. 19. The Wrongful Death Act damages recoverable in this case because of the Petitioner's Decedent's death include funeral and related expenses which total $7,910.40, as evidenced by the funeral bill attached hereto as "Exhibit I" (the current balance due on the funeral bill is $7,711.34); ambulance and hospital bills incurred for Decedent following the motor vehicle collision, which were the responsibility of the Department of Public Welfare; and the losses of the Decedent's above-named minor child of support and contributions from her father as well as the services, society and comfort she would have received from her father. See Pennsylvania Suggested Standard Civil Jury Instructions 7.220 and citations thereunder. 557111-1 20. The Petitioner suggests that, as the Decedent's minor child is the survivor entitled to Wrongful Death Act recovery as well as his intestate heir, and given the small recovery under the settlement proposed herein in relation to the actual losses of the minor child, Elisa J. Perry, it would be appropriate for the entire net proceeds of the settlement proposed herein to be allocated to the wrongful death recovery as opposed to the Decedent's estate. The Pennsylvania Department of Revenue has agreed to this allocation as indicated in the letter attached hereto as Exhibit"J." 21. The Petitioner proposes that after payment of the attorney's fee of twenty-five percent, the reimbursement to the law firm of Metzger, Wickersham, Knauss & Erb, P.C., of the costs and expenses, the payment to the Department of Public Welfare, and the funeral bill, the net remaining proceeds be paid for the benefit of Decedent's minor child, to be deposited in a federally insured account or certificate of deposit until such child reaches the age of 18. WHEREFORE, the Petitioner, Chris P. Perry, respectfully requests that Your Honorable Court enter an Order authorizing him to execute an appropriate release on behalf of the estate and survivors of Madison J. Perry in exchange for payment in the amount of$33,333.33, and, further authorizing him to make payment from the said proceeds as set forth in the foregoing Petition and in the proposed Order of Court attached hereto. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: Edward E. Knauss, IV, Esquire Attorney ID No. 19199 2321 Paxton Church Road Harrisburg, PA 17110 Phone (717) 238-8187 Attorney for Petitioner Chris P. Perry, Administrator of the Estate of Madison J. Perry, Deceased 557111-1 VERIFICATION I, Chris P. Perry, hereby verify that the facts set forth in the foregoing Petition are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of the 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. Chris P.. Perry, Administrator of the Estate of Madison J. Perry 557111-1 Exhibit A COMMONWEALTH OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND I, GLENDA FARNER STRA SBA UGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 30th day of September, Two Thousand and Thirteen, Letters of ADMINISTRATION in common form were granted by the Register of said County, on the estate of MADISON J PERRY late of SOUTHAMPTON TOWNSHIP /First,Middle,Lasd in said county, deceased, to CHRIS P PERRY (First,Middle,Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 30th day of September Two Thousand and Thirteen. File No. 2013- 01039 PA File No. 21- 13- 1039 Date of Death 1/10/2013 S. S. # A)/)-)j Register Of Wills- 0 Deputy NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL i Exhibit B EXI IIBIT C Exhibit C Print CRS W0322637 Pagel of 8 .J COMMONWEALTH OF PENNSYLVANIA IE RASH REPORTING FORViA POLICE ge Crash Number Case Closed Reportable Crash Patl..� AA'500 1 0 Yes i No a Yes Q No j W0322637 Incident Number Police Agency Patrol Zone 2012-13720 28401 1 E {f} ® Agency Name Precinct Investigation Date(MM-DD-YYYY)-YYYY) g Chambersburg 12 31 1-12012 t 6, Dispatch Time(mil) Arrival Time(mil) Investigator Badge Number 10111MATTHEW 0018 0019 PTLM IAN ARMSTRONG 269 Riewer ge Number Ap royal Date (MM-DD-YYYY))T CODY SGT O l 08 2013 County County Name Municipality Municipality Name �Y of Mleek I 2$ Fr,tzktin 401 hambersbut Borough �� O sun p Thu s ® Crash Date(MM-DD-YYYY) Crash Time(mil) No of Units People Injured Killed' "If>00 Mon Q Fri 12 31 e 2012 0016 4 I-� � = complete ©Tue Q Sat Ly---� Ponn F Q Wed Q Unk Workzone(If Yes Complete O Yes No School Bus O Yes No School Zone Yes No Notify PENNDOTQ Yes a No form(v1 Section 29) Related Related ARaintenance A a i 4 Way Intersection Q "Y"intersection Q Mu"-Leg 0 Off Ramp O Railroad CrossingIntersectionInters@ on 7o Q Midblock Q °T"Intersection 0Traffic Circle! Round About O On Ramp (�Crossover O Other See overlay ((Roou�ut'e Number Se``g``ment(Optional) Travel Lanes speed Limit Q North' Nouse Number (if applicable) L�J LY, I 02 3S CD south E Street Name Street Ending 0 East For Mid-block crashes only.Use j 4 fa ?' 