HomeMy WebLinkAbout14-6032966975.1
Karen Salvemini, Esquire, I.D. No. 307174
RHOADS & SINON LLP
One South Market Square, 12'x' Floor
P.O. Box 1146
Harrisburg, PA 17108-1146
PH: (717) 233-5731
FX: (717) 260-4438
Attorneys for Allstate Settlement Corporation
Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
Pro Se
F LEO -O F1CE,
THE PROs HONO li t�`t
2314 OCT 13 Aid IO: 35
CU PENNSYLVAN COUNTY TY
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: PETITION OF TYLER MICHAEL
CONAWAY AND ALLSTATE
SETTLEMENT CORPORATION FOR
APPROVAL OF TRANSFER OF
STRUCTURED SETTLEMENT
PAYMENT RIGHTS
NO.'Yrl - 603 0 Ca.itL
JOINT PETITION OF TYLER CONAWAY
AND ALLSTATE SETTLEMENT CORPORATION FOR
APPROVAL OF TRANSFER OF STRUCTURED
SETTLEMENT PAYMENT RIGHTS
By and through its undersigned counsel, Allstate Settlement Corporation ("Allstate
Settlement") and Tyler Conaway a/k/a Tyler Michael Conaway ("Mr. Conaway" or "payee")
(collectively, the "Petitioners") hereby petition this Court for approval of the transfer of
structured settlement payment rights between Mr. Conaway and Allstate Settlement, pursuant to
the Pennsylvania Structured Settlement Protection Act (the "Act"), 40 P.S. § 4001 et seq. and
Pennsylvania Rule of Civil Procedure 229.2, copies of which are attached hereto as Exhibit "A."
In support of this Petition, Petitioners aver as follows:
its-. 7s -pd Affy
C# /157
0-3/V00
1. Pursuant to the Act, specifically 40 P.S. § 4004, jurisdiction over the transfer of a
payee's structured settlement is properly brought before the Court in the county in which the
payee is domiciled. Mr. Conaway resides in Cumberland County and therefore, jurisdiction is
proper in this Court.
2. On or about February 11, 2002, Ronald and Kimberly Conaway, as parents and
natural guardians and on behalf of Mr. Conaway, then a minor, entered into a Settlement
Agreement and Release (the "Settlement Agreement") with a liability insurer (the "Insurer")
resolving a personal injury claim. See Settlement Agreement, a redacted copy of which is
attached hereto as Exhibit "B."
3. On or about April 24, 2000, the Settlement Agreement was approved by this
Court. See Order of Court, a redacted copy of which is attached hereto as Exhibit "C."
4. The Settlement Agreement provided for the disbursal of certain periodic payments
(the "Periodic Payments") to Mr. Conaway, including: one (1) lump sum payment of $3,500.00
due on November 4, 2015; one (1) lump sum payment of $4,500.00 due on November 4, 2019;
one (1) lump sum payment of $6,400.00 due on November 4, 2022; and one (1) lump sum
payment of $8,000.00 due on November 4, 2024.
5. The Insurer assigned to Allstate Assignment Company ("Allstate Assignment")
the obligation of the Insurer to provide the Periodic Payments to Mr. Conaway. See Uniform
Qualified Assignment, a redacted copy of which is attached hereto as Exhibit "D."
6. Allstate Assignment purchased an annuity (the "Annuity") from Allstate Life
Insurance Company ("Allstate Life") to fund Allstate Assignment's obligation to make the
2
Periodic Payments to Mr. Conaway. See Annuity, a redacted copy of which is attached hereto as
Exhibit "E."
7. On or about July 23, 2014, Mr. Conaway entered into a Funding Exchange
Agreement (the "Agreement") with Allstate Settlement, under which Mr. Conaway is to receive
certain funds from Allstate Settlement in exchange for waiving and alienating the right to receive
the following Periodic Payments: one (1) lump sum payment of $3,500.00 due on November 4,
2015; one (1) lump sum payment of $4,500.00 due on November 4, 2019; one (1) lump sum
payment of $6,400.00 due on November 4, 2022; and one (1) lump sum payment of $8,000.00
due on November 4, 2024 (the "Transferred Payments"). See Agreement, a copy of which is
attached as Exhibit "F."
8. Allstate Settlement has timely provided Mr. Conaway with all disclosures
required by the Act. See Disclosure Statement, a copy of which is attached hereto as Exhibit
«H5,
9. In compliance with Pa.R.C.P. 229.2(d)(2)(i), the net amount payable to the
payee after deduction of all commissions, fees, costs, expenses, and charges will be no less
than $12,494.21.
10. In compliance with Pa.R.C.P. 229.2(d)(2)(ii), based on the net amount that
the payee will receive from this transaction ($12,494.21) and the amounts and timing of the
structured settlement payments that would be assigned, the payee is, in effect, paying
interest at a rate of 8.8% per year.
3
11. For the purposes of the Agreement and this Petition, the parties and Allstate
Assignment and Allstate Life desire to waive any anti -assignment or anti -encumbrance language
in the Settlement Agreement and related contracts. See Affidavit of Allstate Assignment
Company and Allstate Life Insurance Company, a copy of which is attached hereto as Exhibit
12. The transfer of structured settlement payment rights described in this Petition and
as set forth in the Agreement (the "Proposed Transaction"), is not opposed by Allstate Life or
Allstate Assignment. See id.
13. The Proposed Transaction (i) does not contravene any federal or state statute or
the order of any court or responsible governmental administrative authority, and (ii) is in the best
interest of the payee, taking into account the welfare and support of the payee's dependents, if
any, and (iii) the net amount payable to the payee is not unfair, unjust, or unreasonable.
14. The Proposed Transaction complies with the requirements of the Act and
Pa.R.C.P. 229.2.
15. In compliance with Pa.R.C.P. 229.2(d)(3)(i) and the Act, Mr. Conaway has
established that the Proposed Transaction is in the best interests of Mr. Conaway or his
dependents, if any. See Affidavit of Tyler Michael Conaway, a copy of which is attached hereto
as Exhibit "I."
16. Mr. Conaway has confirmed that he has been advised, in writing, by Allstate
Settlement to obtain independent professional advice regarding the legal, tax, and financial
4
implications of the Proposed Transaction and has knowingly waived such advice in writing. See
Waiver of Independent Professional Advice, attached hereto as Exhibit "J."
17. Allstate Settlement has provided the Court with written notice of its name,
address, and taxpayer identification number. See Exhibit "K."
18. Allstate Settlement has provided the Court with a list of Mr. Conaway's
dependents and their ages. See Exhibit "L."
19. In compliance with Pa.R.C.P. 229.2(d)(3)(iii), certification of Karen Salvemini,
Esquire, counsel for Allstate Settlement, is attached hereto as Exhibit "M."
20. In compliance with Pa.R.C.P. 229.2(d)(3)(ii), a proposed initial order or court is
attached hereto as Exhibit "N."
21. In compliance with Pa.R.C.P. 229.2(d)(3)(iv), a proposed final order of court
granting this Petition is attached hereto as Exhibit "0."
WHEREFORE, Tyler Michael Conaway and Allstate Settlement Corporation respectfully
request that this Court approve this Petition and enter the attached proposed final order of court.
Respectfully submitted,
Dated: bativ, � ' , 2014 /a
Karen Simini, Esquire, I.D. No. 307174
RHOADS & SINON LLP
One South Market Square, 12th Floor
P.O. Box 1146
Harrisburg, PA 17108-1146
PH: (717) 233-5731
FX: (717) 238-8622
Attorneys for Allstate Settlement Corporation
5
Dated / '" , 2014
Respectfully submitted,
yler Michael Conaway, Pro Se
ACTIVE/ 76942149.1 6
VERIFICATION
I, Rebecca Baldwin, hereby state that I am a Product and Financial Manager for Allstate
Settlement Corporation and that the statements made in the foregoing Petition of Tyler Michael
Conaway and Allstate Settlement Corporation for Approval of Transfer of Structured Settlement
Payment Rights 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 PA. C.S.A. §4904
relating to unsworn falsification to authorities.
Dated:
),(D\ ,2014 0 -be
Rebecca Baldwin
ACTIVE/ 76942149.1 1
Pot
CERTIFICATE OF SERVICE
I hereby certify that on October /0 , 2014, a true and correct copy of the Joint Petition
for Approval of Transfer of Structured Settlement Payment Rights and proposed Initial Order of
Court has been served upon the following via certified mail, return receipt requested:
Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
Allstate Assignment Company
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M3
Northbrook, IL 60062
Allstate Settlement Corporation
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M4
Northbrook, IL 60062
Allstate Life Insurance Company
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M3
Northbrook, IL 60062
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9 of 9 DOCUMENTS
PENNSYLVANIA STATUTES, ANNOTATED BY LEX1SNEXIS(R)
*** Pa.C.S. documents are current through 2013 Regular Session Act 133, Enacted December 23, 2013.***
*P.S. documents are current Through 2013 Regular Session Acts 88, 91, 93 to 97, 99 to 103*
* Annotations current through October 16, 2013 *
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
40 P.S. § 4009 (2013)
§ 4009. Applicability
This act shall apply to any petition for the transfer of structured settlement payment rights under a transfer agreement
sought on or after the effective date of this act, provided, however, that nothing contained in this act shall imply that any
transfer under a transfer agreement reached prior to such date is effective or that any party is under any obligation to
make transferred payments to the transferee of any such prior transfer.
HISTORY: Act 2000-1 (S.13. 818), P.L. 1, § 9, approved Feb. 11, 2000, eff. in 60 days.
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PENNSYLVANIA RULES OF COURT, ANNOTATED BY LEXISNEXIS(R)
* Pennsylvania State Court Rules reflect amendments received December 15, 2013 *
* Annotations current through August 27, 2013. *
PENNSYLVANIA RULES OF CIVIL PROCEDURE
BUSINESS OF COURTS
Pa. R.C.P. No. 229.2 (2013)
Rule 229.2. Petition to Transfer Structured Settlement Payment Rights
(a) Words used in this rule, which are defined by the Structured Settlement Protection Act, shall have the meaning set
forth in the Act.
Note: See Section.2 of the Act, 40 P.S. § 4002, which defines
numerous terns including "best interests", "dependents", "payee",
"structured settlement obligor", and "structured settlement payment
rights."
(b) A petition to transfer structured settlement payment rights shall be filed in the county in which the payee is
domiciled.
Note: See Section 4 of the Act, 40 P.S. § 4004, providing that the
court of common pleas of the judicial district in which the payee is
domiciled shall have jurisdiction over the petition.
(c) The parties to the petition shall be the payee and the transferee.
(d) The petition shall be verified by the transferee and shall contain:
(1) a statement setting forth the payment provisions of the structured settlement agreement and the payment rights that
the payee seeks to transfer,
(2) separate paragraphs which in bold type set forth
(i) the net amount payable to the payee after deduction of all
commissions, fees, costs, expenses, and charges, and
(ii) the following statement setting forth the interest rate:
"Based on the net amount that the payee will receive from this
Pa. R.C.I'. No. 229 .2
transaction (5 ) and the amounts and timing of the structured •
settlement pavwcnts that would he assigned, the payee is, in effect,
paying interest at a rate of --- % per year." •
(3) four attachments: .
{i} a Payee's Affidavit in Support of Petition, in the form prescribed
by subdivision (0 as Attachment 1,
(ii) an initial order of court scheduling the hearing, in the form
prescribed by subdivision (g),
(iii) a certification by an attorney for the transferee representing to
the best of his or her knowledge, information and belief, formed after
reasonable inquiry, that the transfer will comply with the requirements
of the Act and will not contravene any other applicable federal or
state statute or regulation or the order of any court or administrative
authority, and
(iv) a final order of court granting the petition, in the form
prescribed by subdivision (i).
Note: These four attachments arc in addition to any other documents
which are required to support the findings set forth in Section 3 of
the Act, 40 P.S. § 4003.
Subdivision (d) requires that twodocuments be verified. As the two
documents contain different information, each must be verified by a
different person. The petition to transfer structured settlement
payment rights must be verified by the transferee. The Payee's
Affidavit in Support of Petition must be verified by the payee. The
transferee is not required to verify the information set forth in the
Payee's Affidavit.
(e)(l) If the petition and Payee's Affidavit in Support of Petition meet the requirements of this rule and contain factual
allegations which, if established, will support the findings set forth in Section 3 of the Act, the court shall promptly
enter an order scheduling a hearing date. The transferee shall give notice of the hearing, in the form prescribed by
subdivision (h), to the payee, the structured settlement obligor, the annuity issuer, the payee's spouse andanyperson
who receives child support, alimony or alimony pendente lite from the payee.
(2) If the petition is denied without a hearing for failure to meet the requirements of this rule or to contain necessary
factual allegations, which will support the findings set forth in Section 3 of the Act, the court shall state reasons for the
denial and the payee may file an amended petition as of course.
(0 The Payee's Affidavit in Support of Petition shall be substantially in the following form:
(CAP'T'ION)
PAYEE'S AFFIDAVIT IN SUPPORT OF PETITION TO TRANSFER STRUCTURED SETTLEMENT
RIGHTS
Pa. R.C.P No. 229 .2
t, -- --------, the payee, verify that the statements below arc true and correct:
I. Payee's name, address and age:
2. Marital Status:
#'TABLE#
--- Never Married; --- Married; --- Separated; --- Divorced
If married or separated, name of spouse:
3. Minor children and other dependents:
Names, ages, and places bf residence:
4. Income:
(a) Payee's monthly income and sources:
(b) If presently married, spouse's monthly income and sources:
5. Child support, alimony or alimony pendente lite:
#TABLE#
Obligation to pay: --- Yes --- No
If yes, state the amount of the obligation, to whom payable, and whether there are arrearages:
6. Previous transfers: Have you previously filed a petition to transfer payment rights under the structured settlement
that is the subject of this petition? --- Yes --- No
If yes, for each petition that you filed,
(a) If the transfer was submitted for court approval, list the court, the case caption and case number, and state whether
the court approved or disapproved the transfer:
(h) If the transfer was approved,
(i) State the name of the transferee and identify (listing due dates
and payment amount(s)) the payments involved in the transfer:
PR. lt.(.P No. 229.2
(ii) State the amount of money and the manner in which the money was
used:
(c) Have you ever transferred payments without court approval? If so, please explain:
7. Reasons for transfer:
Describe in detail your reasons for the proposed transfer, including an explanation as to why a sale of a -lesser amount
of the structured settlement amount will not better serve your interests:
8. Payment of debts:
If you seek the transfer in order to pay debts, list each debt, including the name of the creditor and the amount
presently owed:
#TABLE#
DTBLH Debt Creditor Amount Owed
$
VERIFICATION
I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are
made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.
