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HomeMy WebLinkAbout01-0639 111 ~ ~ ~ 1 o ~~ ~ ~ 1 ~ PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of V< ~G4.., L ~qC >" also known as No. 21=01=639 To: Register of Wills for the .,?' County of Ct",.., J,..,-k,.......r in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/are 18 years of age or older, appl for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decendent was domiciled at death in C,-- hp'- J...J County, Pennsylvania, with h " ~ last family or principal residence at -:>;:- tfl-J D,.. '...,-, >J...r~c:: 6."'-$ P,A. I ::>~.s 7 (list street, number and municipality) Decendent at death owned property with estimated values as folllows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: ,....1-9::: c~,y C".o- k... $ 0 $ /'-"//9 $ /Y/A $ /""/.a . Petitioner_ after a proper search ha.s:..-- ascertained that decedent left no will and was survived by the following spouse (if any) and heirs: Name Relationship Residence 1,& ,. it THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. ,....., ~ <IJ ~ ~ (L~ ~~ '" '-' <IJ .... p::~ ",,0 co,;,: ~.+:: 3tt "''- 50 ~ I': Of) iJ3 OATH OF PERSONAL REPRESENTATIVE COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND } ss The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law. swo.rn to. .. or affirmed and subscribed f 1: ~ before me this 5th day of JULY ~~ 2001 ry/'l.(2~--f'<'./AL/~<fY .. Register E ~~ ...... en '-' Q) ..... ;::l ..... tU s::: l:lIl V5 N 21-01-639 o. Estate of Rajahn L Bass , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW JULY 6 n:200 1 ,in consideration of the petition on the reverse side hereof, satisfactory proof having been presented before me, IT IS DECREED that TRACIE A MONTAGUE is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration are hereby granted to TRACIE A MONTAGUE in the estate of ~<;r'~ ~<<...~u/h"l" / 4<<-:.y RegIster 0 WIlls FEES Letters of Administration $ Short Certificates( ) 0 . 0 . . . 0 . o. $ Renunciation .. 0 . 0 . . . . . . . . . o. $ PETITION $ JCP TOTAL _ $ Filed. -.JUI:.Y. oj,. 0200100... A.D. 18.00 15.00 ATTORNEY (Sup. Ct. I.D. No.) 1~.00 .uO 19 )::5.UO ADDRESS PHONE IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT IN RE: RAJAHNL. BASS No. DATE OF DEATH: AUGUST 26, 2000 : PETITION TO OPEN ESTATE AND APPOINT ADMINISTRATOR AND NOW, comes Aaliyah Kiana Montague-Bass, by and through her natural mother, Tracie A. Montague and petitions the Court as follows: 1. Rajahn L. Bass was an adult individual born on April 13, 1974, with a social security number of 146-64-3474. 2. On August 26,2000, Rajahn L. Bass perished in Carbon County, Pennsylvania. (A true and correct copy of the death certificate ofRajahn L. Bass is attached and incorporated as if set forth at length as Exhibit "A"). 3. At the time of his death, Rajahn L. Bass' mailing address was 56 Bard Drive, Shippensburg, Pennsylvania, 17257, in Cumberland County, Pennsylvania. 4. Rajahn L. Bass did not leave a will. 5. At the time of his death, Rajahn L. Bass was not married. 6. Rajahn L. Bass was survived by his minor child, his sole beneficiary, Aaliyah Kiana Montague-Bass. 7. Petitioner, Tracie A. Montague, is the natural mother of Aaliyah Kiana Montague-Bass. 8. Rajahn L. Bass' estate consists of, inter alia, the possibility of a personal injury action. 9. The only individual entitled to receive any proceeds from the estate is Rajahn L. Bass' minor child, Aaliyah Kiana Montague-Bass. 10. In Northampton County, pursuant to an Order of Court dated October 12,2000, in Court File Number 2000-1189, natural mother/petitioner Tracie A. Montague as well as her mother (Aaliyah Kiana Montague-Bass' grandmother), Barbara L. Montague, were appointed co-guardians of the Estate of Aaliyah Kiana Montague-Bass and were authorized to collect insurance proceeds. (A true and correct copy of the Order of Court and Petition are attached and incorporated as if set forth at length as Exhibit "B"). 11. Rajahn L. Bass was also survived by his parents, Jerry Bass and Diane Bass/Carrington. 12. Jerry Bass, natural father of Rajahn L. Bass, has signed a renunciation form. ( A true and correct copy of the renunciation form is attached and incorporated as if set forth at length as Exhibit "C"). 13. Several attempts have been made to discuss this matter with natural mother, Diane Bass/Ca.rrington. Counsel for the petitioner has forwarded correspondence to Diane Bass/Carrington dated December 6, 2000; December 19, 2000; January 11,2001, as well as March 7, 2001. In addition, counsel for petitioner has spoken with Diane Bass/Carrington who has indicated she does not oppose the signing of such a renunciation form, however, she has not signed such a form. 14. Pursuant to 20 Pa.C.S.A. ~ 3155(b) as there is no will and as Rajahn L. Bass did not have a surviving spouse, ~ 3155(b)(I) and (2) do not apply. 15. Pursuant to 20 Pa.C.S.A. ~ 2103, Aaliyah Kiana Montague-Bass is entitled under the intestate law to recover under the estate. 15. Aaliyah Kiana Montague-Bass is the sole beneficiary under the Estate of Rajahn L. Bass under the intestate laws of Pennsylvania. 16. Aaliyah Kiana Montague-Bass is a minor. It is necessary that an administrator be appointed during the minority of Rajahn L. Bass' sole heir so that Rajahn L. Bass' assets can be conserved and the estate can be administered in accordance with law. 17. Petitioner, Tracie A. Montague, is the natural mother and primary physical custodian of Aaliyah Kiana Montague-Bass. Under 33 1 55(b)(5), Tracie Montague would be an appropriate individual to be granted Letters of Administration. WHEREFORE, Petitioner respectfully requests that Tracie A. Montague be granted Letters of Administration to administer the assets ofRajahn L. Bass, deceased, in Pennsylvania. c:'CU~AGUEJII2'CT.DOC'CUM8EIU.A.PET VERIFICATION The undersigned hereby states that the statements of fact made in the foregoing document are true and correct to the best of my information and belief. The language of the document was prepared on the advice of my attorney and any legal claims or legal defenses asserted in the document, are pleaded on the advice of my attorney. If the document contains averments which are inconsistent in fact, then I have been unable after reasonable investigation to ascertain which of the inconsistent averments are true, but to the best of my information and belief, one of them is true. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S.A. ~4904 relating to unsworn falsification to authorities. ~~4!-~ Tracie A. Montague Date: - . ~,,,v'y. June 29. 1953. - -- ---- ... .""\..u~uan WARNING: It Is Illegal to duplicate thl. copy by photostat or photograph. ~""'S~ ....- -'r. Robert S.' erman, Jr., MPH Secretary of Health 1172516 No. ~II~ Charles Hardester State Registrar SEP 14 2000 Date .101.,"_. .... aJU&C'l'ID InKS: 3 nil: rD DAn:9-14-00~Of'HHNSYUIUM. DEPMTMEln'OI'HEAL1'H. Y1TAlMCOflOS CERTIFICATE OF DEATH (CcNorw) -...- - 146 '" 3474 - -.........-.. ..-..~...... " -.- .... 1 0.,._ _Ill ..0 -. :-...."'i.-~-=l=~~ e In ~ ~ flit 11 ANDCIIIfI'YIIII.................. ....,.,....,..,....................._.... ...-....---....---.......................--.-......................... ~ I. -.i&.1V__ . o. .....-..--........-.......-...--.....-.-.-......--..........- .................. ...... ... ...... .................... ...................... .... ... ...... ............ .............................. ....... ... .... - ------ I "'8i4~~ I -.....- ... Exhibit "A" IN THE COURT OF COMMON PLEAS OF NORTHAMPTON COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 2000- 'Itq IN RE: AALIY AH KIANA MONTAGUE-BASS GUARDIANSHIP PROCEEDINGS ) ) ) ORDER OF COURT AND NOW, this Iv(. day of October, 2000, upon consideration of the attached Petition, and after consultation with Karl H. Kline, counsel for Petitioners, it is ordered as follows: I. Tracie A. Montague and Barbara L. Montague are appointed Co-Guardians of the Estate of Aaliyah Kiana Montague-Bass pursuant to 20 Pa. C.S.A. ~5111 et seq. 2. The Co-Guardians are authorized to collect the insurance proceeds from Met Life Insurance Co. for Aaliyah Kiana Montague-Bass, and any other funds to which Aaliyah Kiana Montague-Bass is entitled. 