0 West postal House Number and make sure g MCKINLEY ST o (� Unknown Principal Roadway Street Name is filled in if using this option O InterstateO Turnpike 0 Turnpike Q State Q County - Local Road © Private O Other/ (Not Turnpike) (East/West) Spur Highway Road or Street Road Unknown Route Number Segment(Optional? Travel Canes Speed Limit North i I - I I 1 02 1 35 Q South i Lp Street Name Street Ending c O East s 1; CLEVELAND AV v west O O Unknown Signi,o Route Interstate Turnpike Tumpike State County Local Road Private Other/ g M $ O (Not Turnpike) Q (Ea pike Q Spur O Highway O Road or Street Q Road Q Unknown r 11Ti te�rse'ctin�g Rtt Hum IOr Mile -Post �11 Or Segment Marker z � - m O North Feet „O South Please Or Intersecting Street Name St Ending 7 O East E O WeOr Miles Enter .E Information 14 st s '0 for BOTH j K .a Landmarks Intersecting Rt Num Or Mite Post Or segment Marker O North ! if Using N ° Distance From Crash I C This Option ro t 1 . O South Scene to landmark 1 s Or Intersecting Street Name St Ending O East (for Crash between 15 c Landmark i and O West Landmark 2) Lil 0:1 FA Degrees Minutes Seconds Degrees Minutes Seconds r Latitude: �; Longitude: — Traffic CfirL DevikePolice Officer or m fUrxtfonlno Q Yield Sign Flagman Device Functioning Emergency a O Not Applicable O Traffic Signal O Active RR Crossing O Other Type TCD O No Controls O Improperly O Preemptive Flashing Traffic Controls Signal I O Signal a Stop Sign O Passive RR Q Unknown (� Device Not Device Functioning Q Unknown Crossing Controls Functioning Properly I t (if-Not Applicable,skip rest of the Lame Obsure section) tune Ctnsrar O North O East O North and South f' Ail e ® Q Not Applicable O Partially 0 Fully O Unknown 'AhKdw Q South O West O East and West (N,S,E,W) g Ir is Yes 0 No QLizo-- FORM 3D Min. Q 1-3 hrs Q Unknown Unknown O ©30 fi0 Min. 3 6 hrs {�S�9 hrsQ>9 hours•Aa-soo(tntoz) PENNDO'T COPY s i http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles/201300251020130... 1/8/2013 4 Print CRS W0322637 Page 2 of 8 COMMONMEALIM Or-POLICE CRASH REPORTING FORM PENNSYLVANIA Page: Crash Number An 500 2 1 Police Use Only I W0322637 { o Motor Vehicle in fj � Type � Transport O Nit&Run Vehicle Q Illegally Parked O Legally Parked QNon-Motorized Commercial Vehicle j top Unit Pedestrian on Skates, Disabled From O Yes No g O Pedestrian O in Wheelchair,etc O Previous Crash Q Train O Phantom Vehicle (!f'Pedestrian"Or"Pedestrian on Skates,in Wheelchair,etc",Complete Form M,Section 28) (if Yes,Complete Form C) unit No first Name ANI Date of Birth(MM-DD-YYYY) 01 AGUSTIN 03 20 1985 Delete? Last Name Telephone Number Q MACIAS-MARQUEZ 7173329211 i( Address/C /State r17268 e a 358 AYCHER AVE WAYNESBORO PA Driver License Number State Class { g 16PLUS PA Alcoho0rugs Suspected Driver or Pedestrian Physical Condition tt Q No 0 Illegal Drugs Q Medication Apparently Illegal Drug Q Normal Q Use O Fatigue Q Medication 0 Alcohol O Alcohol and Drugs Q UnknownHad Been a Drinkin O Sick Q Asleep Q Unknown Alcohol Test Type Q Test Not Given Q Breath O Other Primary Vehicle Cade Violation Charged? Q/ l0 Blood Q Urine Q Unknown if HOMICIDE WHILE DUI i Yes O No g Test Given Results Driver Preserve 1=Driver Operated 3=Driver Fled Scene y Alcohol Test Results Q Test Refused O 14� Test Given, Vehicle 4--Hit and Run" O Contaminated Results 1 2=No Driver 9=Unknown OwnerlLirner 00--Not Applicable 02=Private Vehicle Not 04--State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98--01her 02 teased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as Owner First Name Owner Last Name or Business Name(If Pedestrian,skip this Section) Driver�} 11GERARDO GARCIA )t Address/City/State/Zip Vehicle Make *Make Code ! 1315 BENDERSVILLE RD ASPERS PA 17304 Ford 12 VIPs Model Year Vehicle Model (see overlay) 1 FMRU 18W5 WLB53132 111998 EXPEDITION�� License Plate Reg.State Est.Speed Vehicle Towed Towed By HZW9099PA 999 a Yes Q NO RIFE MOTOR CO Insurance Insurance Company Policy No Yes Q NO O knoU11-wn FTRAVELERS INS CO 977540210 101 1 E ! u * Tre",;lineype 1=Towing Pass.Veh 4=Mobile/Modular Home 7=Semi-Trailer Tag No Tag Year Tag St Unrt No. Unit D 2=Towing Truck S=Camper 8--Other m Trailing 3=Towing Utility Trailer 6--Full Trailer 9=Unknown `v Direction ofN *Vehide Position 01 Movement 1 *See Special Usage Traver— ❑ Overlay Vehicle Color Vehicle pw 05--Large Truck 20--Unicycle,Bicycle, 00 12=Commerdal 06=Yellow 01-Automobile 06=SUV Tricycle Passenger 01 07=Silver 06 02=Motorcycle 07=Van 21=OtherPedalcyde 00=NOtApplicabie Carrier 08=Gold 03=Bus 10=Snowmobile 22=Horse&Buggy 01-Fire Veh 13=Taxi 01=81ue 09--Brown 04--Small Truck 11=Farm Equip 23=Horse&Rider 02—Ambulance 21=Tractor Trailer 02=Red 10=Orange (tf"02",Complete Farm 12=Construction Equip 24=Train 03=Paiice 22=Twin Trailer 03=White 11=Purple M,Section 26) 13=ATV 25=Trolley 08=Other Emergency 23=Triple Trailer 04=Green 12=Other (if"20"or"21" Complete 18=Other Type Spec Veh 98=Other Vehide 31=Unkno d Veh 15--Black 99=Unknown p 19=Unk.Type Spec Veh 99=Unknown 1 t=Pupil Transport 99=Unimown Form M,Section 2J) Initial Impact Point Damage Indicator Gradient 3=Downhill Road Alignment 00-Non-Collision 14=Undercarria a O=None 2=Functional 4=Bottom of Hill 1=Straight 1 01-12=Clack Points 15=Towed Unit D 1=Minor 3=Disabling Q 1=Uphi S=Top of Hi F 2=Curved 13=Top 99=Unknown 9=Unknown 2=Uphril 9=Unknown 9=Unknown FORM a AA-SW ttuozl PENNDOT COPY I1 I http://www.dot6.state.pa.us/ersapp/Printlmages/XmIFiles/201300251020130... 