#TABLE#
DATE: - Signature
(g) The initial order of court shall be substantially in the following form:
(CAPTION)
INITIAL ORDER OF COURT
On this --- day of , 2---, it is ordered thata hearing on this Petition to Transfer Structured Settlement Payment
Rights will be held on , in Courtroom at --- o'clock. The payee shall bring income tax returns for the
prior two (2) years to the hearing.
Within seven (7) days, the transferee shall give notice of the hearing date to the payee, the structured settlement
R.C.P. No. 229.2
obligor, the annuity issuer, the payee's spouse and any person receiving child support, alimony, or alimony pendente
The. The transferee shall attach a certificate of service to the notice of hearing date. A copy of the notice with the
certificate of service shall be tiled with the court prior to the hearing.
BY TI'IE COURT:
J.
(h) The notice of hearing shall be substantially in the following form:
(CA !'TION)
NOTICE OF HEARING ON PETITION TO TRANSFER STRUCTURED SETTLEMENT PAYMENT
RIGHTS
To:
You are hereby given notice that (name of payee) has filed a petition to transfer structured settlement
payment rights. A hearing in this matter has been scheduled on , 2--- at --- o'clock in courtroom no. ---,
courthouse, (address).
You are entitled to support, oppose or otherwise respond to the payee's petition, either in person or by counsel, by
filing written comments with the court prior to the hearing or by attending the hearing.
#TABLET!
Date Transferee
Address •
(i) The final order of court shall be substantially in the following form:
(CA i TION)
FINAL. ORDER OF COURT
On this --- day of
granted.
Telephone Number
, 2- , it is ordered that the Petition to Transfer of Structured Settlement Payment Rights is
The court specifically finds that:
(I) the payee has established that the transfer is in the best interests of the payee or the payee's dependents;
(2) based on the certification by an attorney for the transferee, and the court having not been made aware of any
statute, regulation or order that would be incompatible with the proposed transfer, the transfer will not contravene any
applicable federal or state statute or regulation, or the order of any court or administrative authority;
Pa. R.C.P. No. 229 .2
(3) the transfer complies with the remaining requirements of the Strictured Settlement Protection Act, including
Sections 3(a)(2), 3(a)(4), 3(a)(5) and 3(a)(6);
(4) the payments that arc to be transferred are designated as follows:
(5) the tenns of this order shall survive the death of the payee and shall he binding on the payee's heirs, beneficiaries
and assigns;
(6) the payee shall receive from the transferee, as of , the amount of S ---, from which no funds are owed for
counsel fees, administrative fees, or other costs, fees or expenses.
BY THE COURT:
J.
Note: The form of order does not preclude a court from adding
additional language to the order as deemed appropriate in the
individual circumstances of a case.
EXPLANATORY COMMENT --2007
In 2000, the General Assembly passed the Structured Settlement Protection Act, Act of February 11, 2000, P.L. 1, 40
P.S. § 4001 et seg., providing for, inter alia, the court of common pleas to permit the transfer of structured settlement
payment rights only upon an express finding that the transfer is in the best interests of the payee. While the Act requires
the disclosure of information to the payee concerning the transfer, it does not specify what factual allegations or other
information must be included in the petition to enable the trial court to make its determination. New Rule 229.2 is
intended to provide the additional information necessary for atrial court to determine whether a petition to transfer
structured settlement payment rights satisfies the best interest standard.
Subdivision (c) of the rule identifies the parties to the petition as the payee and the transferee. The transferee is
required to verify the petition and, in doing so, must set forth the circumstances surrounding the proposed transfer of
structured settlement payment rights. The petition must contain averments that the requirements of the Act have been
satisfied, e.g., the proper disclosures have been made to the payee. In contrast, the payee is required through the Payee's
Affidavit in Support of Petition to provide the necessary information to enable the trial court to determine whether the
transfer is in the best interests of the payee. The court will enter an order scheduling a hearing date only if the petition
and the payee's affidavit meet the requirements of the rule and contain factual allegations, which, if established, satisfy
the requirements of Section 3 of the Act, 40 P.S. § 4003.
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1 of 9 DOCUMENTS
PENNSYLVANIA STATUTES, ANNOTATED BY LEXISNEX]S(R)
*** Pa.C.S. documents are current through 2013 Regular Session Act 133, Enacted December 23, 2013.***
*P.S. documents are current through 2013 Regular Session Acts 88, 91, 93 to 97,99 to 103*
* Annotations current through October 16, 2013 *
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
40 P.S. § 4001 (2013)
§ 4001. Short title
i
This act shall be known and may be cited as the Structured Settlement Protection Act.
HISTORY: Act 2000-1 (S.I3. 818), P.L. I, § 1, approved Feb. 11, 2000, eff. in 60 days.
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2 of 9 DOCUMENTS
PENNSYLVANIA STATUTES, ANNOTATED BY LEXISNEXIS(R)
*** Pa.C.S. documents are current through 2013 Regular Session Act 133, Enacted December 23, 2013.***
*P.S. documents are current through 2013 Regular Session Acts 88, 91, 93 to 97, 99 to 103*
* Annotations current through October 16, 2013 *
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
40 P.S. § 4002 (2013)
§ 4002. Definitions
The following words and phrases when used in this act shall have the meanings given to them in this section unless
the context clearly indicates otherwise:
"Annuity issuer." An insurer, or subsidiary or affiliate thereof,.that has issued an insurance contract used to fund
periodic payments under a structured settlement.
"Applicable law." The laws of the United States, the laws of this Commonwealth and the laws of any other
jurisdiction under whose laws a structured settlement agreement was approved by a court or responsible administrative
authority.
"Best interests." The standard applicable to transfers of structured settlement payment rights based on judicial findings
regarding the payee and his dependents, as required by section 3(a)(3), unless if at the time the payee and the transferee
enter into the transfer agreement a different standard is contained in the Internal Revenue Code of 1986 (Public Law
99-514, 26 U.S.C. § I ct seq.) or in a United States Treasury. regulation adopted pursuant thereto, then such different
standard.
"Dependents." Include a payee's spouse and minor children and all other family members and other persons for whom
the payee is legally obligated to provide support, including alimony.
"Discounted present value." The fair present value of future payments, as determined by discounting such payments to
the present using the most recently published applicable Federal rate for determining the present value of an annuity, as
issued by the United States Internal Revenue Service.
"Favorable tax deterrninatton." With respect to a proposed transfer of structured settlement payment rights, any of the
4l1 P.S. ti =4002
hollowing authorities that is binding on the parties to such transfer and on the parties to the structured settlement
agreement and any qualified assignment agreement and that definitively establishes that the Federal income tax
treatment of the structured settlement for the parties to the structured settlement agreement and any qualified assignment
agreement, other than the payee, will not be affected by such transfer:
(1) a provision of the Internal Revenue Code of 1986 (Public Law
99-514, 26 U.S.0 § / et seq.) or United States Treasury regulation;
(2) a published ruling by the United States Internal Revenue Service;
(3) a private letter ruling by the United States Internal Revenue
Service with respect to such transfer; or
(4) other controlling legal authority that is binding on the United
States Internal Revenue Service."
"Payee." A person domiciled in this Commonwealth who is receiving tax-free payments under a structured settlement
and proposes to make a transfer of payment rights thereunder.
"Periodic payments." Payments made pursuant to a structured settlement agreement, including scheduled future lump
sum payments..,
"Qualified assignment agreement." An agreement providing for a qualified assignment within the meaning ofsection
130 of the Internal Revenue Code of 1986 (Public Law 99-514, 26 U.S.C. § 1 et seq.).
"Settled claim." The original personal injury or sickness claim or workers' compensation claim resolved by a
structured settlement.
"Structured settlement." An arrangement for periodic payment of damages established by settlement, judgment or
decree in resolution of a settled claim.
"Structured settlement agreement." The agreement, judgment, decree, stipulation or release embodying the terms of a
structured settlement, including the rights of the payee to receive periodic payments.
"Structured settlement obligor." With respect to any structured settlement,the party that has the continuing obligation
to provide periodic payments to the payee under a structured settlement agreement or a qualified assignment agreement.
"Structured settlement payment rights." Rights to receive periodic payments under a structured settlement, whether
from the settlement obligor or the annuity issuer, where the payee is domiciled in this Commonwealth.
"Terms of the structured settlement." Include, with respect to any structured settlement, the terms of the structured
settlement agreement, the annuity contract, any qualified assignment agreement and any order, decree or approval of
any court or responsible administrative authority authorizing or approving such structured settlement.
"Transfer." Any direct or indirect sale, assignment, pledge, hypothecation or other form of alienation, redirection or
encumbrance made by a payee for consideration, provided, however, that this shall not apply to a blanket security
agreement used to secure a loan originating from a Federal or State chartered lending institution. Any transfer made or
agreed to under this act shall be considered to be a consumer transaction.
',Transfer agreement." The agreement providing for transfer of structured settlement payment rights from a payee to a
AO l'.s. 40102
transferee.
"Transferee." The party acquiring or proposing to acquire structured settlement payment rights through a transfer.
HISTORY: Act 2000-1 (S.B. 818), Y.L. 1, } 2, approved Feb. 1 i, 2000, eft: in 60 days.
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3 of 9 DOCUMENTS
ENTS
PENNSYLVANIA STATUTES, ANNOTATED BY LEXISNEXIS(R)
*** Pa.C.S. documents are current through 2013 Regular Session Act 133, Enacted December 23, 2013.***
*P.S. documents are current through 2013 Regular Session Acts 88, 91, 93 to 97, 99 to 103*
* Annotations current through October 16,2013 *
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
40 P.S. § 4003 (20I3)
§ 4003. Conditions to transfers of structured settlement payment rights
(a) PETITION.-- No transfer of structured settlement payment rights shall be effective and no structured settlement
obligor or annuity issuer shall be required to make any payment to any transferee of structured settlement payment
rights unless the payee has filed a petition requesting such transfer•and the petition has been granted by final order or
decree of a court of competent jurisdiction based on such court's express written findings that:
(I) The transfer complies with the requirements of this act and will
not contravene other applicable Federal or State statutes or
regulations or any applicable law limiting the transfer of workers'
compensation claims.
(2) Not less than ten days prior to the date on which the payee first
incurred any obligation with respect to the transfer, the transferee
has provided to the payee a disclosure statement setting forth all of
the following:
(i) The amounts and due dates of the structured settlement payments
to be transferred.
(ii) The aggregate amount of such payments.
(iii) The discounted present value of such payments, together with
the discount rate or rates used in determining such discounted
present value.
ll) P S. 400 i
(iv) The gross amount payable to the payee in exchange for such
payments .
(v) An itemized listing of all brokers' commissions, service charges,
application or processing fees, closing costs, filing or
administrative charges, legal fees, notary fees and other
commissions, fees, costs, expenses and charges payable by the payee
or deductible from the gross amount otherwise payable to the payee.
(vi) The net amount payable to the payee after deduction of all
commissions, fees, costs, expenses and charges described in
subparagraph (v) .
(vii) The quotient, expressed as a percentage, obtained by dividing
the net payment amount by the discounted present value of the
payments.
(viii) The amount of any penalty and the aggregate amount of any
liquidated damages, inclusive of penalties, payable by the payee in
the event of any breach of the transfer agreement by the payee.
(3) The payee has established that the transfer is in the best
interests of the payee or his dependents.
(4) The payee has received or expressly waived in a separate written
acknowledgment signed by the payee, independent legal advice regarding
the implications of the transfer, including consideration of the tax
ramifications of the transfer.
(5) If the transfer would contravene the terms of the structured
settlement:
(i) the transfer has been expressly approved in writing by:
(A) the payee, the structured settlement obligor and the annuity
issuer, provided, however, that such approval may not he
unreasonably withheld and further provided that the structured
settlement obligor and the annuity issuer shall be required to
consent to the transfer if the transferee has agreed to indemnify
the structured settlement obligor and annuity issuer from all
liabilities arising from the factoring transaction and compliance
or noncompliance with this act and further provided that if at the
time the payee and the transferee propose to enter into the
transfer agreement a favorable tax result is in effect, then the
approval of the annuity issuer and the structured settlement
obligor shall not be required; and
(B) any court or responsible administrative authority that
previously approved the structured settlement; and
.10 P.S. 1003
(ii) signed originals of all approvals required under subparagraph
(i) have been filed with the court from which the authorization of
the transfer is being sought and originals or copies have been
furnished to the payee, the structured settlement obligor and the
annuity issuer.
(6) The payee has given written notice of the transferee's name,
address and taxpayer identification number to the annuity issuer and
the structured settlement obligor and has filed a copy of such notice
with the court.
(b) NOTICE.-- Prior to entering into any agreement to make a transfer under this act, the payee shall be provided with
a written notice on a separate sheet that contains the following, in bold print and at least 12 -point type:
IMPORTANT NOTICE: You are strongly urged to consult with an attorney
who can advise you of the potential tax consequences of this
transaction.
(c) BONDS.-- If the indemnity in subsection (a)(5)(i)(A) is offered, the court shall require that the transferee obtain a
surety bond or an irrevocable standby letter of credit to secure the indemnity obligation. In considering the necessity
and amount of any bond, the court shall consider the size of the underlying transaction and the potential liabilities of the
structured settlement obligor and annuity issuer.