3. In lieu of posting a bond, Co-Guardians are authorized to deposit funds of Aaliyah Kiana Montague-Bass in insured accounts, including certificates of deposit, with state or national banks, the accounts to be marked "Principal not to be withdrawn, except by order of the Court, until Aaliyah Kiana Montague-Bass reaches age 21". ....... \ 1 ..1,... , .;;~...~....:: ~-~.-", " !c'rJa; , . " .l~ _ 1/; -!"" l"'i' ~ ; , ':",;~-. ,I /'/ ,-- .... ..s<' I " &.. It I ;:~/ '.~' , .t/', '\ ! vi- I ~ '\ ~-. ..... 1 - . J" " - , " '" - .;.;,;: ") ~ .' ~./ f"" ~,-." '''~-I ~~- .~ t;-;, ',t... _'. /.-j' 4;.,,_ i:..!, .', "';"-;;:',.., ...> I .,'>'+, .. I ~ .' ... ,.>0._ . ..~~:. :'i.> j":.:,.'.~~-~,r";':.~~:J ~: f'C~ 'j~ ~ . ) "'".....,. ----:5-,. ';;,~ , . <, :_:,t$~_.~'~'~" .:..~'..' -.....~~.:- ~~ \ ,),',:)~-...kt .", "',5\;";,\i'V,,,:\' . .. ,/ t - ...:?. 'J'.., ._:'U" " J. Exhibit "B" IN THE COURT OF COMMON PLEAS OF NORTHAMPTON COUNTY, PENNSYL YANIA ORPHANS' COURT DIVISION IN RE: AALIY AH KIANA MONTAGUE-BASS GUARDIANSHIP PROCEEDINGS NO. 2000- 1/69 ) ). ) PETITION FOR APPOINTMENT OF GUARDIANS FOR THE ESTATE OF A MINOR Pursuant to 20 Pa. C.S.A. ~5111 et seq., Tracie A. Montague and Barbara L.. Montague, mother and grandmother, respectively of Aaliyah Kiana Montague-Bass, a minor, petition the Court to enter an order appointing them as guardians of the estate of Aaliyah Kiana Montague- Bass, and in support thereof aver the following: 1. Petitioner, Tracie A. Montague, is an adult individual residing at 700 Wolf A venue, Apartment 1 E, Easton, Pennsylvania, 18042. Tracie A. Montague is the parent and natural guardian of Aaliyah Kiana Montague-Bass. 2. Petitioner, Barbara L. Montague, is an adult individual residing at 2101 Birch Street, Easton, Pennsylvania, 18042. Barbara L. Montague is the mother of Tracie A. Montague and the grandmother of Aaliyah Kiana Montague-Bass. 3. Aaliyah Kiana Montague-Bass is a minor whose date of birth is June 12, 1996. She resides with her mother, Tracie A. Montague, and has resided with her mother, Tracie A. Montague, since birth. 4. Aaliyah Kiana Montague-Bass's father was Rajahn L. Bass. 5. Rajalm L. Bass was killed in a motorcycle accident on August 26, 2000. 6. AaIiyah Kiana Montague-Bass is a beneficiary under Rajahn L Bass's life insurance policy with Met Life Insurance Co., and is possibly entitled to additional funds from Mr. Bass's employer and otherwise. The Met Life Insurance Co. proceeds are approximately $40,000.00, after deduction of payment for the funeral bill. 7. Petitioners seek appointment as Co-Guardians of the estate of Aaliyah Kiana Montague-Bass so that ~ey can receive the insurance pros=eeds and such other funds to which Aaliyah Kiana MontagUe-Bass is entitled and hold them in a fiduciary capacity for the minor until the minor reaches the age of majority. 8. Petitioners request that the Court waive the requirement of posting bond. 9. Petitioners agree and aver that, as Co-Guardians of the estate of Aaliyah Kiana Montague-Bass, all investments will be in accordance with 20 Pa. C.S.A. ~5I45 and Chapter 73 of the Probate, Estates and Fiduciaries Code. WHEREFORE, Petitioners request this Court to enter an Order: 1. Appointing Tracie A. Montague and Barbara L. Montague as Co-Guardians of the Estate of Aaliyah Kiana Montague-Bass pursuant to the terms and conditions of 20 Pa. C.S.A. ~5IIl et seq.; 2. Authorizing the Co-Guardians to collect the insurance proceeds for Aaliyah Kiana Montague-Bass from Met Life Insurance Co. and any other funds to which Aaliyah Kiana Montague-Bass is entitled; 3. Providing that, in lieu of posting a bond, Co-Guardians are authorized to deposit funds of Aaliyah Kiana Montague-Bass in insured accounts, including certificates of deposit, with state or national banks, the accounts to be marked "Principal not to be withdrawn, except by order of the Court, until Aaliyah Kiana Montague-Bass reaches age 21"; and 4. Granting such other relief as the Court deems just and proper. Respectfully submitted, KARL KLINE, P.C. By ~~~ Attorney J.D. #23321 2925 William Penn Highway Suite 301 Easton, PA 18045-5283 Phone: 610-559-8668 Attorney for Petitioners VERIFICATION Tracie A. Montague deposes and says that she is duly authorized to make this verification; and that the facts set forth in the foregoing Petition are true and correct to the best of her knowledge, information and belief. This verification is made subject to the penalties of 18 Pa. C.S.A. ~904 relating to unsworn falsification to authorities. Dated: ID/ID/DD # . .~a~ Tracie A. Montague ~ CERTIFCATION OF NOTICE UNDER RULE 5.6(A) Name of Decedent: Raiahn L. Bass Date of Death: August 26, 2000 Will No.: 2001-00639 Admin No.: To the Register: I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on October 10. 2001 Nam~ Address Aaliyah Kiana Bass Montague c/o Tracie A. Montague 700 Wolf Avenue. Apt. 1E. Easton. PA 18042 Notice has now been given to all persons entitled thereto under Rule 5.6(a) except N/A~ Signature Date: October 10, 2001 Steven N. Goudsouzian. Esquire Name 2925 William Penn Highway Suite 301 Easton, PA 18045-5283 Address 610-253-9171 Telephone Capacity: D Personal Representative ~ Counsel for personal representative -, IN RE: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF RAJAHN L. BASS 01-00639 ORPHAN'S COURT IN RE: PETITION FOR COURT APPROVAL OF SETTLEMENT OF ESTATE'S CLAIMS ORDER OF COURT AND NOW, May 2,2002, hearing on the Petition for Court Approval of Settlement of Estate's Claims is set for Monday, June 10, 2002, at 2:30 p.m. in Courtroom 3 of the Cumberland County Courthouse; counsel to notify all interested parties. By the Court, Steven N. Goudsouzian, Esquire 2925 William Penn Highway, Ste. 301 Easton, P A 18045-5283 For the Administrator ~: )~') .~. ':.~-' L:: Z: [- ZOo PROGRESSIVE 5053 Ritter Road, Suite 101 Mechanicsburg. PA 17055 Telephone: BOO 274-4499 Facsimile: 717697-6711 February 5, 2002 progressive. com STEVEN GOUDSOUZIAN, ESQ. 2925 WILLIAM PENN HWY, STE 301 EASTON, PA 18045-5283 VIA FACSIMILE 610-559-9281 Insured Claim No. Claimant DOL Rajahn Bass 016965010 Estate of Rajahn Bass 8/26/00 Dear Goudsouzian: Please be advised that Progressive Northern Insurance Company agrees to waive it's right of subrogation and consents to the settlement of $100,000 with the tort feasors insurance carrier. I am awaiting management review of the liability issues and will then be in touch with you to advise our position on settlement of the excess underinsured motorist claim you have presented against our insured's policy. Please do not hesitate to contact me if there is anything further you would like to discuss now. Progressive Northern Ins. Co., /) / lkt rdila~ Patricia F. Faller Senior Claims Representative (717)791-5141 rr ENCOMPASS.. INSURANCE Formerly known as CNA Personal Insurance encompassinsurance.com May 9,2002 Jeffrey Miller AIC LPCS Claims Representative Telephone (610) 320-4390 (800) 936-4203 x4390 Facsimile (800) 936-4202 Internet jeffreyscott.miller@encompassins.com P.O. Box 16203, Reading, PA 19612 A TIORNEY STEVEN GOUDSOUZIAN 2925 WILLIAM PENN HIGHWAY SUITE 301 EASTON, PA 18045-5283 Our Claim Number: R1228105 HE Your Client: Rajahn Bass Estate Date of Loss: 08/27/2000 Our Insured: Denise And Leonard Evans Insuring Company: Continental Ins Co Dear Steven: Per your request of May 7, 2002, we have no objection to the Petition for Court Approval of Settlement of the Estate of Rajahn Bass. Sincerely, Jeffrey :Miffer }lIe Lq>(;S SF AIEl FIRARCIAl ASSOCIATES ~ June 6, 2002 Steven N. Goudsouzian, Esquire 2925 William Penn Highway Suite 301 Easton, PA 18045-5283 Re: On Behalf of Rajahn L. Bass Your File No.: 2000-082 Our File No.: 01-07-8427 Dear Mr. Goudsouzian: In follow-up to our conversation this afternoon, please find enclosed copies of the Settlement Agreement and Unifonn Qualified Assignment and Release. which have been signed on