1/8/2013 ,. Print CRS W0322637 Page 3 of 8 I POILCE H REPORTING MONWEALTH OF � M ��lt� � Iilll Crash Number Page: AA 500 2 Police use Onry # 1 1 W0322637 4 0 Transport Motor Vehicle in O TY� Hit&Run Vehicle O Illegally Parked O Legally Parked 0 Non-Motorized Commercial Vehicle � 10 a unitO Pedestrian O Pedestrian on Skates, Disabled From O Yes 0 No g — in Wheelchair,etc O Previous Crash O Train O Phantom Vehicle (!f'Pedestrian"or"Pedestrian on Skates,in Wheelchair,etc",Com Jete Form M,Section 18) (If Yes,Complete Form C) Unit No first?dame MI Date of Birth(MM-DD-YYYY) 02 NICHOLAS 09 27 19$2 Delete? Last Name Tele hone Number 0 IFORTENBERRY f; Address/Ctt State Zi a 43 1/2 W KING ST APT 3 SHIPPENSBURG PA 17257 Driver License Number State Class g F66675900009824 I NJ C d AlwholiDnms Suspected Driver or Pedestrian Physical Condition 11 (0 No Illegal Drugs 0 Medication O Normalntly illegal Drug O Fatigue 0 Medication O Alcohol O Alcohol and Drugs O Unknown 0 Had Seen 0Sick Drinkin O Aslee p O Unknown Alcohol Test Type b Primary Vehicle Code Violation Charged? O Test Not Given O Breath O Other 0 Blood O Urine O unknown if DUI O Yes O No s Test Given S Alcohol Test Results O Test Refused a Rensku nr Driver Presence 1=Driver Operated 3=Driver Fled Scene a" O Test Given, Vehicle 4--Hit and Run Contaminated Results FLI 2=No Driver 9=Unknown ownerlDriver 00=Not Applicable 02=Private Vehicle Not 04=State Police Vehicle 07=Municipal Police Veh 09=Federal Gov Veh Q 01=Private Vehicle Owned/ Owned/Leased by Driver 05=PENNDOT Vehicle 08=0ther Municipal 98--Other 02 Leased by Driver 03=Rented Vehicle 06=Other State Gov Veh Government Vehicle 99=Unknown Same as owner First Name Owner Last Name or Business Name Of Pedestrian,skip this Section) Driver Q HEATHER M/ERI COBLE Address City Make "Make Code l 43 1/2 W KING ST APT 3 SHIPPENSBURG PA 17257 Saturn 24 t VIN Model Year Vehicle Model (see overlay) 1 G8JU52F41 Y584620 2001 L200 License Plate Reg.State Est.Speed Vehicle Towed Towed By HYM0261 PA 999 1 a Yes O No I RIFE MOTOR CO Insurance Insurance Company Policy No } Yes 0 No O Un- known NATION WIDE 586416629 12 Treilm T 1=Towing Pass.Veh 4=Mobile/Moduiar Home 7=Semi Trailer Tag No Tag Year Tag St it e UTrailing of u 2 Yawing Truck 5--Camper B=Other nits 9� 3=Towing Utility Trailer 6=Full Trailer 9=Unknown v Direction ofE *Vehide Position 01 -Alovement 1 *See Saeaial Usage rev. ❑ Overlay Vehicle ColorVehide Time 05=Large Truck 20--Unicycle,Bicycle, 00 12=Commercial O6=Yellow 01=Automobile 06--SUV Tricycle Passenger 04 07=Silver 01 02=Motorcycle 07=Van 21=Other Pedalcycle 00=Not Applicable Carrier 08--Gold 03=Bus 10=Snowmobile 22=Horse&Buggy 01=Fire Veh 13=Taxi 01=Blue 09=8rown 04--Small Truck 11=Farm Equip 23=Norse&Rider 02=Ambulance 21=Tractor Trailer 02=Red 10=Orange (if"02",Complete Form 12--Construction Equip 24=Train 03=Police 22=Twin Trailer 03=White 11=Purple M,Section 26) 13=ATV 25=Trolley 08=Other Emergency 23=Triple Trailer 04=Green12=Other (if"20"or"21",Complete 18=Other Type Spec Veh 98=Other Vehicle 31=Modified Veh 05--Black 99=Unknown p 19=Unk.Type Spec Veh 99=Unknown 11=Pupil Transport 99--UnknownFarm M,Section 27} Initial Impact Paint Damage Indicator Gradient 3=Downhill Road Alignment 00=Non-Collision 14--Undercarriage 3 O=None 2=Functional 4=Bottom of Hill t=Straight Q3 01-12=Clack Points 15=Towed Unit 1=Minor 3=Disabling E]1=Levet S=To of Hill 2=Curved 13=Tap 99=Unknown 9=Unknown 2=Uphill g=Unknown 9=Unknown F0RM s AA-son(12to2) PENNOOT COPY } f http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles/201300251020130... 1/8/2013 s Print CRS W0322637 Page 4 of 8 —J COMMONWEALTH OF POLICE CRASH REPORTING FOR WdA�9IA crash Number Page AA 500 3 1 Police Use only W0322637 Person Tvne: Seat Position. Sjy�uipr�ent One: Ejection: A 1=Driver D 00-Not A Passenger/Occupant E 00=None Used 1 Nat Applicabie G O=Not Applicable 2=Passenger 01=Driver-All Vehicles 01=Shoulder Belt Used 1=Not Ejected 7=Pedestrian 02-Front Seat Middle Position 02=Lap Belt Used 2=Totally Ejected 8-Other 03=Front Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected 9--Unknown 04--Second Row-Left Side Or 04--Child Safety Seat Used 9--Unknown Motorcycle Passenger 05`Motorcycle Helmet Used 05=Second Row-Middle Position 06=Bitycle Helmet Used H Ejection Pati: Sex: 06=Second Row-Right Side 10=Safety Belt Used improperly 0-- of Ejected/Not Applicable B F =Female 07=Third Row Or Greater- 11=Child Safety Seat Used Improperly ® M=Male Left Side 12=Helmet Used Improperly 1=Through Side Door Opening U=Unknown 08-Third Row Or Greater- 90=Restraint Used,Type Unknown 2=Through Side Window Middle Position 99=Unknown 3=Through