HISTORY: Act 2000-1 (S.B. $18), P.L. 1, § 3, approved Feb. II, 2000, eff. in 60 days.
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PENNSYLVANIA STATUTES, ANNOTATED BY LEXISNEXIS(R)
*** Pa.C.S. documents are current through 2013 Regular Session Act 133, Enacted December 23, 2013.***
*P.S. documents are current through 2013 Regular Session Acts 88, 91, 93 to 97, 99 to 103*
*Annotations current through October 16, 2013 *
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
40 P.S. § 4004 (2013)
§ 4004. Jurisdiction; procedure for approval of transfers
The court of common pleas of the judicial district in which the payee is -domiciled shall have jurisdiction over any
petition as required under section 3 for a transfer of structured settlement payment rights. Not less than 20 days prior to
the scheduled hearing on any petition for authorization of a transfer of structured settlement payment rights under
section 3, the payee shall file with the court and serve on the transferee a notice of the proposed transfer and the
application for its authorization, including in such notice a copy of the payee's petition to the court, a copy of the
transfer agreement, a copy of the disclosure statement required under section 3, notification that the transferee, the
structured settlement obligor or the annuity issuer is entitled to support, oppose or otherwise respond to the payee's
petition, either in person or by counsel, by submitting written comments to the court or by participating in the hearing
and notification of the time and place of the hearing and notification of the manner in which and the time by which
written responses to the petition must be filed, which shall be not less than 20 days after service of the payee's notice, in
order to be considered by the court.
HISTORY: Act 2000-1 (S.B. 818), P.L. 1, § 4, approved Feb. 11, 2000, eft: in 60 days.
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PENNSYLVANIA STATUTES, ANNOTATED BY LEXISNEXIS(R)
*** Pa.C.S. documents are current through 2013 Regular Session Act 133, Enacted December 23, 2013.***
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* Annotations current through October 16, 2013 *
PENNSYLVANIA STATUTES
TITLE 40.. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
40 P.S. § 9005 (2013)
§ 4005. Discharge of structured settlement obligor and annuity issuer
Upon an appropriate judicial order approving a petition for a transfer of structured settlement payment rights, the
structured settlement obligor and annuity issuer shall be discharged from all liability for the payments and portions
thereof transferred as to all parties except the transferee.
HISTORY: Act 2000-1 (S.B. 818), P.L. 1, § 5, approved Feb. 11, 2000, eff. in 60 days.
exisNexis'
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PENNSYLVANIA STATUTES, ANNOTATED BY LEXISNEXIS(R)
4`** Pa.C.S. documents are current through 2013 Regular Session Act 133, Enacted December 23, 2013,***
*P.5. documents are current through 2013 Regular Session Acts 88, 91, 93, to 97, 99 to 103*
. Annotations current through October 16, 2013 *
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT •
Go to the Pennsylvania Code Archive Directory
40 P.S. § 4006 (2013)
§ 4006. No waiver; no penalties
(a) WAIVER.-- The provisions of this act may not be waived.
(b) PENALTIES.-- No payee who files a petition for the transfer of structured settlement payment rights shall incur
any penalty, forfeit any application fee or other payment or otherwise incur any liability to the proposed transferee
based on any failure of such transfer to satisfy the conditions of section 3.
HISTORY: Act 2000-1 (S.B. 818), P.L. 1, § 6, approved Feb. 11,2000, eff in 60 days.
LexisNexis®
7 01-9 DOCUMENTS
PENNSYLVANIA STATUTES, ANNOTATED BY LEXISNEXIS(R)
*** Pa.C.S. documents are current through 2013 Regular Session Act 133, Enacted December 23, 2013.***
*P.S. documents are current through 2013 Regular Session Acts 88, 91, 93 to 97, 99 to 103*
Annotations current through October 16, 2013 *
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
40 P.S. § 4007 (2013)
§ 4007. Penalty
A violation of this act shall be deemed a violation of the act of December 17, 1968 (P.L. 1224, No. 387), known as the
Unfair Trade Practices and Consumer Protection Law.
HISTORY: Act 2000-1 (S.B. 818), P.L. I, § 7, approved Feb. 11, 2000, eff. in 60 days.
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* Annotations current through October 16, 2013 *
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
90 P.S. § 4008 (2013)
§ 1008. Construction
Nothing contained in this act shall be construed to authorize any transfer of structured settlement payment rights in
contravention of applicable State statutes or regulations or to give effect to any transfer to structured settlement payment
rights that is void under applicable State statutes or regulations.
HISTORY: Act 2000-1 (S.B. 818), P.L. 1, § 8, approved Feb. 11,2000, eff. in 60 days.
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9 of 9 DOCUMENTS
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* Annotations current through October 16, 2013
PENNSYLVANIA STATUTES
TITLE 40. INSURANCE
CHAPTER 40. STRUCTURED SETTLEMENT PROTECTION ACT
Go to the Pennsylvania Code Archive Directory
40 P.S. § 9009 (2013)
§ 4009. Applicability
This act shall apply to any petition for the transfer of structured settlement payment rights under a transfer agreement
sought on or after the effective date of this act, provided, however, that nothing contained in this act shall imply that any
transfcr under a transfer agreement reached prior to such date is effective or that any party is under any obligation to
make transferred payments to the transferee of any such prior transfer.
HISTORY: Act 2000-1 (S.I3. 818), P.L. 1, § 9, approved Feb. 11, 2000, eff. in 60 days.
G
LED
Settlement Agreement and Release
This Settlement Agreement and Release (the "Settlement
Agreement") is made and entered into this day of
, 2001, by and between:
"Claimants"
"Insured"
"Insurer"
Recitals
Ronald Conaway and Kimberly Conaway
as parents and natural guardians of
Tyler Conaway, a Minor
REDACTED
REDACTED
A. On or about July 8, 2000, Tyler Conaway was injured in
an accident occurring at or near Wellsboro, Pennsylvania.
Claimants allege that the accident and resulting physical and
personal injuries arose out of certain alleged negligent acts or
omissions of Insured, and have made a claim seeking monetary
damages on account of those injuries.
B. Insurer is the liability insurer of the Insured, and as
such, would be obligated to pay any claim made or judgment
obtained against the Insured, which is covered by its policy with
the Insured.
C. The parties desire to enter into this Settlement
Agreement in order to provide for certain payments in full
settlement and discharge of all claims which have, or might be
made, by reason of the incident described in Recital A above,
upon the terms and conditions set forth below.
Agreement
The parties agree as follows:
1.0 Release and Discharge
1.1 In consideration of the payments set forth in Section 2,
Claimants hereby completely release and forever discharge the
Insured and Insurer from any and all past, present, or future
claims, demands, obligations, actions, causes of action, wrongful
death claims, rights, damages, costs, losses of services,
expenses and compensation of any nature whatsoever, whether based
on a tort, contract or other theory of recovery, which the
Claimants now have, or which may hereafter accrue or otherwise be
acquired, on account of, or may in any way grow out of the
incident described in Recital A above, including, without
limitation, any and all known or unknown claims for bodily and
personal injuries to Claimants, or any future wrongful death
claim of Claimants' representatives or heirs, which have resulted
or may result from the alleged acts or omissions of the Insured_
1.2 This release and discharge shall also apply to the
Insured's and Insurer's past, present and future officers,
directors, stockholders, attorneys, agents, servants,
representatives, employees, subsidiaries, affiliates, partners,
predecessors and successors in interest, and assigns and all
other persons, firms or corporations with whom any of the former
have been, are now, or may hereafter be affiliated.
1.3 This release, on the part of the Claimants, shall be a
fully binding and complete settlement among the Claimants, the
Insured and the Insurer, and their heirs, assigns and successors.
1.4 The Claimants acknowledge and agree that the release
and discharge set forth above is a general release. Claimants
expressly waive and assume the risk of any and all claims for
damages which exist as of this date, but of which the Claimants
do not know or suspect to exist, whether through ignorance,
oversight, error, negligence, or otherwise, and which, if known,
would materially affect Claimants' decision to enter into this
2
Settlement Agreement. The Claimants further agree that they have
accepted payment of the sums specified herein as a complete
compromise of matters involving disputed issues of law and fact.
Claimants assume the risk that the facts or law may be other than
Claimants believe. It is understood and agreed to by the parties
that this settlement is a compromise of a doubtful and disputed
claim, and the payments are not to be construed as an admission
of liability on the part of the Insured, by whom liability is
expressly denied.
2.0 Payments
In consideration of the release set forth above, the Insurer on
behalf of the Insured agrees to pay to the individual(s) named
below ("Payee(s)") the sums outlined in this Section 2 below:
2.2 Periodic Payments. Insurer agrees to make payment to
Tyler Conaway "Payee" in the following manner:
REDACTED
On November 4, 2015, guaranteed payment of Three
3
Thousand Five Hundred Dollars ($3,500.00).
On November 4, 2019, guaranteed payment of Four
Thousand Five Hundred Dollars ($4,500.00).
On November 4, 2022, guaranteed payment of Six
-Thousand Four Hundred Dollars ($6,400.00).
On November 4, 2024, guaranteed payment of Eight
Thousand Dollars ($8,000:'00).
All sums set forth herein constitute damages on account of
personal injuries and sickness, within the meaning of Section
104(a)(2) of the Internal Revenue Code:of 1986, as amended.
3.0 Payee's Rights to Payments
Claimants acknowledge that the Periodic Payments cannot be
accelerated,- deferred, increased;'or decreased by the Claimants or
any Payee; nor shall the.Claimantsor any Payee have the power to
sell, mortgage,, encumber,.or anticipate the Periodic Payments, or
any part thereof, by assignment or otherwise._
4.0 Payee's Beneficiary
Any payments to be made after the death of Payee, pursuant
to the terms of this Settlement Agreement, shall be made to his
named beneficiary. If no person or entity is so designated by
Payee; or if -the person designated is not living at time of the
Payee'sdeath, such payments shall -be made to the estate of �..-
Payee Payee may request in writing that Assignee - change the
payee and/or beneficiary designation under this Agreement.
Assignee will do so but will not be liable, however, for any
payment made prior to receipt of the request or so soon
thereafter that payment could. not reasonably be stopped.
4
PECYCLED
/
kug .28: 2001 12:0741 ALLiTE INS HBG PA
TYLER CONAWAY, a minor by
and through his parents and
guardians RONALD & KIMBERLY
CONAWAY,
Petitioners
No.0884 P. 3/4
: IN THE COURT OF COMMON PLEAS
:CUMBERLAND COUNTY, PENNSYLVANIA
: NO.
v.
: CIVIL ACTION -LAW
REDACTPD
Respondent
AND NOW, this
•
ORDER OF CO IRT
day of U,. t,L5
, 2001, upon
consideration of the foregoing Petition,
IT IS HEREBY ORDERED that:
1. The above parties may compromise the action upon the terms and
conditions of the above -proposed compromise set forth in attached Petition;
2. Ronald and Kimberly Conaway, as natural parents and guardians
of Tyler Conaway, minor, is authorized to pay the following counsel fees and other
costs from the amount to which said minor is entitled to receive in this action:
Aug.28. 2001 12:07PM ALLSTATE INS HBG PA
•
No.0684 P. 4/4
c, Approve payment of the remaining settlement funds in the form of
a structured settleMent as follows:
REDACTED
$3,500 on November 4, 2015;
$4,500 on November 4, 2019;
$6,400 on November 4, 2022;
$8,000 on November 4, 2024.
COPY FROM RECORD
f,I here unto sat my hand
C t aJadisle. Pa. .,4/
RECYCLED
"Claimant"
It
ignor"
"Assignee"
"Annuity issuer'
"Effective Date"
•
•
Uniform Qualified Assignment
Tyler Conaway
Allstate Assignment Company
Allstate Life Insurance Company
14,ACO I
This Agreement is made and entered into by and between
the parties hereto as of the Effective Date with reference to
the following facts:
A. Claimant has ex aced a settlement agreement or
release dated X , so 2doL
(the "Settlement Agreement") that provides for the
Assignor to make certain periodic payments to or for
the benefit of the Claimant as stated in Addendum
No. 1 (the "Periodic Payments"); and
B. The parties desire to effect a "qualified assignment"
within the meaning and subject to the conditions of
Section 130(c) of the Internal Revenue Code of 1986
(the "Code").
NOW, THEREFORE, in consideration of the foregoing and
other good and valuable consideration, the parties agree
as follows:
1. The Assignor hereby assigns and the Assignee
hereby assumes all of the Assignor's liability to make
the Periodic Payments. The Assignee assumes no
liability to make any payment not specified In
Addendum No. 1.
2. The Periodic Payments constitute damages on
account of personal injury or sickness in a case
involving physical Injury or physical sickness within
the meaning of Sections 104(a)(2) and 130(c) of the
Code.
3. The Assignee's liability to make the Periodic
Payments is no greater than that of the Assignor
immediately preceding this Agreement. Assignee is
not required to set aside specific assets to secure the
Periodic Payments. The Claimant has no rights
against the Assignee greater than a general creditor,
None of the Periodic Payments may be accelerated,
deferred, increased or decreased and may not be
anticipated, sold, assigned or encumbered.
4. The obligation assumed by Assignee with respect to
any required payment shall be discharged upon the
mailing on or before the due date of a valid check in
the amount specified to the address of record.
S. This Agreement shall be governed by and
interpreted in accordance with the laws of the
State of
6. The Assignee may fund the Periodic Payments by
purchasing a "qualified funding asset" within the
meaning of Section 130(d) of the Code in the form of
an annuity contract issued by the Annuity Issuer. All
rights of ownership and control of such annuity
contract shall be and remain vested in the Assignee
exclusively.
7. The Assignee may have the Annuity Issuer send
payments under any "qualified funding asset"
purchased hereunder directly to the payee(s)
specified in Addendum No. 1. Such direction of
payments shall be solely for the Assignee's
convenience and shall not provide the Claimant or
any payee with any rights of ownership or control
over the "qualified funding asset" or against the
Annuity Issuer.