behalf of Encompass Insurance. Once the court order has been issued, please send us a copy so we can proceed with implementing the structured settlement annuity. Thank you for your assistance in completing this matter. Very truly yours, STRUCTURED FINANCIAL ASSOCIATES, INC. By: / tK.n ~0rf Trish Swigart :pgs(bass) Enclosures Structured Financial Associates, Inc. Philadelphia Office I Chester County Commons I 8 Mystic Lane. I P.O. Box 880 I Frazer. PA 19355 1_- ____~___ - I JEFFREY F. SWIGART, J.D. VICe President DONALD B. SUSS, J.D. VICe President WARREN J. ADAIR, J.D. SetlIement Specialist JOHN J. LUKE, Jr. Setllement Specialist OFFICES: Anchorage AUanIa BaIlmore BatDn Rouge Boston CharIesIDn Chicago CIeYeIand 0alIas Denver Delrcit Grand Rapids H0n0IuIu Houslon Los~ Mami New York Oklahoma City Orlando ~ Phoenix Pittsburgh Roanoke Roddord Sl Pa\j San Francisco SeaUIe Topeka Tulsa Washington, D.C. " "t ., I, ~ SETTLEMENT AGREEMENT This Settlement Agreement is entered into between Releasor, Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague, and Continental Insurance Company (hereinafter sometimes called the "Obligor") as liability insurer of Releasee, Denise Evans. RECITALS A. On or about August 26, 2000, Releasor, Aaliyah Kiana Montague-Bass, a minor, sustained personal injuries as a result of a vehicular accident at or near Kidder Township, State of Pennsylvania (hereinafter called "the Incident") which resulted in the wrongful death of Rajahn L. Bass. Releasee, Denise Evans, is insured by Continental Insurance Company and claim number US219185267 has been assigned. B. The parties desire to enter into a settlement in order to provide for certain payments in full settlement and discharge of all claims which are the subject of the Incident and/or Complaint on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as follows: 1. Full Release ofLicrbility. In consideration of the payments provided for herein, Releasor hereby releases and forever discharges the Releasee, Denise Evans, and the liability insurer, Continental Insurance Company, and their past, present and future officers, directors, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest and assigns, of and from any and all past, present or future claims, demands, obligations, actions, causes of action, wrongful death claims, claims for loss of services, comfort and society, rights, damages, costs, expenses and compensation of any nature whatsoever, which the Releasor now has, or which may hereafter accrue or otherwise be acquired, on account of, or in any way growing out of, or which are the subject of, the Incident and/or Complaint, including, without limitation, any and all known or Unknown claims for personal injuries to the Releasor, and the consequences thereof, which have resulted or may result from the alleged negligent acts or omissions of the Releasee. As a condition of this settlement, Releasor waives any rights. to punitive damages. This release and discharge shall be a fully binding and complete settlement as to the parties to this Agreement and all parties represented by or claiming through such parties, except only the executory provisions of this Agreement. Releasor understands that injuries may have been suffered that are unknown at present and that unknown complications may arise in the future. Releasor acknowledges that the sums paid in consideration of this Agreement are intended to and do release and discharge any claims in regard to such unknown or future complications. a:\ Bass.SA - 1 - 04/25/2002 . . r '~ 2. Payments. Obligor hereby agrees to make payment of the following amounts: (a) Periodic Payments: For the benefit of Aaliyah Kaina Montague-Bass, to be paid as the Court directs, or upon reaching the age of majority, to Aaliyah Kiana Montague- Bass, i) $2,405 annually for 8 years, guaranteed, beginning August I, 2002, increasing at a rate of 2%, compounded annually; ii) $4,220 annually for 4 years, guaranteed, beginning August 1,2010, increasing at a rate of 2% compounded annually; and iii) $20,000 annually for.4 years, guaranteed, beginning August 24,2014. (b) Forthwith Payments: To Releasor, Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague, and her attorney, the Law Firm of Steven N. Gondsouzian, jointly, the sum of $40,000.00, to be disbursed as the Court directs. All payments set forth above constitute damages on account of personal injuries or sickness arising under the Complaint or as a result of the Incident, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. 3. Ri~t of Original Obli~or to Substitute Designated New Obligor. It is understood and agreed by and between the parties hereto that Releasee or Obligor may, as a matter of right, and in Releasee or Obligor's sole discretion, assign the duties and obligations as set forth herein with respect to the periodic payments to Releasor, to Allstate Assignment Company and that such assignment, if made, shall be accepted by the Releasor without right of rejection and in full discharge and release of the duties and obligations of the Obligor. In the event of such an assignment of the duties and obligations of the Obligor as authorized above, the payments and rights of the parties shall conform to Section 130 of the Internal Revenue Code. If an assignment is made, the Obligor shall.be released from all such future obligations and the assignee shall at all times remain directly and solely responsible for the payment of all such sums and obligations. 4. Purchase of Assets(s) to Fund Periodic Payments. To assure the ready availability to the Obligor or an assignee, should an assignment. be made pursuant to paragraph 3 hereof, of Periodic Payments payable under paragraph 2 of this Agreement, the Obligor or an assignee, should an assignment be made, may, promptly upon the execution of this Agreement, purchase an annuity from Allstate Life Insurance Company as sole owner. Releasor acknowledges that the periodic payments cannot be accelerated, deferred, increased, or decreased by the Releasor or any Payee; nor shall the Releasor or any Payee have the power to sell, mortgage, encumber, or anticipate a:\ Bass.SA -2- 04/25/2002 the periodic payments, or any part thereof, by assignment or otherwise. As a matter of convenience, Releasor may be designated as a payee and Releasor's estate designated as a beneficiary in applying for the aforesaid annuity. Any payments to be made after the death of the Payee pursuant to the terms of this Settlement Agreement shall be made to such person or entity as shall be designated in writing by said Releasor to the Assignee. If no such person or entity is so designated by said Releasor or if the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. The obligation of the Obligor, or of an assignee should an assignment be made, to make each periodic payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee named in this Agreement. It shall be the obligation of said Releasor to keep Assignee advised of the address to which payments are to be tendered. Any change of address shall be supplied in writing at least thirty (30) days prior to the due date of any payment date. 5. Release of All Liens. In consideration of the payments provided for herein, the Releasor hereby releases and forever discharges the Obligor, Releasee, and their past, present, and future officers, directors, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, assigns, and all other persons, firms, or corporations, of and from any and all liens and/or expenses incurred as a result of, and reasonably related to the above-referenced Complaint and/or Incident. 6. Final Compromise; No Admissions. The Releasor agrees and acknowledges payment of the sums specified in this Agreement are accepted as a full and complete compromise of matters involving disputed issues; thai neither payment of the sums nor the negotiations for this settlement (including all statements, admissions or communications) by the parties and their attorneys or representatives, shall be considered admissions; and that no past or present wrongdoing on their part shall be implied by such payment or negotiations. 