Windshield 09--Third Row Or Greater- 4--Through Back Door Right Side Sa ty Egtrjgment Two: S--Through Back Door Tailgate Opening Jaiury Severirv: 10=Sleeper Section of Truckcab F 00=None Med Not Applicable 6=Through Roof Opening Sunroof/ e 0--Not Injured 1 Wn Other Enclosed 01=Front Air Bag Deployed(For This Seat) Convertible Top Down) �, a i=Killed Passenger Or Cargo Area 02=Side Air Bag Deployed(For This Sea#} 7=Through Roof Opening(Convertible ® 2=Major Injury 12=ln Open Area 03=Other Type Air Bag Deployed Top Up) 3=Moderate (Back Of Pickup,Etc.) 04=Multiple Air Bags Deployed 9=Unknown 1 Injury 13=Trailing Unit 05=Motorcycle Eye Protection 4--Minor Injury 14=Riding On Vehicle Exterior 06=8icyclist Wearing Elbow/Knee/Pads 8=Injury,Unk 15=Bus Passenger 10=Air Bag Not Deployed,Switch On O=NottAp Severity 98=Other ,I=Air Bag Not Deployed,Switch Off I=Not Applicable 9=Unknown if 99=Unknown 12=Air Bag Not Deployed, 1=Not Extricated g 2=Extricated By Mechanical Means Injury 13=Un Sag Removed(Prior To Crash)Switch 3=Freed By Non-Mechanical Means 19=Unknown If Air Bag Deployed B=Other 99--Unknown9=Unknown 13 EMs Agency: MARION,FAYETTEVILLE Medical Facility: CHAMBERSBURG HOSPITAL,YORK HOSP Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H I ra O 1 01 Dei�ete? 03 - 20 - 2 985 01 99 O i10 Name/Address/Phone ❑same as MACIAS-MARQUEZ AGUSTIN 358 AYCHER AVE WAYNESBORO PA 172 EMs Transport Operator ° i Yes O No Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H I Delete 02 O1 O ? Fog--]- 27 - 19$2 FI—] M❑ 2 ] O1 02 O1 OQr_J Name/Address i Phone EMs Transport ❑Ope �r FORTENBERRY,NICHOLAS 43 1/2 W KING ST APT 3 SHIPPENSBUR EM Yes O No f Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G (�H`� I 02 02 p 10 - Q 1 - 1987 D a 03 99 01 a L 'a Name/Address 1 Phone EMS Transport El some as COBLE,HEATHER 43 1/2 W KING ST APT 3 SHIPPENSBURG PA 17 Operator 0 Yes O No Unit No Person No Deletes Date of Birth (MM-DD-YYYY) A B C D E F G H I 02 03 O 06 - 30 - i988 2❑ 99 99 00 D11 21 Same as EMs Transport El Same /Address/Phone operator PERRY,MADISON 416 FRANKLIN HEIGHTS SHIPPENSBURG PA 1725 W Yes O No Unit No Person No Date of Birth (MM-DD-YYYY) A B C D E F G H I If Name/Address/Phone Same as EMS Transport Ei Operator O Yes O No Unit No Person No DehrteDate of Birth (MM-DD-YYYY) A`} B C D E F G H jj��``��I O ? =- - FIFIE] �❑❑ —1 Name I Address/Phone ❑Same asEMS Transport Operator O Yes O No IL- FORM a AA-500(tuos) PENNDOT COPY — http://www.dot6.state.pa.us/crsapp/PrintImap-es/XmIFiles/20130025102013O... 1/$/2013 Print CRS W0322637 Page 5 of 8 POLCE CRASH REPORTING 1FOR6NilA IA Page Crash Number AA 500 Ponce Use Only W0322637 Crash Descrfation 0--Non-Collision 2=Head On 4=Angle 64ldeswiPe 8--Hit Pedestrian ( tear End 3rRear t°Rear eswtpa (Oppos==e Direction) a _ (backing) ma Direction) 7--Hit Fixed Object 9=0tharlUnknown 1=On Travel Lanes 3--Median 5--Outside Trafficwa 7--Gore Ra Intersection ^-� E Relat{on to Roadway Y (Ramp ) s 2--Shoulder 4--Roadside 6=ln Parking Lane 9--Unknown 151=Daylight 3--Dark-Street 5--Dawn 8-liher N e Illumination 3 2=Dark-Na Lights 6 Dark- Inknown ti Street tarts 4=Dusk Roadwa+�Lk�hting i SVlleather Conditions i=Gond oe se 3--Sleet(Hall) 5--Fog 7--Sleet 8 Fog _ 9=Unknown —� I 2--Rain_ 4-.-Snow 6--Rain&Fog 8--Other F&ydSurface Conditions p O=Dry —' 2= nd,Mud,Dirt, 4--Slush 6 Ice Patches 8_-pthar�� 1=Wet 3--Snow Covered 5=Ice 7=W t r-.Standing II orMovmg Harm Event LIR dost? VuI Pole-Plumiter Harmful Events(Harm Event) 30--Hit fence Or Wail 9 02 ❑ 01=Hit Unit 1 31=Hh Building Unit No 02=Hit Unit 2 32=Hit Culvert l 03=Hit Unit 3 33--HR Bridge Pier Or Abutment O 1 2 F-10 04--Hit Unit 4 34=Hh Parapet End it 05=Hit Unit 5 35=Hit Bridge Rail 4 06=Hit Other Traffic Unit 36--HitBoulder Or Obstacle I Please Put 07=Hit Deer On Roadway Events in 3 ❑ Q 08=Hit Other Animal 37--Hit Impact Attenuator Sequential 09=Collision With Other Non 38--Hit Fire Hydrant Order Fixed Object 39--Hit Roadway Equipment C11=Struck B Unit 1 40--Hit Mail Box $ 12=Struck By Unit 2 41=Hit Traffic Island ss E 13--Struck By Unit 3 42=Hit Snow Bank o Harm Event LIR Most? Utifity Pole Number 14--Struck By Unit 4 43--Hit Temporary Construction 15=Struck By Unit 5 Barrier 1 11 ❑ 16=Struck By Other Traffic Unit 48--Hit Other Fixed Object v Unit No 21=Hit Tree Or Shrubbery 49=Hh Unknown Fixed Object W 22=Hit Embankment 5D-Overturn/Roll rntR hr Over 23=Hit Utility Pole S1=Struck By Thrown Or Falling 24--Hit Traffic Sign Object 25=Hit Guard Rail 52=Pot Holes Or Other Please Put26=Hit Guard Rail End Pavement Irregularities Events in 3 27=Hit Curb 53=jacknife { Sequential 28=Hit Concrete Or 54 Fire In Vehicle I OrderLongitudinal Barrier 58=Other Non-Collision jl 4 0 29--Hft Ditch 99=Unknown Harmful Event 1 firsIt Unit No Harm Event Most Unit No Harm Event Driver Action(D) 17--Careless Or Illegal ti ;�rn—Nin � fin � 00=No Contributing Action Backing n Roadway v�enfin Q 1 02 rre�nt in 01 02 01--Driver Was Distracted 18--Driving On The Wrong tie�r ssh tush 02=Driving