8. Assignee's liability to make the Periodic Payments
shall continue without diminution regardless of any
bankruptcy or Insolvency of the Assignor.
9. In the event the Settlement Agreement Is declared
terminated by a court of law or In the event that
Section 130(c) of the Code has not been satisfied,
this Agreement shall terminate. The Assignee shall
then assign ownership of any "qualified funding
Assignor:
By:
REDACTED
�� �_ rho�z epr to ive
Title �1---
asset" purchased hereunder to Assignor, and
Assignee's liability for the Periodic Payments shall
terminate.
10. This Agreement,shall be binding upon the respective
representatives, heirs, successors and assigns of the
Claimant, the Assignor and the Assignee and upon
any person or entity that may assert any right
hereunder or to any of the Periodic Payments.
Assignee Allstate Assignment Company
By:
Title
Aut96ri ed Representative
Printed in USA
National Structured Settlements Trade Association
UOA ED. 4.88
0,
Initials
Assignor:
Assignee:
c.PW
cig
• •
Addendum No. 1
Description of Periodic Payments
To Tyler Conaway:
REDACTED
$3,500 paid on November 4, 2015;
$4,500 paid on November 4, 2019;
$6,400 paid on November 4, 2022;
$8,000 paid on November 4, 2024.
Printed in USA
UOA ED. 4-88
ALL -STATE LEGAL SUPPLY CO.. 1-800-222-0510 ED 11
Allstate Life Insurance Company
A Stock Company - Home Office Address: Northbrook, Illinois 60062
,i.
Single Premium Immediate Certain Annuity
CONTRACT --This contract is issued to Allstate Assignment Company (called "AAC") in consideration of the
application, a copy of which is attached, and the payment of the single premium. The contract and the application are
the entire contract. All statements made in the application are representations and not warranties. No statement will
be used by us in defense of a claim or to void this contract unless it is in the signed application. Only our officers may
change this contract or waive a right or requirement. No agent may do this.
Allstate Life Insurance Company (called "we" or "us") will make the payments shown on Page 3 to the Measuring Life
or other payee designated by AAC, provided that the Measuring Life is alive. In addition, if the Measuring Life is not
living, any payments shown on Page 3 will be made to the beneficiary.
This contract stops when all payments have been made.
RIGHT TO CANCEL --If AAC is not satisfied with this contract, it may be voided by returning it to Allstate Life In-
surance Company, Northbrook, Illinois 60062, or our agent. MC must notify us and return the policy by midnight
of the 10th day after AAC receives it. Notice given by mail is effective on being postmarked, properly addressed and
postage prepaid. We will return the single premium, less any payments already made, within 10 days after
we receive the policy and notice.
This is a legal contract between MC and us. READ THIS POLICY CAREFULLY.
COPY
Signed for ALLSTATE LIFE INSURANCE COMPANY at our Home Office in Northbrook, Illinois.
NAdo044
Secretary President
Page 1
LU 3406
TABLE OF CONTENTS
Contract 1 Issue Date 3
Right to Cancel 1 Beneficiary' 4
Schedule of Payments 3 Incontestability 4
Measuring Life Information 3 Minimum. Values 4
Contract Number 3 Non -Participating, < ' ` 4
Owner 3 Non -Assignable 4
Page 2 •
ALLSTIIE LIFE INSURANCE dlIMPANY
Home Office: Northbrook, Illinois 60062
Application for Single Premium Immediate Annuity
1. Measuring Life
Full Name:
Address:
Tyler Conaway
Phone:
5 Locust Circle Mechanicsburg, PA 17055
Social Security No.:
Date of Birth: REDACTED Sex:
2. Joint Measuring Life (if applicable)
Full Name:
Address:
Phone: ( )
Social Security No.:
Relationship to Measuring Life:
Date of Birth: Sex:
3. Owner
Full Name: Allstate Assignment Company Phone: ( )
Address: 2940 South 84th Street, Suite 2B2 Lincoln, NE 68506
4. Payee (will be Measuring Life if left blank)
Full Name:
Address:
Phone: ( )
Relationship to Measuring Life:
5. Payment Information (Submit proof of age for life or joint life payments.)
Start Type (e.g., certain, life,
Date lump sum, joint) Amount
REDACTEE!
Lump Sutti-- $3,500.00 1
Lump Sum $4,500.00 1
Lump Sum -$6,400.00 1
Lump Sum $8,000.00 1
11/04/2015
11/04/2019
11/04/2022
11/04/2024
• Number of Frequency of
Payments Payments
6. Beneficiary (will be Estate of Measuring Life if left blank)
Full Name:
Address:
Phone:
Social Security No.: Relationship to Measuring Life:
7. Premium $1 and other valuable consideration
The Applicant represents that all statements and answers on this Application are true lathe best of
his or her knowledge and belief and completely recorded herein.
Applicant: by
c,?,(
Owner sig wrearitie
LR877 W. Ross Duncan/Ringler Associates
Date:
BENEFICIARY --Unless changed by MC, the beneficiary is as named in the application. If there is no bene-
ficiary named or living, the beneficiary is the Measuring Life's estate. For purposes of this section, living" shall
mean living on the earlier of:
1. The day we receive due proof of the Measuring Life's death; or
2. The 15th day past the Measuring Life's death.
Unless AAC states otherwise by irrevocably naming a beneficiary, MC may change the beneficiary while the
Measuring Life is alive. A change must be made to us in writing. The change must be acceptable to us.
Once we accept the change, it takes effect as of the day AAC signed the request. Each change is subject to
any payment we make or action we take before we accept it.
Any payments due a beneficiary will be paid on their specified due dates, and will not be commuted or paid
in a lump sum.
INCONTESTABILITY --We may not contest this contract after it is issued.
MINIMUM VALUES --The payments provided by this contract are not less than the minimum values required
by the state in which this contract is sold.
NON -PARTICIPATING --This contract does not pay dividends.
NON -ASSIGNABLE --Payments may not be anticipated, assigned or pledged as collateral. Payment dates and
amounts may not be changed, either to provide for earlier payment or longer deferral. The contract has no
cash surrender or policy loan value.
So far as the law allows, all payments to any person named by AAC to receive them are exempt from that
person's creditors, debts and contracts, and from seizure or attachment by court order or other legal process.
Page 4
ALL STATE LEGAL SUPPLY CO. ONE COMMERCE DRIVE. CRANFORD,MEW JERSEY 07016 (2) ED11
ALLSTATE ADVANCED FUNDING EXCHANGE AGREEMENT
This Agreement and its Exhibits (respectively, the "Agreement" and "Related
Documents") is entered into between Tyler Conaway a/k/a Tyler Michael Conaway (the "Payee"
or "Mr. Conaway") and Allstate Settlement Corporation ("Allstate Settlement") as of July 23,
2014 ("Date of Agreement").
WHEREAS, the Payee is entitled to receive certain periodic payments (the "Periodic
Payments") due under a personal injury or wrongful death settlement agreement (the "Settlement
Agreement").
NOW, THEREFORE, in consideration of the representations, warranties, covenants,
and agreements set forth herein, the parties hereto, intending to be legally bound, hereby agree as
follows:
1. Funding Exchange
(a) The Payee hereby transfers, alienates, assigns, waives, divests, and conveys to
Allstate Settlement all right, title, and interest of the Payee in and to certain Periodic Payments
set forth on Schedule 1 of this Agreement (the "Transferred Payments"), and in reliance on the
representations, warranties, and covenants contained herein, and subject to the terms and
conditions hereof, Allstate Settlement hereby agrees to pay to the Payee the amount set forth on
Schedule 1 of this Agreement (the "Net Funding Exchange Payment").
(b) In the event that any Transferred Payment comes due prior to satisfaction of all of
the requirements set forth in Schedule 2 of this Agreement, Payee hereby agrees that Allstate
Settlement may retain said Transferred Payment(s) until such time as either it is finally
determined that all of the requirements of Schedule 2 are met or cannot be met.
(c) Subject to the terms and conditions hereof, the Net Funding Exchange Payment
shall be payable to the Payee within fourteen (14) business days of execution by the Payee of this
Agreement and satisfaction of all of the requirements set forth on Schedule 2 of this Agreement
(the "Requirements").
(d) The Payee hereby agrees and acknowledges that no other party or entity
(including but not limited to the Payee's heirs, beneficiaries, contingent beneficiaries, executors,
administrators, successors, or assigns) has or shall ever have any interest in the Transferred
Payments.
(e) This Agreement constitutes a modification of the Settlement Agreement, and not a
loan. If this Agreement is subsequently determined by a final court order to be a loan, the Payee
will take any steps necessary to satisfy the usury laws and other laws, if any, that may apply, as a
result, to this Agreement.
2. Representations and Warranties of the Payee The Payee hereby represents and
warrants to Allstate Settlement the following:
�� ]niiials of Payee
laitials of Payee's Spouse (if applicable)
- 1 -
(a) Except as set forth in this Agreement, the Transferred Payments are free and clear
of all liens, charges, security interests, encumbrances, and agreements of any kind whatsoever,
and only Allstate Settlement shall have any present or future right in or to those Transferred
Payments.
(b) No party has asserted any rights in or any right to receive any of the Transferred
Payments, and the Payee is not aware of any circumstances that may result in the assertion of any
such rights or right.
(c) Except as set forth in this Agreement, the Payee has not waived, diverted,
alienated, assigned, transferred, conveyed, encumbered, mortgaged, or otherwise affected any
rights in or to the Transferred Payments.
(d) The Payee has not failed to satisfy any child support, spousal support, alimony, or
other support obligations, or, in the alternative, the Payee intends to address any such failure
upon approval of this Agreement by a court of competent jurisdiction, and the Payee has notified
Allstate Settlement of this intention.
(e) The Payee is not currently insolvent of a debtor in any bankruptcy proceeding,
and is not aware of any circumstances that may result in the Payee becoming a debtor in any
bankruptcy proceeding.
(1) The Payee is competent to enter into this Agreement. As of the date of this
Agreement and each of the Related Documents, the Payee is over eighteen (18) years of age, is
mentally sane, and is of sound mind. The Payee understands the terms and provisions of this
Agreement and the Related Documents.
3. The Payee's Obligations Under this Agreement The Payee hereby agrees and
understands that the Payee has the following continuing obligations under this Agreement:
(a) The Payee shall deliver to Allstate Settlement a fully executed and completed
Waiver of Independent Professional Advice or Affirmation of Independent Professional Advice
in the form attached as Exhibit "A" to this Agreement (or otherwise in form and substance
satisfactory to Allstate Settlement), attesting either that he/she has obtained independent
professional advice or, having been advised of his/her right to obtain such advice, has knowingly
waived his/her right to receive such advice.
(b) The Payee shall deliver to Allstate Settlement a letter of irrevocable instructions
addressed to the executor of his/her estate, heirs, beneficiaries, contingent beneficiaries,
administrators, assigns, and others in the form of Exhibit "B" (or otherwise in form and
substance satisfactory to Allstate Settlement) to this Agreement instructing them, among other
things, that upon his/her death they are to abide by the terms of this Agreement (if applicable).
(c) If the Payee is married or was married at the time the Settlement Agreement was
executed, the Payee shall deliver to Allstate Settlement a Spousal Consent Confirmation for any
Initials of Payee
Initials of Payee's Spouse (if applicable)
-2-
PHL1T/ 1775148.9
current and, if applicable, former spouse(s), in the form of Exhibit "C" to this Agreement (or
otherwise in form and substance acceptable to Allstate Settlement), unless this requirement is
waived by Allstate Settlement.
(d) The Payee shall deliver to Allstate Settlement a letter of instructions in the form
of Exhibit "D" to this Agreement (or in form and substance satisfactory to Allstate Settlement)
(the "Change of Beneficiary Form") addressed to the structured settlement obligor and the
annuity issuer directing that all payments to be made in relation to any of the Transferred
Payments after the death of the Payee shall be made directly to Allstate Settlement, and changing
the beneficiary of the Transferred Payments, after the death of the Payee, to Allstate Settlement
as sole beneficiary dul•ing the period for which this Agreement is in effect.
(e) The Payee agrees that, when required and at his/her expense, he/she will promptly
execute and deliver all further instruments, documents, agreements, and acknowledgments, and
take such further action, that may be necessary or appropriate, or that Allstate Settlement may
reasonably request, in order to perfect, protect, or more fully evidence the transfer and
assignment of the right to receive the Transferred Payments of to enable Allstate Settlement to
exercise or enforce any of its rights hereunder.
(f) If the Payee learns (before or after execution of this Agreement) of the threat or
institution of any condemnation, garnishment, turnover, or other action, suit, or proceeding
against or affecting any part of the Transferred Payments, or the other rights and benefits of
Allstate Settlement under the terms of this Agreement and the Related Documents, or relating to
or arising out of the ownership, receipt, or utilization of the Transferred Payments, then the
Payee will immediately notify Allstate Settlement of same and will give Allstate Settlement
copies of all notices and other writings relating to it promptly after their receipt by the Payee.
(g) The Payee will notify Allstate Settlement of any Payee address during the period
covered by this Agreement within fourteen (14) days of such change.
4. Release The Payee, for his/her heirs, beneficiaries, contingent beneficiaries,
executors, administrators, successors, and assigns, and for any individuals or entities that may
claim through them, hereby remises, releases, and forever discharges Allstate Settlement,
Allstate Life Insurance Company ("Allstate Life"), and Allstate Assignment Company ("Allstate
Assignment") and their directors, shareholders, officers, agents, employees, servants, successors,
and assigns, and any parent, subsidiary, or affiliate thereof, and their directors, shareholders,
officers, agents, employees, servants, successors, and assigns, past and present, of and from any
and all manner of actions and -causes of action, suits, debts, dues, accounts, bonds, covenants,
contracts, agreements, judgments, settlements, damages, claims, and demands whatsoever, in law
or in equity, in connection with, related to, or arising out of, any claim or allegation that was or
could ever be asserted in connection with, related to, or arising out of the Transferred Payments
or this Agreement, except for claims to enforce any party's rights under this Agreement. The
Payee specifically agrees that Allstate Life, and Allstate Assignment are third -party beneficiaries
of this Agreement for purposes of enforcing the provisions of this paragraph.