7. Integration Clause. This Agreement contains the entire agreement of the parties with regard to the matter set forth in it and shall be binding upon and inure to the benefit of the parties hereto, jointly and severally, and the executors, administrators, personal. representatives, heirs and successors of each. 8. Jurisdiction. This Agreement is entered into in the State of Pennsylvania and shall be construed and interpreted in accordance with its laws. 9. Advice of Attorneys. In entering into this Settlement Agreement, the Releasor represents that Releasor has relied upon the advice of attorneys, who are attorneys of Releasor's own choice, and that they have completely read and explained the terms of this Agreement and that Releasor fully understands and voluntarily accepts these terms. a:\ Bass.SA -3- 04/25/2002 10. Tax Disclaimer. It is understood, between the parties that the Releasor and/or Releasor's attorney did not rely upon any representations, express or implied, made by Obligor and/or Releasee or any of their representatives, as to the tax consequences of this Agreement and that Releasor releases Obligor and Releasee from any and all liability in connection with any such tax consequences. 11. Indemnity Agreement. Further, in consideration of the payments provided herein, Releasor agrees to indemnify and hold Obligor and Releasee harmless from all future claims, demands or actions that may hereafter at any time be made or brought against them or either of them by Releasor, or anyone on whose behalf Releasor enters into this Agreement, for the purpose of enforcing a further claim for damages on account of any injury or damage sustained in or arising from the Incident. 12. COQperation of Parties. All parties agree to cooperate fully and to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the basic terms and intent of this Agreement, and which are not inconsistent with its terms. 13; . Confidentiality. Releasor, Releasee and their attorneys agree that they, and each of them, will not disclose . to any person not a party to the action described herein, including but not limited to, members of the press and media, government agencies or elective representatives, absent subpoena or applicable statutory provisions, or any other third parties, confidential reports for attorneys, either orally or in writing, the terms and/or conditions of this settlement and/or the dismissal or the amounts thereof. Releasor and Releasor's attorneys and each of them agree to take such steps as are necessary to assure their compliance therewith. Releasor and Releasor's attorneys, and each of them, also agree that this portion of this Agreement shall support an Order of any Court of general jurisdiction which shall include the above prohibition of disclosure of the terms of the settlement and violation of this provision shall subject violator(s) to civil fines and penalties according to proof. 14. Court Approval. This Settlement is subject to court approval and shall become effective (notwithstanding the date of execution hereof) upon such approval. This Agreement is effective as of ~ tf2. Releasor, Aaliyah Kiana Montague S, a minor, by and through her parent and natural guardian, Tracie Montague a:\ Bass.SA -4- 04125/2002 , ' " " Ste N. Gondsouzian, Esq., Counsel for Releasor Continental Insurance Company as liability insurer of Releasee, Denise Evans a:\ Bass.SA -5- 04/25/2002 Uniform Qualified Assignment and Release "Claimant" Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague "Assignor" Continental Insurance Company as liability insurer of Releasee, Denise Evans "Assignee" Allstate Assignment Company "Annuity Issuer" "Effective Date" Allstate Life Insurance Company 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 executed a settlement agreement or release dated ,20_ (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 payments 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. 5. This Agreement shall be governed by and interpreted in accordance with the laws of the State of Pennsylvania. 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 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. Assignor: Continental Insurance Company as liability insurer of Releasee, Denise Evans By: Title: J{ff' M~t(S C\~.~ ~i"l(~Y \ Claimant: Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague ~az.~ :p~edasro~~ /'" Claimant's Attorney 11. The Claimant hereby accepts Assignee's assumption of all liability for the Periodic Payments and hereby releases the Assignor from all liability for the Periodic Payments. Assignee: Allstate Assignment Company By: Authorized Representative Tit/e: NSST A National Structured Settlements Trade Association Initials Claimant: Assignor: Assi2nee: Addendum No. 1 Description of Periodic Payments Periodic Payments: For the benefit of Aaliyah Kaina Montague-Bass, to be paid as the Court directs, or upon reaching the age of majority, to Aaliyah Kiana Montague-Bass, i) $2,405 annually for 8 years, guaranteed, beginning August 1, 2002, increasing at a rate of 2%, compounded annually; ii) $4,220 annually for 4 years, guaranteed, beginning August 1, 2010, increasing at a rate of 2% compounded annually; and iii) $20,000 annually for 4 years, guaranteed, beginning August 24, 2014. ~ ~ ..-- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT IN RE: RAJAHN L. BASS No. 2001-00639 DATE OF DEATH: AUGUST 26, 2000 : AFFIDAVIT OF SERVICE I, Steven N. Goudsouzian, attorney for the estate, hereby certify that on or about November 5,2001, I received the attached Proof of Publication Notice from The Patriot News indicating that Notice of the above estate was published on October 22, October 29 and November 5, 2001. (Proof of Publication is attached hereto, marked Exhibit "A," and made apart hereof.) I further certify that on or about November 9,2001, I received the attached Proof of Publication Notice from The Cumberland Law Journal indicating that Notice of the above estate was published on October 26, November 2 and November 9,2001. (Proof of Publication is attached hereto, marked Exhibit "B," and made apart hereof.) teven N. Goudsouzian, Esquire J.D. # 74831 2925 William Penn Highway Suite 30 I Easton, PA 18045-5283 (610) 253-9171 Date: June 10,2002 F:\Clienls'VOOO\KK\MONT AGU E.082\CT. [)()(:\(:eniticllte.service. wpd ;-~) CLASSIFIED ADVERTISING INVOICE Questions regarding this invoice call (717) 255-8138 ~t ~t~ttu~ BILLING DATE /11'05'01 I To Place your ad Call Classified (717) 255-8121 Tearsheet Request call (717) 255-8417 ~ Exhibit "A" THE PATRIOT NEWS THE SUNDAY PATRIOT NEWS Proof of Publication Under Act No. 587, Approved May 16,1929 Commonwealth of Pennsylvania, County of Dauphin} ss Michael Morrow being duly sworn according to law, deposes and says: That he is the Asst. Controller of The Patriot News Co., a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal office and place of business at 812 to 818 Market Street, in the City of Harrisburg, County of Dauphin, State of Pennsylvania, owner and publisher of The Patriot-News and The Sunday Patriot-News newspapers of general circulation, printed and published at 812 to 818 Market Street, in the City, County and State aforesaid; that The Patriot-News and The Sunday Patriot-News were established March 4th, 1854, and September 18th, 1949, respectively, and all have been continuously published ever since; That the printed notice or publication which is securely attached hereto is exactly as printed and published in their regular daily and/or Sunday/ Metro editions which appeared on the 22nd and 29th day(s) of October and the 5th day(s) of November 2001. That neither he nor said Company is interested in the subject matter of said printed notice or advertising, and that all of the allegations of this statement as to the time, place and character of publication are true; and That he has personal knowledge of the facts aforesaid and is duly authorized and empowered to verify this statement on behalf of The Patriot-News