Using Hand Held Phone Side Of Road Li Do not miwt th¢infamotion on multiple pages 03=Driving Using Hands Free Phone 119--Making Improper Environmental/Roadway 04=Making Illegal U-Turn Entrance To Highway 05=Improper/Careless Turning 20--Making Improper Exit Potential factors(F/R} 1 00 1 2= 3= 06=Taming From Wrong Lane From Highway 07=Proceeding W/O 21=Careless Parking/Unparking DD=None t t=A' eery Road Conditions(ice/Snow) Clearance After Stop 22=Over/Under 01=Windy Conditions 12=Substance On Roadway 08=Running St°p Sign Compensation At Curve 02=Sudden Weather Conditions 13=Potholes 09=Running Red Light 23=Speeding 03=Other Weather Conditions 14--Broken Or Cracked Pavement 10=Failure To Respond 7o 24--Dnving Too fast For Conditions 04--Deer In Roadway 15--TCD Obstructed Other Traffic Control Device 25=Fallure To Maintain Proper Speed 05=Obstace On Roadway 16--Soft Shoulder Or Shoulder Drop Off 11=Tailgatingg 26--Driver Fleeing Police(Pol Chase) 06=Other Animal In Roadway 28=0ther Roadway Factor 12=Sudden Slowinotopping 27=Driver Inexperienced re- 07=Glare 29=Other Environmental Factor 13=Illegally Stopped On Road 28=Faiture To Use Specialized Equip c 08--Work Zone Related 99=Unknown 14=Careless Passing Or Lane g2=Affected B Physical Condition g Change 98=Other Improper Driving Actions A Possible Vehicle Failures(N} 12311r" 15=Passing In No Passing Zone 99=Unknown E 00=None 06--Exhaust 13 Or Seating/Control 16=Driving The Wrong Way On .° 01=Tires 07=Headlights 14=Body,Doors,Hood,Etc t-Way Street e 02--Brake System 08=Si nal tights 15=Wh er Hitch unit 03=Steering System 09=Other Lights 16=Wheels No p j 1 0$ 2 3 4 a 04--Suspension 1D=Hom 17=Airbags 05--Power Train 11--Mirrors 18=Trailer Overloaded 19 U railer Load unit c Unit � Trailer Load No 02 9 00 2 3 4 v° No O 1 1 00 � 20=Improper Towing 21--Obstructed WindstNefd Pedestrian Action tPi 03--Working Urtit 99 Unknown 04=Pushin V No 02 1 00 Z 01=None g Vehicle 01=Entering Or Crossing At 05=Approaching Or leaving Vehicle Specified Location 06=Working On Vehicle Indicated Prime Factor Unit No Factor Code 02=Walking,Running,jogging, 074tanding Do not repeat this information on Or Playing 98=Other 19 muhiple pages. O 1 08 99--Unknown E I R V D P Unit Noamt No ( ! 0 0 � 0 if E!R is the Prime Factor 0} Type,leave Unit No blank FOAM f AA-WO it;'IOQ} PNNIiT COPY t http://www.dot6.state.pa.us/crsapp/Printlmages/XmIFiles/201300251020130... 1/8/2013 r • Print CRS W0322637 Page 6 of 8 POLICE CRASH REPORTING FORMCOMMONWEALTH PENNSYLVANIA Crash Number Page AA 500 5 Pol'Ke Use Only � wo3aas37 . 1 i 1 : :` i i ? i i i i i i t ..........1...........:...........:...........:..........:..........1....x....1..,.......,i...........:....... ... ... ... ... •.. ... .......t...........:....... ... ... ... ... ... ... ... ... ... •.. f 3 ..........:..._..._.;..........;..........y....................»...........:......_._?..........•i........_(...........�........._r...... ... ... ... ... ... ... ... .» ... _._...y'.................._i........_._......__............._.._i i i i ........_i......_...i...........i....»...,b................ ....... ------ ... ... ... --------- ... ...... ... ... _.._4__ ... ...._(......, .......i.....................i.._.,..... { E : z I? A »........?.........»?..........J........,..i...........:...........i..........i...........i.._......i.,,.......6..... ... .« ... ... ... .......i................. ... ........... ... ... ... .. ... ... ... I ; 20 i 1 i t t .._«..•.........,.t........_.i...........i...........i...........i........._I».........i......... ..i.,.........i....»...»I..........t.........«i......_..i...... ... ... ... ... ... .......i....... .......1.........,i...... ... ... ............... i i i t 1 1 f _. ... ... .. 1 ........... ........i........_................__......._ ... ... .......... _....._.a.,..«.. : i s Witness Name Address Phone 21 t 2 Narrative and additional witnesses: Accident Investigation Notification Issued?0 Property Damage� I On 12/31112 Chambersburg Police responded to an auto accident in the area of East McKinley Street and Cleveland Avenue. Units arrived on the scene to find a major accident with several severely injured individuals. The Chambersburg Police Department Major Accident Investigation Team was contacted and responded to the I scene. The Major Accident Investigation Team is investigating the accident and will supplement this report once the investigation has been concluded. a b T. C to M 22 a M I Fonar a AA-soop2m2} PENNDOT COPY 1 l http://www.dot6.state.pa.us/crsapp'/Printlmages/XmIFiles/2013 00251020130... 