Initials of Payee
Initials of Payee's Spouse (if applicable)
3
PHLIT/ 1775148.9
5. Defense and Indemnity The Payee shall defend, indemnify, and hold harmless
Allstate Settlement, Allstate Life, and Allstate Assignment, and their directors, shareholders,
officers, agents, employees, servants, successors, and assigns, and any parent, subsidiary, or
affiliate thereof, and their directors, shareholders, officers, agents, employees, servants,
successors, and assigns, past and present, for all claims in connection with, related to, or arising
out of the Transferred Payments or this Agreement, except with respect to claims to enforce this
Agreement. The Payee specifically agrees that Allstate Life, and Allstate Assignment are third -
party beneficiaries of this Agreement for purposes of enforcing the provisions of this paragraph.
6. Assignment and Binding Effect Allstate Settlement may assign its rights in
connection with this Agreement. The Payee has no right or power to assign or transfer any of
his/her rights or obligations in connection with this Agreement without the prior written consent
of Allstate Settlement. The Payee specifically agrees that Allstate Life, and Allstate Assignment
are third -party beneficiaries of this Agreement for purposes of enforcing the provisions of this
paragraph.
7. Cancellation The Payee and Allstate Settlement shall have the irrevocable right
to cancel and rescind this Agreement, without any penalty or obligation, at any time prior to
approval of this Agreement by a court of competent jurisdiction (the "Cancellation Date").
Cancellation by the Payee is effective upon mailing, faxing, or delivering a signed and dated
copy of the attached Notice of Cancellation (Exhibit `B" to this Agreement) or any other written
notice to Allstate Settlement. If the Payee or Allstate Settlement so cancels, neither the Payee
nor Allstate Settlement shall have any further obligations under this Agreement.
8. Entire Agreement The Schedules and Exhibits attached hereto are incorporated
into and are part of this Agreement. This Agreement, with the schedules and exhibits attached
hereto, constitutes the entire contract between the parties with respect to the subject matter
hereof and supersedes any and all prior agreements, representations, understandings, statements,
negotiations, and undertakings, whether oral or written.
9. Amendment, Waiver, and Extension No amendment of this Agreement and no
waiver of one or more of its terms may be effected unless set forth in writing and signed by the
party to be bound. Any waiver of strict compliance with this Agreement shall not operate as a
waiver of, or estoppel with respect to, any subsequent or other failure to so comply.
10. Severability Any provision of this Agreement that is held to be inoperative,
unenforceable, voidable, or invalid in any jurisdiction shall, as to that jurisdiction, be inoperable,
unenforceable, void, or invalid without affecting the remaining provisions in that jurisdiction or
the operation, enforceability, or validity of that provision in any other jurisdiction, and to this
end, the provisions of this Agreement are declared to be severable.
11. Notice All notices and other communications required or permitted to be given
hereunder shall be deemed duly given: (a) upon delivery, if delivered by hand or facsimile
transmission (with valid receipt or proof of transmission, as applicable); (b) three (3) days after
Initials of Payee
Initials of Payee's Spouse (if applicable)
-4-
PI-ILIT/ 1775146.9
posting, if sent by certified mail, return receipt requested; or (c) two (2) days after posting, if sent
by overnight or express mail, in each case at the addresses set forth below:
(a) If to Allstate Settlement:
Allstate Advanced Funding Exchange
c/o Allstate Advanced Funding Exchange Unit
3100 North Sanders Road, M3
Northbrook, IL 60062-9724
(b) If to the Payee:
At the address set forth on the signature page hereto or to such other
address as the applicable party may from time to time designate by providing written notice in
accordance with this Agreement.
12. Power and Authority Allstate Settlement and the Payee each have the full
power and authority to enter into and perform this Agreement. The Payee further acknowledges
that he/she has read this Agreement, understands it, and agrees to be bound by its terms.
13. Survival Sections 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17 of this
Agreement shall survive termination of this Agreement.
14. Forum Selection and Governing Law
(a) This Agreement shall be governed by and construed in accordance with the laws
of the State of Illinois, without giving effect to any applicable choice or conflict of law
provisions thereof.
(b) All disputes arising from this Agreement shall be brought in a court of competent
jurisdiction in the State of Illinois. By signing this Agreement, the Payee hereby expressly
subjects him/herself to the personal jurisdiction of the courts of the State of Illinois.
15. Headings The headings used herein have been included for convenience only
and shall not be considered in interpreting this Agreement.
16. Counterparts This Agreement may be executed in separate counterparts, each of
which shall be deemed an original, and all of which together will constitute one and the same
agreement.
17. Gender Where the context or construction requires, all words applied in the
plural shall be deemed to have been used in the singular, and vice versa; the masculine shall
include the feminine and neuter, and vice versa; and the present tense shall include the past and
future tense, and vice versa.
Initials of Payee
Initials of Payee's Spouse (if applicable)
5
PHLIT/ 1775148.9
IN WITNESS WHEREOF, the parties have caused this Agreement to be signed by the
parties or their duly authorized officers or agents, as applicable, as of the acceptance date set
forth below.
Allstate Settlement Corporation
By: Rebecca Baldwin
Title: Product and Financial Manager
Date: c:M11 \U‘
Mr. Tyler Conaway a/k/a Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
On this, the LI day of A'S10S-14 , 2014, before me Dcaii4a 6e;. jre 1P.
the undersigned officer, personally appeared%(e,. Cotutt.4,y, known to me (or satisfactorily
proven) to be the person(s) whose name(s) is/are subscribed` to the within instrument, and
acknowledged that tt.cticw,v6kw executed the same for the purposes therein contained.
In witness whereof, 1 hereunto set my haals.
NNSY
Initials of Payee
Initials of Payee's Spouse (if applicable)
PHLIT/ 1775148.9
//JJ NOTARIAL SE
DeiNALO GEORGE FORNE
of Harrisburg. Oaup
6
List of Related Documents
Schedule of Payments and Net Funding Exchange Price Schedule 1
Schedule of Conditions Precedent Schedule 2
Affirmation/Waiver of Independent Professional Advisor Exhibit A
Irrevocable Instructions to Estate, Heirs, and Beneficiaries Exhibit B
Spousal Consent Confirmation Exhibit C
Change of Beneficiary Request Exhibit D
Notice of Cancellation Exhibit E
Waiver by Beneficiary Exhibit F
Initials of Payee
Initials of Payer's Spouse (if applicable)
-7-
Schedule 1
The Transferred Payments (which, subject to the terms and conditions hereof, will not be paid)
are as follows:
• One (1) lump sum payment of $3,500.00 clue on November 4, 2015;
• One (1) lump sum payment of $4,500.00 due on November 4, 2019;
• One (1) Lump sum payment of $6,400.00 due on November 4, 2022; and
• One (1) lump sum payment of $8,000.00 due on November 4, 2024.
The Gross Price is the amount that Allstate Settlement is paying for the right to receive the
Transferred Payments:
• $12,494.21
Note: In order to pay the Gross Price, Allstate Settlement may request a loan in the amount
of the Gross Price from Allstate Life.
The Net Funding Exchange Payment will be the amount that the Payee receives, and will be the
same as the Gross Price because Allstate Settlement will not deduct its attorneys' fees and expenses
from the Gross Price:
• $12,494.21 (estimated)
Note: The actual Gross Price and Net Funding Exchange Payment will be determined by
applying the annual discount rate as of the date of approval of this transaction. Accordingly,
the actual amount the Payee receives likely will be slightly higher than that which is set forth
here.
►nilials of Payee
Millais of Payee's Spouse (if applicable)
_g
PHLIT/ 1775148.9
Schedule 2
The Agreement becomes final and the Net Funding Exchange Payment is paid only after each
of the terms set forth below is satisfied:
• At the expense of the Payee, Allstate Settlement is satisfied that a
Qualified Order has been obtained from &court of competent jurisdiction, in
accordance with Section 5891 of the Internal Revenue Code of 1986 (as
amended), and that an appropriate court order has been obtained in satisfaction of
all applicable state statutes.
• The Payee delivers to Allstate Settlement a fully executed and completed
Funding Exchange Agreement Application.
• The Payee delivers to Allstate. Settlement a fully executed and completed
Affirmation/Waiver of Independent Professional Advisor in the form attached as
Exhibit "A."
• The Payee delivers to Allstate Settlement a fully executed and completed
version of irrevocable instructions addressed to the executor of the Payee's estate,
heirs, and beneficiaries in the form attached as Exhibit "B" (if applicable).
• The Payee delivers to Allstate Settlement a fully executed and completed
version of the Spousal Consent Confirmation in the form attached as Exhibit "C"
(if applicable), unless this requirement is waived by Allstate Settlement.
• The Payee delivers to Allstate Settlement a fully executed and completed
version of the Change of Beneficiary Request in the form attached as Exhibit "D."
• The Payee delivers to Allstate Settlement a fully executed and completed
version of the Waiver of Beneficiary in the form attached as Exhibit "F" (if
applicable).
• The information set forth in the Agreement and Schedule 1 and Schedule 2
and all Exhibits and related documents must be accurate at the time of delivery to
Allstate Settlement and at the time the Qualified Order is obtained.
Initials of Payee
Initials of Payee's Spouse (if applicable)
-9-
PHL1T! 1775148.9
Exhibit "A"
Affirmation/Waiver of Independent Professional Advisor
IMPORTANT: You are entitled to receive independent professional advice regarding the legal,
financial, and tax implications of this Agreement.
INSTRUCTIONS:
Do not sign both Part A and Part B. You must sign only Part A or Part B. Sign Part A only if you are
waiving independent professional advice. Sign Part B only if you have obtained independent professional
advice. When the transfer statutes of the following states are triggered, the Payee must obtain
independent professional advice:
Alaska Minnesota
Delaware North Carolina
Louisiana Ohio
Maine Vermont
Maryland
Part A
(if applicable)
WAIVER OF INDEPENDENT PROFESSIONAL ADVICE
I know that I am entitled to receive independent professional advice regarding the legal, financial,
and tax implications of this Agreement. Allstate Settlement has advised me to obtain independent
professional advice, and I have had ample opportunity to obtain such advice. Nevertheless, after careful
and thoughtful consideration, I have voluntarily decided to proceed with this transaction without
obtaining independent professional advice. I have thoroughly reviewed the Agreement between myself
and Allstate Settlement, as well as the Exhibits to the Agreement, and I fully understand this transaction.
My decision is not the product of duress, undue influence, or anything other than my own choice.
Mr. Tyler Conaway a/k/a Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
State of °1`4ft'4-'`"
County of D«vpi,i- r1
On this, the ti day of Au5tA4— , 2014, before me Doc. < C ' ' c Fsenvi , the undersigned
officer, personally appeared Lv C44-tc.c , known to me (or satisfactorily proven) to be the person(s)
whose name(s) is/are subscribed to the within instrument, and acknowledged that executed
the same for the purposes therein contained.
In witness whereof, I hereunto set my h. .and offrc . eals.
PHUT/ 1775148.9
A
R Y, Nota Public
ssion Expires Nov.21, 2015
Not
- 10-
Part B
(if applicable)
AFFIRMATION OF INDEPENDENT PROFESSIONAL ADVICE
I hereby acknowledge and confirm that I have received independent professional advice regarding
the legal, tax, and financial implications of the Advanced Funding Exchange Agreement between myself
and Allstate Settlement Corporation.
Mr. Tyler Conaway a/k/a Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
Certification of Independent Professional Advisor
(All Parts Must Be Completed)
Name of Independent Professional Advisor:
Profession:
(If the Payee resides in Missouri, Nebraska or Pennsylvania, or if the structured
settlement was approved by a Missouri court, the professional advisor must be an
attorney.)
Independent Professional Advisor's Address:
Independent Professional Advisor's Telephone
Number: ( )
I am not affiliated with or compensated by Allstate Settleinent Corporation, and my
compensation for providing the advice is not affected by whether a transfer occurs or does not occur. I
rendered advice to Tyler Conaway a/k/a Tyler Michael Conaway concerning the legal, financial, tax,
and other implications of the Advanced Funding Exchange Agreement between Mr. Conaway and
Allstate Settlement Corporation.
PHL1T/ 1775148.9
By:
Title:
- 11 -
Exhibit "B"
Irrevocable Instructions Addressed
To the Payee's Estate, Heirs, and Beneficiaries
July 23, 2014
To: Any Court Administering My Estate
The Executor of My Estate
Any Other Administrator Under My Final Will
All Heirs and Beneficiaries Under My Final Will
All Heirs and Beneficiaries at Law
Re: Annuity Contract No.:
Annuity Owner:
Annuity Issuer:
Bond Number:
Bond Issuer:
90307718
Allstate Assignment Company
Allstate Life Insurance Company
N/A
N/A
I have entered into a Funding Exchange Agreement (the "Agreement") in which I have
transferred to Allstate Settlement Corporation ("Allstate Settlement") all rights, title, and interest to the
Transferred Payments (as defined in the Agreement) under the above -referenced Annuity and related
Release and Settlement Agreement. The Agreement and Related Documents are, and I expressly and
irrevocably intend them to be, fully binding on my executor, administrator, estate, heirs, beneficiaries,
contingent beneficiaries, successors, and assigns.
I hereby respectfully provide to you the following IRREVOCABLE instructions with respect to
this matter:
I . You are expressly and irrevocably directed to abide by all of the terms and conditions of
the Agreement and Related Documents. Allstate Settlement is now entitled to the
proceeds of, and all other benefits regarding, each of the Transferred Payments.
2. You are specifically instructed not to institute any legal action, proceeding, contest, or
assert any claim to or with respect to the Transferred Payments, and I hereby deprive you
of any standing or legal right to institute or assert any such suit, action, claim, or
proceeding.
Do not under any circumstances attempt to deny Allstate Settlement, or permit Allstate Settlement to be
denied, the benefit of its bargain under the terms of the Agreement and the Related Documents.