Co. aforesaid by virtue and pursuant to a resolution unanimously passed and adopted severally by the stockholders and board of directors of th said Company and subsequently duly recorded in the office for the Recording of Deeds in and for said County 0 D phin in Miscellaneous Book "M", Volume 14, Page 317. I PUBLICA TION COpy ribed efor m Notarial Sear Terry l. Russen, Notary p IC Harrtsb~rg. Dauphin County My CommissIon Expires June 6.2002 NO AR PUBLIC Member, Pennsylvania Association Of NotariMv commission expires June 6, 2002 Estate Notices ESTATE OF RAJAHN L. BASS. LATE OF SHIP!?ENSBURG BOROUGH. COUNTY OF CUMBERL;AND. AND STAlE OF PENN- SYLVANIA, DECEASEQ.; ,., WHEj~EAS. Letters Test!lm1mt!lrv In the !Ibo\le,.n(imed estate haV"l)eell'lIranted to TRACIE A. MONrAGU"E, El\~utrll\ of the Estate (If RAJAHN L. B~~, All, persons In- debted to the said esta~are r~sted to make Immediate paYment. and-thOSe having claims or demands to present the same with- out delav to: " ( steven N. GoUdSOUZla.n.I;SllUlre ' 2925 william penn Hlg~V h SUite 301 r Easton, PA 18045-5283 Attorney for the Estate . STEVEN N. GOUDSOUZIAN ATTORNEY-AT-LAW 2925 WILLIAM PENN HIGHWAY EASTON, PA. 18045 Statement of Advertising Costs To THE PATRIOT-NEWS CO., Dr. For publishing the notice or publication attached hereto on the above stated dates $ Probating same Notary Fee(s) $ Total $ 232.50 1.50 234.00 Publisher's Receipt for Advertising Cost The Patriot News Co., publisher of The Patriot-News and The Sunday Patriot-News, newspapers of general circulation, hereby acknowledge receipt of the aforesaid notice and publication costs and certifies that the same have been duly paid. By............................................................... ..... CUMBERLAND LAW JOURNAL 2 LIBERTY AVENUE CARLISLE, P A 17013 NOVEMBER 9, 2001 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Steven N. Gouldsouzian, ESQUIRE Rajahn L. Bass, ESTATE RE: Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. Advertisement inserted on following dates: OCTOBER 26, NOVEMBER 2, 9, 2001 Total Amount Due $ 75.00 $ 0.00 $ 0.00 $ 0.00 ------------- $ 75.00 ---- ----- Advertising Cost Proof of Publication Second Proof Request Payment received Payment received by Exhibit "B" PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 STATE OF PENNSYLVANIA : SSe COUNTY OF CUMBERLAND : Roger M. Morgenthal, Esquire, Editor ofthe Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, V1Z: October 26, November 2,9,2001 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. R~ror Bass, Rajahn L., dec'd. Late of Shippensburg Borough. Executrix: Tracie A. Montague. Attorney: Steven N. Goudsouzian. Esquire. 2925 William Penn High- way. Suite 301. Easton. PA 18045-5283. SWORN TO AND SUBSCRIBED before me this 9 day of NOVEMBER. 2001 NOTARfALSEAl LOIS E. SNYDER, NoW'y PI.Ibllc Cat1lslG Sem, Q.mlOOl1and County My Commiasiori &pna Marth 5, 2005 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHAN'S COURT IN RE: RAJAHN L. BASS No. 2001-00639 DATE OF DEATH: AUGUST 26, 2000: AND NOW, this J 0 , 2002, upon consideration of the attached petition, it is hereby ORDERED and DECREED that Petitioner, Tracie A. Montague, as Administrator of the Estate, on behalf of the Estate of Rajahn Bass, is hereby granted leave of court and is authorized as follows: 1. To settle the claims against the third party and the vehicle operated by Rajahn L. Bass for the policy limits in the gross sum of one hundred and fifteen thousand ($115,000.00) dollars; 2. To sign the releases and agreements set forth as Exhibits "B" and "C" to the within petition to effectuate the settlement of the above claims; To make payment ~f attorneys' fees to Attorney Steven N. Goudsouzian in -+~+\ TUI..... ~~ the amount of.thi]lr eight thousand, ~ hundred and tki", Mu~e ~3~} dollars in accordance with Exhibit "A>> to the PetitiOn) j- ~ GfJk- ~ 'j..'f,1 S1J "'- r<<dM~ IPJ.. 1 ~10. 3. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHAN'S COURT IN RE: RAJAHN L. BASS No. 2001-00639 DATE OF DEATH: AUGUST 26, 2000 : PETITION FOR COURT APPROVAL OF SETTLEMENT OF ESTATE'S CLAIMS AND NOW, comes Tracie A. Montague, Administrator of the Estate of Rajahn L. Bass and petitions the Court as follows: 1. Rajahn L. Bass was an adult individual born on April 13, 1974, with a social security number of 146-64-3474. 2. On August 26, 2000, Rajahn L. Bass perished in Carbon County, Pennsylvania in a motor vehicle accident. 3. At the time of his death, Rajahn L. Bass' mailing address was 56 Bard Drive, Shippensburg, Pennsylvania, 17257, in Cumberland County, Pennsylvania. 4. Rajahn L. Bass did not leave a will. 5. At the time of his death, Rajahn L. Bass was not married. 6. Rajahn L. Bass was survived by his minor child, his sole beneficiary, Aaliyah Kiana Montague-Bass (date of birth June 12, 1996) who resides with her mother at 700 Wolf Avenue, Apt. IE, Easton, Northampton County, Pennsylvania 18042. 7. Petitioner, Tracie A. Montague, is the natural mother of Aaliyah Kiana Montague- Bass. 8. The only individual entitled to receive any proceeds from the estate, both through a survival action and/or a wrongful death action is Rajahn L. Bass' minor child, Aaliyah Kiana Montague-Bass. 9. On July 6, 2001 Letters of Administration were granted to Tracie A. Montague. 10. The Petitioner retained the undersigned counsel on the behalf of her child as well as on behalf of the estate pursuant to the fee agreement attached as Exhibit "A". 11. Rajahn L. Bass perished in a motor vehicle accident. He was riding another individual's motorcycle when the motorcycle and another vehicle struck. There are three potential claims ( a) The Third party vehicle; (b) The vehicle Rajahn Bass was operating; and @ Rajahn Bass's motor vehicle policy. 12. As of this date, no action has been filed. 13. The undersigned counsel has negotiated a settlement with the third party carrier for the policy limits of one hundred thousand ($100,000.00) dollars. Specifically, forty thousand ($40,000) dollars will be paid in a lump sum and the remaining sixty thousand ($60,000) will be paid over time. The letter and the agreements setting forth the terms of the settlement are outlined in the settlement agreement attached as Exhibit "B" to the within petition. 14. The undersigned counsel has negotiated a under insurance settlement with the carrier for the owner of the vehicle Rajahn Bass was driving for the policy limits of fifteen thousand ($15,000.00) dollars. A true and correct copy of the correpsondence outlining the settlement and the release are attached collectively as Exhibit "C" to the within petition. 15. Both carriers have provided the undersigned counsel with affidavits of no further insurance. In addition, undersigned counsel has obtained authority from the remaining underinsured carrier to settle the first underinsured claim. 16. Presently, the undersigned counsel is attempting to negotiate the under insurance settlement with the carrier for Rajahn Bass's insurance policy. 17. Petitioner requests that this Honorable Court permit Petitioner to accept the settlements set forth above and sign the releases and agreeements attached as exhibits to this Petition. 18. Petitioner has retained undersigned counsel to investigate the case, interview witnesses, and take appropriate stempts to prosecute the survival and wrongful death actions. Petitioner and counsel recommend the accepting of the proposed settlements for the policy limits of the respective insurance policies. WHEREFORE, Petitioner respectfully requests this Honorable Court permit Petitioner to settle the third party carrier claim as well as the underinsured claim for the vehicle that Rajahn Bass was driving for the policy limits as set forth above and to permit Petitioner to sign the appropriate releases and pay all relevant costs and attorney's fees. Steven N. Goudsouzian, Esq. I.D. No. 74831 2925 William Penn Highway Suite 301 Easton, PA 18045-5283 (610)253-9171 Attorney for Petitioner F:\l:L1ENTS\2000\KK\MONTAGUE.082\CT.DOC\MINERS.COM VERIFICATION The undersigned hereby states that the statements of fact made in the foregoing document are true and correct to the best of my information and belief. The language of the document was prepared on the advice of my attorney and any legal claims or legal defenses asserted in the document, are pleaded on the advice of my attorney. If the document contains averments which are inconsistent in fact, then I have been unable after reasonable investigation to ascertain which of the inconsistent averments are true, but to the best of my information and belief, one of them is true. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S.A. 94904 relating to unsworn falsification to authorities. ~6!~ Date: 'I />J./~ VERIFICATION I, Steven N. Goudsouzian, Esquire, counsel the Petitioner and the Estate in the above-captioned action, hereby verify that I have investigated the facts of the incident as set forth in the attached petition, and the settlement of one hundred fifteen thousand ($115,000.00) dollars in this case is reasonable under the circumstances based upon the severity of the injuries causing death and the limits of insurance. I verify that the statements contained in the foregoing document are true to the best of my knowledge and belief. Said statements are made subject to the penalties of 18 Pa. C.S.A. ~4904, relating to unsworn falsification to authorities. ~ Steven N. Goudsouzian Date: April 22, 2002 STEVEN N. GOUDSOUZIAN ArrORNEY AT LAw 2925 WILLIAM PENN HIGHWAY, SUITE 301 EAsTON. PA 18045-5283 ---....------- (610) 253-9171 FAX: (61 0) 559-9281 E-MAIL: GoUDSOUZIA@AOLCOM October 30,2000 Barbara L. Montague 2101 Birch Street Easton, PA 18042 Tracie A. Montague 700 Wolf Avenue Apartment IE Easton, PA 18042 RE: Contingent Fee Agreement Letter Our File No: 2000-082 Dear Ms. Montague: You have asked me to represent you in connection with regard to the actions up to, including, and following the incident concerning Rajahn L. Bass on or about August 26, 2000, and I am pleased to do so. My representation will include but will not be limited to any wrongful death, survivor, or any other type of claim. It is my practice to confirm in writing the identity of any client whom I represent, the nature of my undertaking on behalf of that client, and billing and payment arrangements with respect to my legal services. I understand that I was engaged to act as counsel for Barbara L. Montague, in her individual capacity; Tracie A. Montague, in her individual capacity; Barbara L. Montague and Tracie A. Montague as co-guardians for the Estate of Aaliyah Kiana Montague-Bass; and on behalf of Aaliyah Kiana Montague-Bass and for no other person or entity. The following paragraphs reduce our agreement to writing: You hereby constitute, appoint and retain, Steven N. Goudsouzian, Attorney at Law, as lawful attorney to conduct all negotiations, make settlement, receive payments, institute actions at law in any appropriate forum, and in any and every proper and ethical manner to recover damages for injuries to my Exhibit "A" Barbara L. Montague Tracie A. Montague. Contingent Fee Agreement Letter Page 2 October 30, 2000 person and my children from such persons as may be liable therefore resulting from or incidental to a happening on or about August 26, 2000. You understand that you shall be totally and solely responsible to pay any and all medical and hospital bills, witness fees, filing fees, deposition costs, costs for medical reports, long distance telephone calls, photocopying and all other costs, and any and all other expenses which may be incurred incident to the preparation for or conduct of litigation. You agree to pay to the attorney for services to be rendered pursuant to this agreement, 33 1/3% of the total recovery on my claim and cause of action, if the recovery is obtained through settlement prior to trial, and 40% of the total recovery if the same is obtained after trial commences. Such fee is to be paid whether such recovery is obtained: (1) by the attorney directly; or (2) by any other person or agency whatsoever. You will reimburse Steven N. Goudsouzian, J.D. at the close of the case, the termination of representation or whenever funds are recovered in the case, whichever shall first occur, for any costs which he may choose to advance throughout the case, as listed above. If there is recovery, these costs will be paid out of the portion of the recovery which goes to the client, after the payment of attorney I s fees. You understand that reimbursement of such costs must be made regardless of the outcome of my claim. My clients, of course, may terminate my services at any time. However, if my services are terminated by my clients, I reserve the right to charge for my time expended. My statements for professional services are substantially based upon my hourly rate for services on your behalf. My current hourly rate is one hundred fifty ~) dollars per hour. At noted, you may also be billed for disbursemetand other charges relating to my professional services. Any remaining b lance not paid in full within thirty (30) days will accrue interest at the rate of ne percent (1 %) per month~ (twelve percent (12%) per year). v I J'>p.u. 5~ Barbara L. Montague Tracie A. Montague Contingent Fee Agreement Letter Page 3 October 30,2000 I will keep you informed as to the progress of my engagement, as appropriate, and I will send you copies of significant papers prepared or received by me. If you have any questions about my services or about the status of my engagement, please feel free to contact me at any time. If the foregoing does not comport with your understanding of my engagement in any respect, please contact me so that I may address your concerns promptly. Otherwise, please sign below to indicate your acceptance of the outlined terms and return to me in the enclosed, self-addressed, stamped envelope. A copy is enclosed for your record. If you have any questions, please do not hesitate to contact me. I look forward to serving you. ACCEPTED: ~J(~ Barbara L. Montague Individually, As Co-Guardian of the Estate of Aaliyah Kiana Montague-Buss and On Behalf of Aaliyah Kiana Montague-Buss SNG/me ~tZ~ Tracie A. Montague / Individually, As Co-Guardian of the Estate of of Aaliyah Kiana Montague-Buss and On Behalf of Aaliyah Kiana Montague-Buss __" .___. " 11-"-" .J,.I l-.fL".....r. 1.......L.. I'1V.J...:J:::> r". J. ~, ~ T7' ENCOM,PASSou INSURANCE Formerly kI'lowo as CNA Perso/lil InslJrance encompassinsurance.com P.O. Box 76203J ReadiTl9, PA 19612 Jeffrey Miller,: LPCS Clafms Representatfve Telephone ' (610) 320-4390 (800) 936-4203 )(4390 Facsimile (800) 936-4202 1ntBrr/9f jeffreYSCOftmlller@encompa$$lm.com , July 23, 2001 AlTORNEY STEVEN GOUDSOUZIAN 2925 WILLIAM PENN HIGHWAY EASTON I PA 18045-5283 VIA FAX ONLY, 610-559-9281 Our Claim Number: R1228105 HE Your Client: Rajahn Leon Bass Your Reference Number: Our Insured: Denise And Leona Evans Date of Loss: 08/27/2000 Policy Number. US 219185267 Insuring Company: Continental Ins Co Dear Steven Goudsouzian: This will confinn that we have extended an offer of $100,000.00 to settle your client's claim. You will be contacted shortly by Jack Luke of Structured Financial Associates. I am enclosing a copy of our insured's coverage showing the policy'limit of $100,000.00 Sincerely, Jeffrey :Milk,. Ene: Exhibit "B" SETTLEMENT AGREEMENT This Settlement Agreement is entered into between Releasor, Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague, and Continental'- Insurance' . Company (hereinafter sometimes cailed the "Obligor") as liability insurer of Releasee, Denise Evans. RECITALS A. On or about August 26, 2000, Releasor, Aaliyah Kiana Montague-Bass, a minor, sustained personal injuries as a result of a vehicular accident at or near Kidder Township, State of Pennsylvania (hereinafter called "the Incident") which resulted in the wrongful death of Rajahn L. Bass. Releasee, Denise Evans, is insured by Continental Insurance Company and claim number US219185267 has been assigned. B. The parties desire to enter into a settlement in order to provide for certain