1/$/2413 •Print CRS W0322637 Page 7 of 8 _J CONNOMMILM OF IX U IE�D9 Gi( vemoG9a IFORPnl b�Q Page 0 New III II�I�IIIIIIIIIIIIIIIIII Crash NumOsar AA 500 F ftlice9SeOny O Change/ W0322637 Continuation Road Surface Tme Q Brick or Black Q Dirt Speaal Jurisdiction 0 Military 0 Other Federal Sites Za O ConcreteSlag,Gravel or 0 Other No Special 0 Indian Reservation 0 Other 0 Blacktop O Stone Jurisdiction C: a eNnivers O Unknown 0 National Park O Campus 'Ty O Unknown Please complete Unit information for ea h unit involved in a fatal crash.Do not repeat the information in the fields above on multiple pages. Unit No P►lndple Impact Point O1 O Non-Collision 01112 010 Diner Restrict)orrs Restrictions Not a Pennsylvania To 01*._ 2 O Compliance O Complied With Driver 0 P 0 09 030 O Restrictions Not O Unknown 0 Undercarriage O No Restrictions/ Complied With Compliance 04 e Not Applicable 0 Unkn lownCe O Towed Unit O7 06 0500 Driver Endorsement 0 Required- .Not a Pennsylvania 0 Unknown 0 0 a Compliance Complied With Driver 0 Required-Non 0 Unknown Avoidance Maneuver O None Required Compliance Compliance No Avoidance Required- aManeuver Q Braking-Other 0 Other Avoidance ss O Compliance Unknown Evidence Maneuver « Brakin -Skid Steering-Evidence Driver Liaense 0 Not Required for O Unk if CDL or O O Q Inconclusive 1 Com lance Vehicle Class CDL Required Marks vident or Driver Stated 0 No Valid License - Not a Pennsylvania Braking-No Skid Steering and Braking Q Unknown for Class Driver O stated O Evidence or Stated O Not Licensed O Valid License for 0 Unknown Class Under Ride indicator Dma Test Tvpe Underride,No Override,Other 0 Blood 0 Other No Underride or O Compartment 0 0 None0 Urine O Unknown if Test Override Intrusion Vehicle i Given Underride, Underride, Unknown if Drrrrt Test Resuhs-(Up to Four Rmfts► ❑ O Compartment O Compartment O Underride or Intrusion Intrusion Unknown Override 0=No Test Given 5=Ampfietamines 109 D 1=No Drug Reported 6= Ememenc�Use O Li lits Flashin Both Lights and 2=Marijuana 8=Other 9 g O Siren 3=Cocaine 9=Unknown Test ❑ ❑ Not in Emergency 4=Opiates Results Use O Siren Sounding O Unknown I Unit No Prindple Impact Point i 02 Q Non-Collision 0 1 102 0 0 Restrictions Not a Pennsylvania 01 20 ' D�r� O Complied With Driver sy O Top 0 09 03 Restrictions Not Unknown O Undercarriage f 0 Not Applicable O Complied With Q Compliance g O 08 V 4 0 z O Unnkknpownce O Towed Unit 07 06 050 Driver Endorsement 0 Required- -Not a Pennsylvania 0 Unknown O Q prance Complied With Driver 0 Required-Non 0 Unknown Avoidance Maneuver ., Compliance Compliance g O None Required P No AvoidanceOther d 0 Required- Maneuver O Evidence Other O Maneuver Avoidance Compliance Unknown Q Braking-Skid O Steering-Evidence O Inconclusive DA%W Licertse Not Required for Unk if CDL or Marks Evident or Driver Stated ram, 0 Vehicle Class 0 CDL Required No Valid LicenseBraking-No Skid 0 for Class I♦Not a Pennsylvania 0 Marks,Driver O Steering and Braking 0 Unknown Driver Stated Evidence or Stated Q Not Licensed O Valid License for 0 Unknown Class Under Ride Indictor Diu¢Test Ttnse Other No Underride or Underride,No Override,Other Blood O Override 0 Compartment O Vehicle Unknown if Test Intrusion Q None 0 Urine 0 Given Underride, Underride, Unknown if Drug Test Resuft-(Up to four Resufls) O Compartment O Compartment O Underride or Da F1 Intrusion Intrusion Unknown Override 0=No Test Given 5=Amphetamines I=No Drug Reported 6=PCP Both Lights and 2=Marijuana 8=Other F1Ememencv Use O Lights Flashing O Siren 3=Cocaine 9=Unknown Test a Not in Emergency 4=Opiates Results Use O Siren Sounding O Unknown FmG.taaa,costmq PENNDDT COPY i http://www.dot6.state.pa.us/crsapp/PrintImages/XmIFiles/201300251020130... 1/8/2013 a MEW4 1 • +., ac zs t _ r Exhibit D THE LAW OFFICE OF �COP C JAMES M. CURRAN a a A FROFESSIONAL Co"ommoN CERTIFIED CIVIL TRIAL ATTORNEY 86 Washington Avenue ■ Milltown,New Jersey 08850 MEMBER NJ&NY BARS Board Certified Civil Trial Advocate By ncL National Board of Trial Advocacy May 8, 2014 John Keller, Esquire Keller, Keller & Beck, Esquires 343-B South Potomac Street, Suite B Waynesboro, PA 17268-1646 Re: Your Client: Heather Coble My Client: Nicholas Fortenberry D/A: December 31, 2012 Dear Mr. Keller: As you know, this office represents Nicholas Fortenberry for injuries sustained in the above accident. Please be advised that Nicholas Fortenberry was admitted to York Hospital on December 31, 2012 and was discharged on January 29, 2013 . He sustained the following injuries as a result of this accident : 1 . Transection of thoracic aorta from posterior aortic arch to the proximal descending aorta with moderate mediastinal hematoma, small to moderate sized bilateral hemothoraces, right lower lobe contusion and small pneumatocele posteriorly 2 . Right 8th to 12th rib fractures posteriorly 3 . Grade III liver laceration involving the medial segment of the left hepatic lobe 4 . Right renal contusion with a small subcapsular hematoma Telephone: 732-296-0500 ■ Fax-732-296-9090 ■ wwwcurrantriallaw com • email:curranlaw(Prahoo.com FYUTRTT n Page 2 May 8, 2014 Re: Nicholas Fortenberry 5 . Small hemoperitoneum. The above injuries required multiple procedures/surgeries , Mr. Fortenberry's medical bills total over $436, 000. 