Very truly yours,
Ty er Conaway a/k/a ler Michael Conaway
-12-
PHL1T/ 1775148.9
Exhibit "C"
Spousal Consent Confirmation
N/A
PHL1T/ 1775t48.9
-13-
Exhibit "D"
Change of Beneficiary
Allstate Assignment Company
3100 Sanders Rd, Ste M3
Northbrook, IL 60062
Allstate Life Insurance Company
3100 Sanders Rd, Ste M3
Northbrook, IL 60062
Re: Annuity Contract No.: 90307718
Payee: Tyler Conaway a/k/a Tyler Michael Conaway
Settlement Agreement dated: February 11, 2002
To whom it may concern:
Please change your records to show Allstate Settlement Corporation as the beneficiary after my
death under the above -captioned settlement agreement and annuity contract for the period covering one
(1) lump sum payment of $3,500.00 due on November 4, 2015; one (1) lump sum payment of
$4,500.00 due on November 4, 2019; one (1) lump sum payment of $6,400.00 due on November 4,
2022; and one (1) lump sum payment of $8,000.00 due on November 4, 2024. At the expiration of this
period, please change your records to show my Estate as the beneficiary of any remaining Periodic
Payments due under the above -captioned settlement agreement and annuity contract. Kindly confirm
that you have made this modification to your records by signing in the space provided below and
mailing to:
State of .ratwel/ww la
County of Mivc,p24 "1
Allstate Advanced Funding Exchange
c/o Allstate Advanced Funding Exchange Unit
3100 North Sanders Road, M3
Northbrook, IL 60062-9724
Very truly yours,
yler Conaway a/I'a Tyler Michael Conaway
On this, the q clay of (N" 3`"34 , 2014, before me Do°�e c r ""`r , the undersigned
officer, personally appeared 1.44' tor1-4 1', known to me (or satisfactorily proven) to be the person(s)
whose name(s) is/are subscribed to the within instrument, and acknowledged thata•v'/»rexecuted the
same for the purposes therein contained.
In witness whereof, I hereunto set my hand a
By:
Allst ssig e Company
ice Company
Dated:
PHUT/ 1775148.9
seals.
otary
Dated:
- 14 -
0eeT�,,,
to .1 4 HOF PENNSYLVANIA ,
NOT ' ' IAL SEAL
DONALD tEOR c FORNEY, Notary Public
Clty6 '•+Ura, Dauphin County
My CorrVnission Expires Nov. 21, 2015
Exhibit "E"
Notice of Cancellation
(ONLY SIGN THIS PAGE IF YOU INTEND TO CANCEL THIS TRANSACTION)
Date of Agreement: July 23, 2014
Mr. Tyler Conaway a/k/a Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
Dear Payee:
On the date set forth above as the "Date of Agreement," you entered into a Funding Exchange
Agreement to sell to Allstate Settlement Corporation ("Allstate Settlement") the Transferred Payments,
as defined in the Funding Exchange Agreement and its schedules and exhibits (respectively, the
"Agreement" and "Related Documents").
As explained to you at the time you executed the Agreement, you may cancel this transaction,
without any penalty or obligation, at any time prior to the date on which the Agreement is approved by
a court upon mailing, faxing, or delivering a signed and dated copy of this Notice of Cancellation (or
any other written notice) to Allstate Settlement at the address listed below.
Allstate Advanced Funding Exchange
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Road, M3
Northbrook, IL 60062
Fax: (866) 676-2121
If you cancel in accordance with this notice, neither you nor Allstate shall have any further
obligations under the Agreement.
After the Cancellation Date, you may no longer cancel the Agreement, and no provision of the
Agreement, its Related Documents, any other document, or any oral statement made to you shall grant
any such further right of cancellation.
I HEREBY CANCEL THIS TRANSACTION.
DATE:
SELLER'S SIGNATURE:
SELLER'S SIGNATURE:
- 15 -
PHLIT/ 1775148.9
Exhibit "F"
Irrevocable Consent To, and Waiver of All Rights, Related to Transferred Payments
N/A
- 16 -
PHUT/ 17751489
ALL STATE LEGAL SUPPLY CO. ONE COMMERCE DRIVE, CRANFORD, NEW JERSEY 07016
(2) 6011
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: PETITION OF TYLER M. CONAWAY :
AND ALLSTATE SETTLEMENT
CORPORATION FOR APPROVAL
OF TRANSFER OF STRUCTURED
SETTLEMENT PAYMENT RIGHTS .
NO.
AFFIDAVIT OF ALLSTATE ASSIGNMENT COMPANY and
ALLSTATE LIFE INSURANCE COMPANY
I, Rebecca Baldwin, being duly sworn, depose and say as follows:
1. I am over eighteen (18) years of age, suffer from no disability, and am competent
to testify to the natters set forth herein, all of which are based upon personal knowledge.
2. I am a Product and Financial Manager for Allstate Assignment Company
("Allstate Assignment") and Allstate Life Insurance Company ("Allstate Life").
3. As a Product and Financial Manager for Allstate Assignment and Allstate Life, I
am responsible for the management and oversight of the Allstate Assignment and Allstate Life
structured settlements (including the structured settlement at issue in this case).
4. As a Product and Financial Manager for Allstate Assignment and Allstate Life, I
am authorized to submit this affidavit on behalf of Allstate Assignment and Allstate Life.
5. Ronald and Kimberly Conaway, as parents and natural guardians of Tyler
Conaway a/k/a Tyler Michael Conaway ("Mr. Conaway"), then a minor, entered into a
Settlement Agreement and Release (the "Settlement Agreement") with a liability insurer (the
"Insurer") resolving a certain claim. The Settlement Agreement provided for certain periodic
payments to be made to Mr. Conaway. The Insurer assigned its obligations under the Settlement
Agreement to Allstate Assignment.
ACTIVE/ 76272847.1
6. As the obligor under the Settlement Agreement, Allstate Assignment purchased
annuity contract no.90307718 (the "Annuity") from Allstate Life and thereby funded Allstate
Assignment's obligations to make the periodic payments to Mr. Conaway under the Settlement
Agreement,
7. The following language was included in the Settlement Agreement:
Claimant acknowledges that the Periodic Payments cannot be
accelerated, deferred, increased or decreased by the Claimant or
any Payee; nor shall the Claimant or any Payee have the right or
power to sell, mortgage, encumber or anticipate the Periodic
Payments, or any part thereof, by assignment or otherwise (the
"Anti -Assignment Language").
8. Allstate Assignment and Allstate Life have been provided with a copy of the Joint
Petition of Allstate Settlement Corporation and Tyler Conaway for Approval of the Transfer of
Structured Settlement Proceeds (the "Petition").
9. On behalf of Allstate Assignment and Allstate Life, I have thoroughly reviewed
the Petition.
10. Allstate Assignment and Allstate Life do not oppose the Petition, and with respect
only to the payments at issue in this transaction, waive their rights to enforce the Anti -
Assignment Language.
STATE OF ILLINOIS
COUNTY OF COOK
Swor to me this \ day of
, 2014.
Notary Public
ACTIVE! 76272847.1
Rebecca Baldwin
EN
MY J.
A SEAL._
s
Notary psnFx
C rnmyo1 208
ebtua2
-2-
D?t
ALL STATE LEGAL SUPPLY co. ONE COMMERCE DRIVE, CRANFORD, NEW JERSEY 07015
(2)
DISCLOSURE STATEMENT FOR TYLER CONAWAY
(Provided Not Less Than (10) Days Prior to Execution of
Agreement)
(By Federal Express)
Date of Calculations: July 8, 2014
There may be adverse tax consequences affecting you as a result of this
transfer, and you are advised to seek independent professional advice,
including the advice of an attorney or accountant.
Amounts and Dates of Transferred Structured Settlement Payments
The amounts and dates of the structured settlement payments to be
transferred (i.e., the "Transferred Periodic Payments") are as follows:
• One (1) Iump sum payment of $3,500.00 due on November 4, 2015;
• One (1) lump sum payment of $4,500.00 due on November 4, 2019;
• One (1) lump sum payment of $6,400.00 due on November 4, 2022; and
• One (1) lump sum payment of $8,000.00 due on November 4, 2024.
Aggregated Amount of Transferred Structured Settlement Payments
The Aggregated Amount of the Transferred Structured Settlement
Payments (i.e., the aggregate amount of the structured settlement payments to
be transferred) is: $22,400.00.
Discounted Present Value of Transferred Structured Settlement Payments
The Discounted Present Value of the Transferred Structured Settlement
Payments (i.e., the calculation of the current value of the transferred
structured settlement payments under federal standards for valuing
annuities), calculated on July 8, 2014, is: $19,108.48.
The amount of the applicable federal rate used in calculating such
discounted present value (i.e., the discount rate), as published on July 8, 2014,
is: 2.2%.
DISCLOSURE STATEMENT FOR TYLER CONAWAY - PAGE 1
PHUT/ 1775140.4
Gross Price for Transferred Structured Settlement Payments
The Gross Price for the Transferred Structured Settlement Payments
(Le., the gross advance amount payable to you in exchange for the
Transferred Structured Settlement Payments before any reduction for
transfer expenses or other deductions) is at least: $12,494.2L
The annual discount rate, compounded monthly, used to determine the
Gross Price for the Transferred Structured Settlement Payments (Le., the
gross advance amount payable to you in exchange for such payments before
any reduction for transfer or Transfer expenses or other deductions) is:
8.5%.
Note: The actual Gross Price will be determined by applying the annual
discount rate as of the date of approval of this transaction. Accordingly,
your actual Gross Price likely will be slightly higher than that which is
disclosed in this document.
List of Commissions, Fees, Costs, Expenses and Charges
An itemized listing of all commissions, estimated fees, costs, expenses,
and charges payable by you or deductible from the gross amount otherwise
payable to you is as follows: None.
Net Funding Exchange Payment
The Net Funding Exchange Payment (i.e., the net amount payable after
deduction of all commissions, estimated fees, costs, expenses, and charges
described in the immediately preceding section) is at least: $12,494.21 (final
figure to be determined as of the date of approval of this transaction).
Quotient
The net amount that you will receive from us in exchange for your
future structured settlement payments represents 65 percent of the estimated
current value of the payment based upon the discounted value using the
applicable federal rate.
DISCLOSURE STATEMENT FOR TYLER CONAWAY -PACE 2
PHUT/ 1775140.4
Penalties and Damages
The amount of penalties and liquidated damages payable by you in the
event of a breach of the Agreement by you is: None.
Requesting Parties' Right to Cancel
You have the right to cancel this Agreement, without penalty or further
obligation, not later than the date the Agreement is approved by a court.
I hereby acknowledge and confirm that I have received and read this
Disclosure Statement.
Tyler Conaway
5 Locust Circle
Mechanicsburg, PA 17050
gnatureenature
7/////y
Date
DISCLOSURE STATEMENT FOR TYLER CONAWAY -PAGE 3
PHLIT/ 1775140.4
Important Notice: You are strongly urged to consult with an attorney who
can advise you of the potential tax consequences of this transaction.
Tyler Conaway
5 Locust Circle
Mechanicsburg, PA 17050
*Fig 7//
Date
DISCLOSURE STATEMENT FOR TYLER CONAWAY - PAGE 4
PHUT/ 1775140.4
//1
FedEx
Shipment Receipt
Outbound Shipment
Address Information
Ship to:
Tyler Conaway
Allstate Advanced Funding
5 Locust Circle
MECHANICSBURG, PA
17050
US
7174606603
Ship from:
Ben Browning
Allstate Advanced Funding
3100 SANDERS RD
Suite M3
NORTHBROOK, IL
600627155
US
8667392318
Shipment Information:
Tracking no.: 770535354653
Ship date: 07/08/2014
Date Created: 07/08/2014
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Bill transportation to: Structured Settlements -467
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Department no.:
Return Shipment
Address Information
Ship to:
Ben Browning
Allstate Advanced
Funding
3100 SANDERS RD
Suite M3
NORTHBROOK, IL
600627155
US
8667392318
Shipment Information:
Tracking no.: 790025284960
Ship from:
Tyler Conaway
Select or eater
5 Locust Circle
MECHANICSBURG, PA
17050
US
7174606603
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AFFIDAVIT OF TYLER MICHAEL CONAWAY
I, Tyler Conaway a/k/a Tyler Michael Conaway, being duly sworn, according to law,
depose and say:
1. I am nineteen years old, suffer from no mental disability, and am competent to
testify in the matters set forth herein, all of which are based upon personal knowledge.
2. I currently reside at 5 Locust Circle, Mechanicsburg, Pennsylvania 17050.
3. On or about February 11, 2002, Ronald and Kimberly Conaway, as my parents
and natural guardians, and on my behalf, entered into a Settlement Agreement and Release (the
"Settlement Agreement") with a liability insurer ("Insurer"), pursuant to which I became entitled
to receive certain periodic payments (the "Periodic Payments"), including: one (1) lump sum
payment of $3,500.00 due on November 4, 2015; one (1) lump sum payment of $4,500.00 due
on November 4, 2019; one (1) lump sum payment of $6,400.00 due on November 4, 2022; and
one (1) lump sum payment of $8,000.00 due on November 4, 2024.
4.
Court.
On or about August 3, 2001, the Settlement Agreement was approved by this
5. On or about August 14, 2001, Insurer assigned its obligation to make the Periodic
Payments to Allstate Assignment Company ("Allstate Assignment"): Allstate Assignment
purchased annuity contract 90307718 (the "Annuity") from Allstate Life Insurance Company in
. order to fund its obligation to make the Periodic Payments to me.
6. On or about July 23, 2014, I entered into a Funding Exchange Agreement (the
"Agreement") with Allstate Settlement Corporation ("Allstate Settlement"), pursuant to which I
agreed to assign and sell to Allstate Settlement the following Periodic Payments (the
ACTIVE/ 76272795.2
"Transferred Payment(s)"): one (1) lump sum payment of $3,500.00 due on November 4, 2015;
one (1) lump sum payment of $4,500.00 due on November 4, 2019; one (1) lump sum payment
of $6,400.00 due on November 4, 2022; and one (1) lump sum payment of $8,000.00 due on
November 4, 2024.