payments in full settlement and discharge of all claims which are the subject of the Incident and/or Complaint on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as follows: 1. Full Release of Liability. In consideration of the payments provided for herein, Releasor hereby releases and forever discharges the Releasee, Denise Evans, and the liability insurer, Continental Insurance Company, and their past, present and future officers, directors, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest and assigns, of and from any and all past, present or future claims, demands, obligations, actions, causes of action, wrongful death claims, claims for loss of services, comfort and society, rights, damages, costs, expenses and compensation of any nature whatsoever, which the Releasor now has, or which may hereafter accrue or otherwise be acquired, on account of, or in any way growing out of, or which are the subject of, the Incident and/or Complaint, including, without limitation, any and all known or unknown claims for personal injuries to the Releasor, and the consequences thereof, which have resulted or may result from the alleged negligent acts or omissions of the Releasee. As a condition of this settlement, Releasor waives any rights to punitive damages. This release and discharge shall be a fully binding and complete settlement as to the parties to this Agreement and all parties represented by or claiming through such parties, except only the executory provisions of this Agreement. Releasor understands that injuries may have been suffered that are unknown at present and that unknown complications may arise in the future. Releasor acknowledges that the sums paid in consideration of this Agreement are intended to and do release and discharge &I1Y claims illlegard to such unknown or future complications. a:\ Bass.SA - I - 04/1 012002 ;.:. 2. Payments. Obligor hereby agrees to make payment of the following amounts: (a) Periodic Payments: For the.benefit ofAaliy~h Kaina Montague-Bass, to be paid as the Court directs, or upon reaching the age of majority, to Aaliyah Kiana Montague- Bass, i) $2,405 annually for 8 years, guaranteed, beginning August 1, 2002, increasing at a rate of 2%, compounded annually; ii) $4,220 annually for 4 years, guaranteed, beginning August 1, 2010, increasing at a rate of 2% compounded annually; and iii) $20,000 annually for 4 years, guaranteed, beginning August 24,2017. (b) Forthwith Payments: To Releasor, Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague, and her attorney, the Law Firm of Steven N. Gondsouzian, jointly, the sum of $40,000.00, to be disbursed as the Court directs. All payments set forth above constitute damages on account of personal injuries or sickness arising under the Complaint or as a result of the Incident, within the meaning of Section I04(a)(2) of the Internal Revenue Code of 1986, as amended. 3. Right of Original Obligor to Substitute Designated New Obligor. It is understood and agreed by and between the parties hereto that Releasee or Obligor may, as a matter of right, and in Releasee or Obligor's sole discretion, assign the duties and obligations as set forth herein with respect to the periodic payments to Releasor, to Allstate Assignment Company and that such assignment, if made, shall be accepted by the Releasor without right of rejection and in full discharge and release of the duties and obligations of the Obligor. In the event of such an assignment of the duties and obligations of the Obligor as authorized above, the payments and rights of the parties shall conform to Section 130 of the Internal Revenue Code. If an assignment is made, the Obligor shall be released from all such future obligations and the assignee shall at all times remain directly and solely responsible for the payment of all such sums and obligations. 4. Purchase of Assets(s) to Fund Periodic Payments. To assure the ready availability to the Obligor or an assignee, should an assignment be made pursuant to paragraph 3 hereof, of Periodic Paynients payable under paragraph 2 of this Agreement, the Obligor or an assignee, should an assignment be made, may, promptly upon the execution of thts Agreement, purchase an annuity from Allstate Life Illsurance Company as sole owner. ' Releasor acknowledges that: the periodic payments cannot be accelerated, deferred, increased, or decreased by the Releasor or any Payee; nor shall the Releasor or any Payee have the power to sell, mortgage, encumber, or anticipate a:\ Bass.SAd -2- 04/10/2002 the periodic payments, or any part thereof, by assignment or otherwise. As a matter of convenience, Releasor may be designated as a payee and Releasor's estate designated as a beneficiary in applying for the aforesaid annuity. Any payments to be made after the death of the Payee pursuant to the terms of this Settlement Agreement shall be made to such person or e.ntity as shaH be designated in writing by said Releasor to the Assignee. If no such person or entity is so designated by said Releasor or if the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. The obligation of the Obligor, or of an assignee should an assignment be made, to make each periodic payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee named in this Agreement. It shall be the obligation of said Releasor to keep Assignee advised of the address to which payments are to be tendered. Any change of address shall be supplied in writing at least thirty (30) days prior to the due date of any payment date. 5. Release of All Liens. In consideration of the payments provided for herein, the Releasor hereby releases and forever discharges the Obligor, Releasee, and their past, present, and future officers, directors, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, assigns, and all other persons, firms, or corporations, of and from any and all liens and/or expenses incurred as a result of, and reasonably related to the above-referenced Complaint and/or Incident. 6. Final Compromise: No Admissions. The Releasor agrees and acknowledges payment of the sums specified in this Agreement are accepted as a full and complete compromise of matters involving disputed issues; that neither payment of the sums nor the negotiations for this settlement (including all statements, admissions or communications) by the parties and their attorneys or representatives, shall be considered admissions; and that no past or present wrongdoing on their part shall be implied by such payment or negotiations. 7. Integration Clause. This Agreement contains the entire agreement of the parties with regard to the matter set forth in it and shall be binding upon and inure to the benefit of the parties hereto, jointly and severally, and the executors, administrators, personal representatives, heirs and successors of each. 8. Jurisdiction. This Agreement is entered into in the State of Pennsylvania and shall be construed and interpreted in accordance with its laws. 9. Advice of Attorneys. In entering into this Settlement Agreement, the Releasor represents that Releasor has relied upon the advice of attorneys, who are attorneys of Releasor's own choice, and that . they have completely read and explained the !t:llns.of this Agreement and that 'Releasor fully understands and voluntarily accepts these terms. a:\ Bass.SA - 3. 04/1012002 10. Tax Disclaimer. It is understood, between the parties that the Releasor and/or Releasor's attorney did not rely upon any representations, express or implied, made by Obligor and/or Releasee or any of their representatives, as to the tax consequences of this Agreement and that Releasor releases Obligor and Releasee from allY and all liability in connection witli any such tax consequences. I I . Indemnity Agreement. Further, in consideration of the payments provided herein, Releasor agrees to indemnify and hold Obligor and Releasee harmless from all future claims, demands or actions that may hereafter at any time be made or brought against them or either of them by Releasor, or anyone on whose behalf Releasor enters into this Agreement, for the purpose of enforcing a further claim for damages on account of any injury or damage sustained in or arising from the Incident. 