00 with outstanding medical bills over $51, 000 .00. In addition, the State of Pennsylvania has a Public Welfare claim in the amount of $!60, 120.45 for payment of medical bills through charity care. They have agreed to take 500 of Mr. Fortenberry's net settlement. If you have any questions regarding the above or need additional information, please do not hesitate to contact me, .Very truly yours, -/,�TkMES M. CURt /jer Exhibit E Michael V. Farrell Sr. Technical Specialist TRAVELERS, Claims,Pittsburgh, Pa. 412-338-3238 800-238-6285 x-3383238 Insurance. In-synch: mvfarrel@travelers.com Pennsylvania Claim Service.Center P.O.Box 1538 15iftsburgh, PA 1523b August 16, 2013 Mr. John N. Keller, Esq Mr. James M. Curran, Esq Mr. Edward E. Knauss, Esq Keller, Keller and Beck 86 Washington Ave Metzger Wickersham 343 B South Potomac St Milltown, NJ 08850 PO Box 5300 Waynesboro, PA 17268 Harrisburg, PA 17110 RE: Policyholder: Gerardo Garcia Claimants: Estates of Madison Perry and Heather Coble Nicholas Fortenberry Date of Loss: 12/30/2012 Claim #: HQC4119 Dear Gentlemen: As you may recall from our various telephone conversations, my policyholder elected bodily injury liability limits of$50,000 per person and $100,000 per accident. On behalf of Mr. Garcia and Mr. Macias, we are tendering the policy.limits in settlement of all claims. Since the available coverage is not sufficient to fully compensate your respective clients, please advise as to the mutually agreed upon apportionment of the policy limits. Obviously no single settlement can exceed the,$50,000 per person limit and the combined settlements not exceed $100,000. Also, as there are two Estates involved, Court approval will be necessary before I can issue any of the settlement. drafts. Once I have received the agreed upon apportionments, I will prepare releases for signature and send them to your offices. Before I can issue any of the settlement payments, I will need to have all three signed releases and the necessary Court approvals on the Estate settlements. Travelers has been placed on notice of a DPW lien and a child care lien that will need,to be addressed before I can issue payments as well. have enclosed a statement of coverage for your records. Please let me know if you need anything further Sincerety_; Michael V. Farrell Sr. Technical Specialist 412-338-3238 TRAVELERS PERSONAL SECURITY INSURANCE COMPANY Policy issued to: GERARDO GARCIA 2 :GREENWAYACRES THOMASVILLE , PA 17364-9700 Policy #: 977540210 - 101 •- 1 4. Coverages, Limits of Liability A - Bodily Injury $50,000 each person $100,000 each accident B - Property Damage $50,000 each accident By: Michael. V. Farrell Sr. Technical Specialist Travelers Personal Security Insurance Company Exhibit F Pennsylvania a� DEPARTMENT OF:TUBLIC WELFARE October 23, 2013 METZGER WICKERSHAM BRANDY IRVIN GOVERNMENT LIEN PARALEGAL 3211 N FRONT ST P 0 BOX 5300 HARRISBURG PA 17110-0300 Re: Madison Perry CIS #: 500215730 Incident Date: 12/31/2012 Dear Ms. Irvin: The Department of Public Welfare maintains a claim in the amount of $50,826.21 for the above-referenced incident. After attorney fees and costs, the Department agrees to accept 50% of the client's net settlement. The net payment due is $10,901.59. Checks should be made payable to the Department of Public Welfare and sent to my attention at the address listed below. We request that with all transmittal of funds, you provide the Department with a copy of the final distribution sheet. In the event you have already brought or will bring any action resulting in a further recovery, we reserve the right to seek recovery of any unpaid portion of our medical/cash claim. This settlement in no way affects our future rights. Thank you for your cooperation in this matter. If you have any further questions, please contact me. Sincerely, Tina M. Wise TPL Program Investigator 717-214-1204 717-772-6553 FAX Bureau of Program Integrity Division of Third Party Liability i Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 r- s i EXhib'tt G 0 r" CONTINGENT FEE AGREEMENT L I, CA S 0"'? P(?.rN , retain and authorize the law firm of Metzger, Wickersham, Knauss &Erb, P.C.,to do whatever they deem necessary or desirable in order to represent me in all claims for compensation and reimbursement for personal injuries, wage loss,/ medical expense and other damages resulting from Z 1. ATTORNEY'S FEES: ` The fee of the attorneys shall be contingent as follows: (a) Thirty-three and one-third percent (33 1/3%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST ME OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. EXPENSES OF LITIGATION: I acknowledge responsibility for all expenses incurred on my behalf to pursue my claim/case and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses which have not already been paid by me. I do hereby agree to pay all expenses incurred by my attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees,photocopying charges, and mileage charges connected with the rendering of legal services. I understand that I am responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if my attorney deems it necessary, I may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. 