7. I understand that, by entering into this Agreement, I and/or my heirs,
beneficiaries, contingent beneficiaries, executors, and assigns will no longer receive any of the
Transferred Payment(s) or a portion of the Transferred Payment(s). I understand that all of the
Transferred Payment(s) will be paid directly to Allstate Settlement.
8. Allstate Settlement provided to me a Disclosure Statement, at least ten (10) days
prior to execution of the Agreement, which explained the terms of the Agreement. After
carefully reviewing the Disclosure Statement, I signed the Disclosure Statement on July 11, 2014
and returned the Disclosure Statement to Allstate Settlement. I fully and completely understand
all the terms of the Disclosure Statement.
9. Allstate Settlement advised me to obtain independent professional advice
regarding the legal, financial, and tax implications of the Agreement, and, as indicated in Exhibit
A to the Agreement, I received such advice or knowingly waived my right to seek such advice in
writing.
10. I have no dependents.
11. I will use any funds I receive in the event this transaction is approved in order to
purchase a reliable used vehicle. My current vehicle recently suffered irreparable damage and is
not longer in service. Having reliable transportation will allow me to secure gainful
-2-
ACTIVE) 76272795.2
employment. Without the funds from this transaction, I will not be able to purchase any means
of transportation, which will inhibit me from working a job with a normal schedule.
12. I will not be using any of the lump sum proceeds that I receive from Allstate
Settlement to pay for daily living expenses or necessities.
13. I do not have any child support, alimony, or alimony pendente lite obligations.
14. I have not previously filed a petition to transfer payment rights under the
structured settlement that is the subject of this transaction.
15. After careful consideration of my current financial resources and obligations, I
believe that selling my right to receive the Transferred Payment(s) is in my best interest.
Therefore, I respectfully request that this Court approve the Proposed Transfer.
I verify that the statements made in this affidavit are true and correct. I understand that
false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn
falsification to authorities.
Tyler Conaway a/k/ y er Michael Conaway
Daofy/,t,l�
STATE OF tl 11 fLre f r)A
COUNTY OF '�p V (/t
On this, the day of a i , 2014, before me_nrw, it -4,46y , the
undersigned officer, personally appeare• - t► nown to me (or satisfactorily proven) to be
the person(s) whose name(s) is/are subscribe to the withih instrument, and acknowledged that
`*4ric-11" Texecuted the same for the purposes therein contained.
In witness whereof •e - • • - • hair),ani :._i:_• _seals.
Nota l,1yi}NWEA 0
` LW'
rARIAL s`'11111r•
DONALD GEORGE FORNEY,Nor • • 3 I
City of Harrisburg, Dauphin County
My Commission ExptresiNov, 21, 2015
ACTIVE/ 76272795.2
RECYCLED
Exhibit "A"
Affirmation/Waiver of Independent Professional Advisor
IMPORTANT: Von are entitled to receive independent professional advice regarding the legal,
financial, and tax implications of this Agreement.
INSTRUCTIONS:
Do not sign both Part A and Part 13. You must sign only Part A or Part B. Sign Part A only if you are
waiving independent professional advice. Sign Part B only if you have obtained independent professional
advice. When the transfer statutes of the following states are triggered, the Payee must obtain
independent professional advice:
Alaska Minnesota
Delaware North Carolina
Louisiana Ohio
Maine Vermont
Maryland
Part A
(if applicable)
WAIVER OF INDEPENDENT PROFESSIONAL ADVICE
I know that I am entitled to receive independent professional advice regarding the legal, financial,
and tax implications of this Agreement. Allstate Settlement has advised me to obtain independent
professional advice, and I have had ample opportunity to obtain such advice. Nevertheless, after careful
and thoughtful consideration, 1 have voluntarily decided to proceed with this transaction without
obtaining independent professional advice. I have thoroughly reviewed the Agreement between myself
and Allstate Settlement. as well as the Exhibits to the Agreement, and I fully understand this transaction.
My decision is not the product of duress, undue influence, or anything other than my own choice.
State of `^'41fu`-")`'"
County of t ,I. 14
On this, the day of 44,-,5 4- , 2014, before me 4- e1 , the undersigned
officer, personally appeared -ill Lk (.e+« «y , known to me (or satisfactorily proven) to be the person(s)
whose name(s) is/are subscribed to the within instrument, and acknowledged that executed
the same for the purposes therein contained.
Mr. Tyler Conaway a/k/a Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
In witness whereof, I hereunto set my h. .and offtc . cals.
PFtLIT/ 1775148.9
Not
A
R ` Y Nota Public
isburg, Oaup n our:
salon Expires Nov. 21, 2015
- 10 -
ALL STATE LEGAL SUPPLY CO. ONE COMMERCE DRIVE, CRANFORD, NEW JERSEY 07018
ED12K
Allstate Settlement Corporation's Address and Taxpayer 1.D. No,
Allstate Advanced Funding Exchange
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, M3
Northbrook, IL 60062
Taxpayer I.D. No.: 36-2554642
Allstate Settlement Corporation
206 South 13th Street
Suite 200
Lincoln, NE 68508-2010
Taxpayer..I.D. No.: 36-2554642
pi-HAT/585160 I
TYLER CONWAY — List of Dependents
Tyler Conway has no legal dependents.
CERTIFICATION OF ATTORNEY FOR TRANSFEREE
I, Karen A. Salvemini, Esquire, attorney for Transferee, Allstate Settlement Corporation,
hereby certify to the best of my knowledge, information and belief, formed after reasonable
inquiry, that the Proposed Transfer will comply with the requirements of the Act (40 P.S. § 4000
et seq.) and will not contravene any other applicable federal or state statute or regulation or the
order of any court or administrative authority.
I, Karen A. Salvemini, Esquire, attorney for Transferee, Allstate Settlement Corporation,
hereby verify that the facts and statements set forth herein are true and correct to the best of my
knowledge, information, and belief. I understand that false statements made herein are subject to
the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsification of authorities.
Dated: ati/D`"�2014
Kaeft'Qaly=ini
Attorney for Transferee, Allstate Settlement
Corporation
ALL STATE LEGAL SUPPLY CO, ONE COMMERCE DRIVE, CRANFORD, NEW JERSEY 07016
(2)
ED)i
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: PETITION OF TYLER MICHAEL
CONAWAY AND ALLSTATE
SETTLEMENT CORPORATION FOR :
APPROVAL OF TRANSFER OF
STRUCTURED SETTLEMENT
PAYMENT RIGHTS
NO.
INITIAL ORDER OF COURT
On this day of , 2014, it is ordered that a hearing on this
Petition to Transfer Structured Settlement Payment Rights will be held on
2014, in Courtroom
at o'clock. The payee shall bring income tax returns
for the prior two (2) years to the hearing.
Within seven (7) days, the transferee shall give notice of the hearing date to the payee,
the structured settlement obligor, the annuity issuer, the payee's spouse and any person receiving
child support, alimony, or alimony pendente lite. The transferee shall attach a certificate of
service to the notice of hearing date. A copy of the notice with the certificate of service shall be
filed with the court prior to the hearing.
BY THE COURT:
J.
Distribution List
Karen A. Salvemini, Esquire, Rhoads & Sinon LLP, One South Market Square, 12th Floor, P.O. Box 1146, Harrisburg, PA
17108-1146, Phone: (717) 233-5731, Fax: (717) 238-8623, Email: ksalvemini@rhoads-sinon.com
Allstatt Assignment Company, c/o Allstate Advanced Funding Exchange Unit, 3100 Sanders Rd., Suite M3, Northbrook, IL
60062
Allstate Settlement Corporation, do Allstate Advanced Funding Exchange Unit, 3100 Sanders Rd., Suite M4, Northbrook, IL
60062
Allstate Life Insurance Company, c/o Allstate Advanced Funding Exchange Unit, 3100 Sanders Rd., Suite M3, Northbrook, IL
60062
Tyler Michael Conaway, 5 Locust Circle, Mechanicsburg, PA 17050
966973.1
ALL-STATE LEGAL SUPPLY CO.. 1-800-222-0510 EDI I RECYCLED
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: PETITION OF TYLER MICHAEL
CONAWAY AND ALLSTATE
SETTLEMENT CORPORATION FOR :
APPROVAL OF TRANSFER OF
STRUCTURED SETTLEMENT
PAYMENT RIGHTS
On this day of
•
NO.
FINAL ORDER OF COURT
, 2014, it is ordered that the Petition of Allstate
Settlement Corporation ("Allstate Settlement") and Tyler Michael Conaway ("Mr. Conaway" or
"payee") for Approval of the Transfer of Structured Settlement Payment Rights, pursuant to 40
P.S. § 4001 et seq., is granted.
The Court specifically finds that:
1. The transfer of the structured settlement proceeds, specifically, one (1) lump sum
payment of $3,500.00 due on November 4, 2015; one (1) lump sum payment of $4,500.00 due
on November 4, 2019; one (1) lump sum payment of $6,400.00 due on November 4, 2022; and
one (1) lump sum payment of $8,000.00 due on November 4, 2024 (the "Transferred Payments")
by Mr. Conaway to Allstate Settlement as described in the petition in this matter (the "Proposed
Transfer") complies with the requirements of the Pennsylvania Structured Settlement Protection
Act, 40 P.S. § 4001 et seq., 26 U.S.C. § 5891, and does not contravene any other applicable law.
2. Based on the certification of counsel for Allstate Settlement, and the Court having
not been made aware of any statute, regulation or order that would be incompatible with the
Proposed Transfer, the Proposed Transfer will not contravene any applicable federal or state
966979.1
statute or regulation, or the order of any court or administrative authority, or any applicable law
limiting the transfer of workers' compensation claims.
It is hereby ORDERED, ADJUDGED, and DECREED as follows:
1. The Proposed Transfer is approved, and the following payments shall be
transferred to Allstate Settlement: one (1) lump sum payment of $3,500.00 due on November 4,
2015; one (1) lump sum payment of $4,500.00 due on November 4, 2019; one (1) lump sum
payment of $6,400.00 due on November 4, 2022; and one (1) lump sum payment of $8,000.00
due on November 4, 2024.
2. Within fourteen (14) days of its receipt of this order, Allstate Settlement will
forward to Mr. Conaway a lump sum payment(s) of no less than $12,494.21, from which no
additional funds are owed for counsel fees, administrative fees, or other costs, fees or expenses.
3. The terms of this Order shall survive the death of the payee and shall be binding
on the payee's heirs, beneficiaries and assigns.
4. During the period the structured settlement payment rights are being assigned or
encumbered pursuant to the transaction at issue, the designated beneficiary under annuity
contract no. 90307718 for the Transferred Payments shall be Allstate Settlement.
5. Allstate Settlement's, Allstate Life Insurance Company's, or Allstate Assignment
Company's lack of opposition to this matter, or stipulation hereto or compliance herewith, shall
not constitute evidence in any other matter, and is not intended to constitute evidence in any
other matter, that
(a) payments under a structured settlement contract or annuity or related
contracts can be assigned or that "anti -assignment" or "anti -encumbrance"
2
provisions in structured settlement contracts or annuities or related
contracts are not valid and enforceable; or
(b) Allstate Settlement, Allstate Life Insurance Company, or Allstate
Assignment Company has waived any right in connection with any other
litigation or claims.
6. Mr. Conaway and his heirs, beneficiaries, contingent beneficiaries, administrators,
executors, successors, and assigns, or individuals or entities that may claim through them (the
"Releasors"), hereby remise, release, and forever discharge Allstate Settlement, Allstate Life
Insurance Company, Allstate Assignment Company, and their respective directors, shareholders,
officers, agents, employees, servants, successors, executors, administrators, and assigns, and any
parent, subsidiary, or affiliate thereof, and their directors, shareholders, officers, agents,
employees, servants, successors, executors, administrators, and assigns, past and present (the
"Releasees"), of and from any and all manner of actions and causes of action, suits, debts, dues,
accounts, bonds, covenants, contracts, agreements, judgments, settlements, damages, claims, and
demands whatsoever, in law or in equity, in connection with, related to, or arising out of, any
claim or allegation that was or could have been asserted in connection with, related to, or arising
out of, the Funding Exchange Agreement, the Transferred Payments, which against each other or
the Releasees, the Releasors can, shall, or may have, except for claims to enforce any party's
rights under the Funding Exchange Agreement.
7. This Order shall constitute a "Qualified Order" within the meaning of 26 U.S.C. §
5891.
3
8. This Order constitutes a Final Order of the Court and resolves the last pending
claim and closes the case.
BY THE COURT:
, JUDGE
Distribution List
Karen A. Salvemini, Esquire, Rhoads & Sinon LLP, One South Market Square, 12th Floor, P.O.
Box 1146, Harrisburg, PA 17108-1146, Phone: (717) 233-5731, Fax: (717) 238-8623,
Email: ksalvemini@rhoads-sinon.com
Allstate Assignment Company, c/o Allstate Advanced Funding Exchange Unit, 3100 Sanders
Rd., Suite M3, Northbrook, IL 60062
Allstate Settlement Corporation, c/o Allstate Advanced Funding Exchange Unit, 3100 Sanders
Rd., Suite M4, Northbrook, IL 60062
Allstate Life Insurance Company, c/o Allstate Advanced Funding Exchange Unit, 3100 Sanders
Rd., Suite M3, Northbrook, IL 60062
Tyler Michael Conaway, 5 Locust Circle, Mechanicsburg, PA 17050
-4
Karen Salvemini, Esquire, I.D. No. 307174
RHOADS & SINON LLP
One South Market Square, 12th Floor
P.O. Box 1146
Harrisburg, PA 17108-1146
PH: (717) 233-5731
FX: (717) 260-4438
Attorneys for Allstate Settlement Corporation
Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
Pro Se
IN RE:
r:LED-OFFIC;',
OF THE PROTHONOIARI
2014 OCT:13 AM 10: 35
CUMBERLAND COUNTY
PENNSYLVANIA
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
PETITION OF TYLER MICHAEL
CONAWAY AND ALLSTATE
SETTLEMENT CORPORATION FOR
APPROVAL OF TRANSFER OF
STRUCTURED SETTLEMENT
PAYMENT RIGHTS
ENTRY OF APPEARANCE
NO. 6o3'j
TO THE PROTHONOTARY:
Kindly enter the appearance of Karen A. Salvemini, Esquire, as the attorney for Petitioner
Allstate Settlement Corporation in the above -captioned matter.