3. APPEAL: I hereby further agree that my attorney may charge me reasonable additional compensation after consultation with me if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. 4. AUTHORITY: I hereby further agree that my attorney is hereby authorized to bring suit or to settle and compromise the claim,to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on my behalf. 5. MEDICAL EXPENSES AND LIENS: I further authorize my attorney to pay out of any proceeds of settlement or trial any unpaid medical bills or liens for treatments or services or workers' compensation liens made necessary by the injuries sustained in this accident, or back child support payments owed to Pa.SCDU. I understand that my attorney is not guaranteeing the payment of any medical bills or liens, and they remain solely my responsibility. 6. INVESTIGATION OF MERITS OF CASE: I agree that my attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation,the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. EARLY TERMINATION: I hereby further agree that if I decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. I agree that reasonable compensation for Edward E. Knauss, IV, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00)per hour, and other employees One Hundred Dollars ($100.00) per hour, or such higher rate as shall constitute his/her standard billing rate at the time that the work is performed, or the agreed upon percentage fee in paragraph one of this Agreement, whichever is greater. 8. WITHDRAWAL: I agree that my attorney may withdraw from this case at any time after reasonable notice to me, and I agree to keep him advised of my whereabouts at all times and to cooperate at all times in the preparation and trial of this case,to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of me in connection with the preparation and presentation of this case. r` IN WITNESS WHEREOF, I have signed below on this day of a a- c , 2013. CLIENT: METZGER, WICKERSHAM, KNAUSS &ERB,P.C. ATTORNEY: Edward E. Knauss, IV, Esquire Exhibit H COSTS Police Report $15.00 York Hospital Records 94.76 Notary for Estate Renunciation Form 5.00 Cumberland County Register of Wills—Opening Estate 98.50 Cumberland County Register of Wills- Filing Petition 15.00 Advertising Estate 264.00 TOTAL $492.26 558116-1 I V J sown oil, most f t Exhibit 1 Date January 28, 2013 No. Funeral of Madison J. Perry TO Mrs. Lei Loni Vaughn 232 Big Pond Road Shippensburg, PA 17257 Personal,Staff and (A) Services,including merchandise....................... Professional Services Funeral Home $5,400.00 Facilities and Equipment Automobile Equipment Casket $ 950.00 Interment Receptacle Keepsake grns $ 90.00 Monument Engraving Direct Cremation (B) Cash Advanced. We have advanced the following funds Newspaper Notices Total W $6,440.00 for your convenience.........--..................... $ 177.40 Clergy Honorarium $ 150.00 Certified Copies $ 120.00 Flowers $ 212.00 Coroner's Fee $, 25.00 Total'B' $ 684 .40 (C) Additional items,ordered later.......................... Thumb ie Charms —6 $ 786.00 Total 'C' 786.00 Complete Total $7,910.40 Due February 28, 2013 Amount Paid —0— Balance $7,910.40 Exhibit � .1*CS Pennsylvania i s DEPARTMENT OF REVENUE September 24,2014 Edward E.Knauss,IV,Esquire Metzger Wickersham 2321 Paxton Church Rd Harrisburg,PA 17106 Re: Estate of Madison Perry File Number 2113-1039 Court of Common Pleas Cumberland County Dear Mr.Knauss: The Department of Revenue has received your correspondence. Attached was the petition to approve a compromise settlement to be filed on behalf of the above-referenced estate in regard to a wrongful death and survival action. It was sent to this office for the Commonwealth's approval of the allocation to the proceeds paid to settle the actions. According to the Petition,the 24 year old decedent died as a result of a motor vehicle accident. Decedent is survived by his minor child. Pursuant to the Supreme Court of Pennsylvania,damages recoverable under a survival action include those for future.earnings,even where those earnings may be difficult to quantify. Kiser v. Schulte,538 Pa.219,648 A.2d 1 (1994). This is supported by the Commonwealth Court. Roberts v.Dungan,574 A.2d 1193 (Cmwlth.Ct. 1990). Therefore,absent any facts to the contrary,a portion of the recovered proceeds must be allocated to the survival action as compensation for decedent's lost earnings. However as the proceeds in this matter are a minimal net of$4,482.53,this Office has no objection to the allocation that you have requested. Please be advised that,based upon these facts and for inheritance tax purposes only,this Department has no objection to the proposed allocation of the net proceeds of this action,$4,482.53 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 Merryman,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. Jannon .Baker Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes PO Box 280601 Harrisburg, PA 17128 717.783.5824 shabaker@pa.gov