Respectfully Submitted,
Dated: 60 -to /0411 , 2014
967314.1
Karen i, Esquire, I.D. No. 307174
RHOADS & SINON LLP
One South Market Square, 12th Floor
P.O. Box 1146
Harrisburg, PA 17108-1146
PH: (717) 233-5731
FX: (717) 260-4438
Attorneys for Transferee Allstate Settlement
Corporation
CERTIFICATE OF SERVICE
I hereby certify that on October 10 , 2014, a true and correct copy of the Entry of
Appearance has been served upon the following via certified mail, return receipt requested:
Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
Allstate Assignment Company
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M3
Northbrook, IL 60062
2
Allstate Settlement Corporation
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M4
Northbrook, IL 60062
Allstate Life Insurance Company
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M3
Northbrook, IL 60062
•
f'1 .Ot !}
L., THE i' O'TI-1p gni 'VARY
IN THE COURT OF COMMON PLEAS 201 OCT 20 pN 3' 6
OF CUMBERLAND COUNTY, PENNSYLVANIACt1MBERLAND COUNTY
PENNSYLVANIA
IN RE: PETITION OF TYLER MICHAEL
CONAWAY AND ALLSTATE
SETTLEMENT CORPORATION FOR :
APPROVAL OF TRANSFER OF
STRUCTURED SETTLEMENT
PAYMENT RIGHTS
•
•
�v� L
NO. 'L - 603 Z
y� INITIAL ORDER OF COURT
On this old /May of , 2014, it is ordered that a hearing on this
Petition to Transfer Structured Settlement Payment Rights will be held on i% a.6,
A.
2014, in Courtroom at /%-00 o'clock. The payee shall bring income tax returns
for the prior two (2) years to the hearing.
Within seven (7) days, the transferee shall give notice of the hearing date to the payee,
the structured settlement obligor, the annuity issuer, the payee's spouse and any person receiving
child support, alimony, or alimony pendente lite. The transferee shall attach a certificate of
service to the notice of hearing date. A copy of the notice with the certificate of service shall be
filed with the court prior to the hearing.
BY THE COURT:
ribution List
Karen A. Salvemini, Esquire, Rhoads & Sinon LLP, One South Market Square, 12th Floor, P.O. Box 1146,
17108-1146, Phone: (717) 233-5731, Fax: (717) 238-8623, Email: ksalvemini@rhoads-sinon.com
rhoads-sinon.com
Allstatt Assignment Company, c/o Allstate Advanced Funding Exchange Unit, 3100 Sanders Rd., Suite M3,
60062
iAtlstate Settlement Corporation, d/o Allstate Advanced Funding Exchange Unit, 3100 Sanders Rd., Suite M4,
✓ 60062
Ilstate Life Insurance Company, c/o Allstate Advanced Funding Exchange Unit, 3100 Sanders Rd., Suite M3,
60062
Michael Conaway, 5 Locust Circle, Mechanicsburg, PA 17050
966973.1
acipt.ES.
161/acil
1.41
Harrisburg, PA
Northbrook, IL
Northbrook, IL
Northbrook, IL
Allstate Settlement Corporation's Address and Taxpayer I.D. No.
Allstate Advanced Funding Exchange
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, M3
Northbrook, IL 60062
Taxpayer 1.D. No.: 36-2554642
Allstate Settlement Corporation
206 South 13th Street
Suite 200
Lincoln, NE 68508-2010
Taxpayer1.D. No.: 36-2554642
piloT/ 585160 I
Karen Salvemini, Esquire, I.D. No. 307174
RHOADS & SINON LLP
One South Market Square, 12`" Floor
P.O. Box 1146
Harrisburg, PA 17108-1146
PH: (717) 233-5731
FX: (717) 260-4438
Attorneys for Allstate Settlement Corporation
Tyler Michael Conaway
5 Locust Circle
Mechanicsburg, PA 17050
Pro Se
FILU)-i,
Ot 71 -IF
2014 OCT 23
148
CUI°l '_ ijiD CC -IN -FY
PET:SYLVANIA
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: PETITION OF TYLER MICHAEL
CONAWAY AND ALLSTATE
SETTLEMENT CORPORATION FOR :
APPROVAL OF TRANSFER OF
STRUCTURED SETTLEMENT
PAYMENT RIGHTS
TO:
NO. j - 0O3a (civ..)
NOTICE OF HEARING ON PETITION
TO TRANSFER STRUCTURED SETTLEMENT PAYMENT RIGHTS
Tyler Conaway
Allstate Life Insurance Company
5 Locust Circle
c/o Allstate Advanced Funding Exchange Unit
Mechanicsburg, PA 17050
3100 Sanders Rd, Suite M3
Northbrook, IL 60062
Allstate Assignment Company
Allstate Settlement Corporation
do Allstate Advanced Funding Exchange Unit
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M3
3100 Sanders Rd, Suite M4
Northbrook, IL 60062
Northbrook, IL 60062
You are hereby given notice that Tyler Michael Conaway and Allstate Settlement
Corporation have filed a petition to transfer structured settlement payment rights. A hearing in
this matter has been scheduled on November 26, 2014 at 11:00 a.m. in Courtroom No. 5 of the
Cumberland County Courthouse, One Courthouse Square, Carlisle, PA 17013-3387.
You are entitled to support, oppose, or otherwise respond to the Petition of Allstate
Settlement Corporation and Tyler Michael Conaway, either in person or by counsel, by filing
written comments with the Court prior to the hearing or by attending the hearing.
966977.1
Any written response must be filed with the Court, and a copy sent to all interested
parties, not less than twenty (20) days after service of the Petition.
MR. CONAWAY MUST ATTEND THE HEARING.
Dated: October 22, 2014
2
Respectfully submitted,
Karen Salrfii, Esquire, I.D. No. 307174
RHOADS & SINON LLP
One South Market Square, 12th Floor
P.O. Box 1146
Harrisburg, PA 17108-1146
PH: (717) 233-5731
FX: (717) 260-4438
Counsel for Transferee Allstate Settlement
Corporation
EXHIBIT A
IN RE:
( riZ. i ti 1 10 iO
�tif11 OCT 20 PP 3. IaC>
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PEiNN'SYLVAiNIACUMBERLA, NB COUNTY
PENNSYLVANIA
PETITION OF TYLER MICHAEL
CONAWAY AND ALLSTATE
SETTLEMENT CORPORATION FOR :
APPROVAL OF TRANSFER OF
STRUCTURED SETTLEMENT
PAYMENT RIGHTS
INITIAL ORDER OF COURT
On this dv 74Lday of l C�
NO. - 60320 �t L
, 2014, it is ordered that a hearing on this
Petition to Transfer Structured Settlement Payment Rights will be held on `i%C7.%t Z < .
o'clock. The payee shall bring income tax returns
2014, in Courtroom J
at //:0O
for the prior two (2) years to the hearing.
Within seven (7) days, the transferee shall give notice of the hearing date to the payee,
the structured settlement obligor, the annuity issuer, the payee's spouse and any person receiving
child support, alimony, or alimonypenclente lite. The transferee shall attach a certificate of
service to the notice of hearing date. A copy of the notice with the certificate of service shall be
filed with the court prior to the hearing,
BY THE COURT:
A1)4, i'4',ee(
Distritnttion I.1St
Karen A. Sait'emini, Inquire, Rhoads 8: Sinon LLP, One South Market Square, 12th Floor, P.O. Box 1146, Harrisburg. PA
17108-1 146. Phone: (717) 233-573 I. Fax! (717) 235-8623, Email. ksrtltcmini Zrhoads-sinon.corn
Allston Assignment Company. c/o Allstate Adtanced Fundin, Exchange Unit, 71(11) Sanders Rd., Suite M3, Northbrook, IL
60(162
Allstate Settlement Corporation, c'o Allstate Advanced Funding.. Exchange Unit. 3100 Sanders Rd., Suite :AI•I, Northbrook, IL.
601162
Allstate I ile Insurance Company, c/o Allstate Adts need Fundmt. Esehangc flair, 3100 Sanders Rd., Suite M3, Northbrook. IL
60062
Tyler Michael Conaway. 5 Locust Circle, Mechanicsburg, PA 17050
966973.1
CERTIFICATE OF SERVICE
I hereby certify that on October 22, 2014, I caused a true and correct copy of the Notice
of Hearing and the Initial Order of Court to be served, via certified mail, return receipt requested,
on the following parties:
Tyler Conaway
5 Locust Circle
Mechanicsburg, PA 17050
Allstate Life Insurance Company
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd., Suite M3
Northbrook, IL 60062
Allstate Assignment Company •
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M3
Northbrook, IL 60062
Allstate Settlement Corporation
c/o Allstate Advanced Funding Exchange Unit
3100 Sanders Rd, Suite M4
Northbrook, IL 60062
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L
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: PETITION OF TYLER CONAWAY
AND ALLSTATE SETTLEMENT
CORPORATION FOR
APPROVAL OF TRANSFER OF
STRUCTURED SETTLEMENT
PAYMENT RIGHTS
•
FINAL ORDER OF COURT
NO. 14-6032
On this d day of Ajdo y, , 2014, it is ordered that the Petition of Allstate
Settlement Corporation ("Allstate Settlement") and Tyler Michael Conaway ("Mr. Conaway" or
"payee") for Approval of the Transfer of Structured Settlement Payment Rights, pursuant to 40
P.S. § 4001 et seq., is granted.
The Court specifically finds that:
1. The transfer of the structured settlement proceeds, specifically, one (1) lump sum
payment of $3,500.00 due on November 4, 2015; one (1) lump sum payment of $4,500.00 due
on November 4, 2019; one (1) lump sum payment of $6,400.00 due on November 4, 2022; and
one (1) lump sum payment of $8,000.00 due on November 4, 2024 (the "Transferred Payments")
by Mr. Conaway to Allstate Settlement as described in the petition in this matter (the "Proposed
Transfer") complies with the requirements of the Pennsylvania Structured Settlement Protection
Act, 40 P.S. § 4001 et seq., 26 U.S.C. § 5891,E • • - _ • _ _ - _ . _
2. Based on the certification of counsel for Allstate Settlement, and the Court having
not been made aware of any statute, regulation or order that would be incompatible with the
Proposed Transfer, the Proposed Transfer will not contravene any applicable federal or state
ACTIVE/ 77832802.1
statute or regulation, or the order of any court or administrative authority, or any applicable law
limiting the transfer of workers' compensation claims.
It is hereby ORDERED, ADJUDGED, and DECREED as follows:
1. The Proposed Transfer is approved, and the following payments shall be
transferred to Allstate Settlement: one (1) lump sum payment of $3,500.00 due on November 4,
2015; one (1) lump sum payment of $4,500.00 due on November 4, 2019; one (1) lump sum
payment of $6,400.00 due on November 4, 2022; and one (1) lump sum payment of $8,000.00
due on November 4, 2024. / 11 ". M C fetz
ds;
forward to Mr. Conaway a lump sum payment(s) of no less than $12,908.76, from which no h-)
Far S
2. Within fourteen (14) days of its receipt of this order, Allstate Settlement will
additional funds are owed for counsel fees, administrative fees, or other costs, fees or expenses.
3. The terms of this Order shall survive the death of the payee and shall be binding
on the payee's heirs, beneficiaries and assigns.
4. During the period the structured settlement payment rights are being assigned or
encumbered pursuant to the transaction at issue, the designated beneficiary under annuity
contract no. 90307718 for the Transferred Payments shall be Allstate Settlement.
state Settle
Company's lack of opposition to this matter, or stipulation hereto or complian erewith, shall
not constitute evidence in any other matter, and is not intended t• .nstitute evidence in any
other matter, that
(a) payments und- . structured settlement contract or annuity or related
ntracts can be assi
ACTIVE/ 77832802.1
-2-
pro n structu s or annuities-
contracts
nnuities contracts are not valid and enforceable.;-er
(b) Allstate Settlement, 44tat e Life Insurance Company, or Allstate
Asst gta ent Company has waived any right in connection with any other
6. Mr. Conaway and his heirs, beneficiaries, contingent beneficiaries, administrators,
executors, successors, and assigns, or individuals or entities that may claim through them (the
"Releasors"), hereby remise, release, and forever discharge Allstate Settlement, Allstate Life
Insurance Company, Allstate Assignment Company, and their respective directors, shareholders,
officers, agents, employees, servants, successors, executors, administrators, and assigns, and any
parent, subsidiary, or affiliate thereof, and their directors, shareholders, officers, agents,
employees, servants, successors, executors, administrators, and assigns, past and present (the
"Releasees"), of and from any and all manner of actions and causes of action, suits, debts, dues,
accounts, bonds, covenants, contracts, agreements, judgments, settlements, damages, claims, and
demands whatsoever, in law or in equity, in connection with, related to, or arising out of, any
claim or allegation that was or could have been asserted in connection with, related to, or arising
out of, the Funding Exchange Agreement, the Transferred Payments, which against each other or
the Releasees, the Releasors can, shall, or may have, except for claims to enforce any party's
rights under the Funding Exchange Agreement.
7. This Order shall constitute a "Qualified Order" within the meaning of 26 U.S.C. §
5891.
ACTIVE/ 77832802.1 3
8. This Order constitutes a Final Order of the Court and resolves the last pending
claim and closes the case.
BY THE COURT:
0 bre, A.
eefil4ge ,
k/vcored
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ACTIVE/ 77832802.1 4
Pvk
, JUDGE
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