12. Cooperation of Parties. All parties agree to cooperate fully and to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the basic terms and intent of this Agreement, and which are not inconsistent with its terms. 13. Confidentiality. Releasor, Releasee and their attorneys agree that they, and each of them, will not disclose to any person not a party to the action described herein, including but not limited to, members of the press and media, government agencies or elective representatives, absent subpoena or applicable statutory provisions, or any other third parties, confidential reports for attorneys, either orally or in writing, the terms and/or conditions of this settlement and/or the dismissal or the amounts thereof. Releasor and Releasor's attorneys and each of them agree to take such steps as are necessary to assure their compliance therewith. Releasor and Releasor's attorneys, and each of them, also agree that this portion of this Agreement shall support an Order of any Court of general jurisdiction which shall include the above prohibition of disclosure of the terms of the settlement and violation of this provision shall subject violator(s) to civil fines and penalties according to proof. 14. Court Approval. This Settlement is subject to court approval and shall become effective (notwithstanding the date of execution hereof) upon such approval. This Agreement is effective as of ~ u.. Releasor, Aaliyah Kiana Monta -Bass, a minor, by and through her paren and natural guardian, Tracie Montague ~ a:\ Bass.SA -4- 04/10/2002 ~ .----c Steven N. Gcndsouzian, Esq., Counsel for Releasor Continental Insurance Company as liability insurer of Releasee, Denise Evans By: Representative a:\ Bass.SA - 5- 04/10/2002 & Uniform Qualified Assignment and Release "Claimant" Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague "Assignor" Continental Insurance Company as liability insurer of Releasee, Denise Evans "Assignee" Allstate Assignment Company "Annuity Issuer" Allstate Life Insurance Company "Effective Date" 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 executed a settlement agreement or release dated ,20_ (the "Settlement Agreemenr) 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 assignmenr 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 payments 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 t~e 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. 5. This Agreement shall be governed by and interpreted in accordance with the laws of the State of Pennsylvania. 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 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. Assignor: Continental Insurance Company as liability insurer of Releasee, Denise Evans By: Authorized Representative Title: Claimant: Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague ~~~ Approved as to Form and Content: ~ Claimant's Attorney By' 11. The Claimant hereby accepts Assigm assumption of all liability for the Periodic PaymE and hereby releases the Assignor from all liability the Period:c Payments. Assignee: Allstate Assignment Company By: Authorized Representative Title: National Structured Settlements Trade Association Addendum No. 1 Description of Periodic Payments Periodic Payments: For the benefit of Aaliyah Kaina Montague-Bass, to be paid as the Court directs, or upon reaching the age of majority, to Aaliyah Kiana Montague-Bass, i) $2,405 annually for 8 years, guaranteed, beginning August 1, 2002, increasing at a rate of 2%, compounded annually; ii) $4,220 annually for 4 years, guaranteed, beginning August 1,2010, increasing at a rate of 2% compounded annually; and iii) $20,000 annually for 4 years, guaranteed, beginning August 2~ _ 1,0 (l\- . ~itials "lm'Qt:~":' a Pf2 Assignor: Assi2nee: Allstate MARKET CLAIM OFFICE 6345 FLANK DRIVE HARRISBURG PA 17112 717-540-7555 Fax 717-540-7540 EMAIL cdgjp@allstate.com August 21, 2001 Steven N. Goudsouzian, Esquire 2925 William Penn Highway, Suite 301 Easton, PA 18045-5283 Reference: Your Client: Estate of Rajahn L. Bass Our Claim Number: 1553102227-B27 Dear Mr. Gourdsouzian: This letter is to confirm the offer of our policy limits of $15,000 toward the Estate of Rajahn Bass. Enclosed please find the proposed UIM release and declaration page. As we discussed, once this is court approved and the release is executed, we will promptly forward the settlement draft. As always, thank you for your cooperation with this matter. Sincerely, ~ Tim Shaffer, SCLA Staff Claim Representative Exhibit "C" IZI ALLSTATE INSURANCE COMPANY (hereinafter referred to as Allstate) o ALLSTATE INDEMNITY COMPANY (hereinafter referred to as Allstate) RECEIPT AND RELEASE UNDER o UNINSURED MOTORIST INSURANCE -- Coverage SS IZI UNDERINSURED MOTORIST INSURANCE - Coverage SU SUBROGATION AGREEMENT CLAIM # 1553102227-827 1. In consideration of the payment of Fifteen Thousand Dollars by Allstate, the receipt of which is hereby acknowledged, the undersigned hereby forever releases and discharges Allstate from any and all liability and from any and all contractual obligations whatsoever under the coverage designated above of POlicy No. 698411141 issued to John Weaver Jr. by Allstate and arising out of [81 bodily injuries, 0 property damages sustained by Estate of Raiahn Bass due to an accident on or about the 26th day of AUQust, 2000. 2. The undersigned hereby assigns, transfers and sets over to Allstate any and all claims or causes of action for bodily injury and/or property damage which the undersigned now has, or may hereafter have, to recover against any person or persons as the result of said accident and loss above stated to the extent of the payment above made; the undersigned agrees that Allstate may enforce the same in such manner as shall be necessary or appropriate for the use and benefit of Allstate, either in its own name or in the name of the undersigned; that the undersigned will furnish such papers, information or evidence as shall be within the undersigned's possession or control for the purpose of enforcing such claim, demand or cause of action; that the undersigned will do whatever else is necessary to secure such rights of recovery on behalf of Allstate and do nothing after loss to prejudice them; and 3. The undersigned covenants that no release or settlement of any such claim, demand or cause of action has been made. IN WITNESS WHEREOF I have hereunto set my hand this day of (Seal) Witnesses: C560-6, SS-SU Receipt & Release-Subro Agreement Page 1 of 1 rev.06/28100 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE 8li.'lEAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG, PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 001521 DUPLICA TE GOUDSOUZION STEVEN N 2925 WILLIAM PENN HWY SUT 301 EASTON, PA 18045 -------- fold ESTATE INFORMATION: SSN: 146-64-3474 FILE NUMBER: 2101-0639 DECEDENT NAME: BASS RAJAHN L DATE OF PAYMENT: 08/12/2002 POSTMARK DATE: 08/09/2002 COUNTY: CUMBERLAND DATE OF DEATH: 08/26/2000 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $3,757.40 I I I I I I I I TOTAL AMOUNT PAID: $3,757.40 REMARKS: STEVEN N GOUDSOUZION ESQUIRE CHECK# 77053 SEAL INITIALS: CW RECEIVED BY: REGISTER OF WILLS MARY C. LEWIS REGISTER OF WILLS New receipt see void CD0001507 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BI..REAU OF INOIVIDUAL TAXES DEPT. 280601 HARRISBURG. PA 17128-0601 REV-1162 EX(11-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT NO. CD 001507 STEVEN N GOUDSOUZIAN ESQUIRE 2953 WILLIAM PENN HIGHWAY SUITE 301 EASTON, PA 18045-5283 ~~ J-otJ;UJ71ff ~ /1Lw ~~1 r!./ (J L900 J5d. I ACN /UL ~ ASSESSMENT AMOUNT. CONTROL ~3;0J NUMBER '" -------- fold 101 $3,757.40 ESTATE INFORMATION: SSN: 490-18-5478 FILE NUMBER: 2100-0639 LEWIS ALETHA A 08/12/2002 08/09/2002 DECEDENT NAME: DATE OF PAYMENT: POSTMARK DATE: COUNTY: DATE OF DEATH: TOTAL AMOUNT PAID: $ 3,757.40 REMARKS: STEVEN N GOUDSOUZIAN ESQUIRE CHECK# 77053 SEAL INITIALS: CW RECEIVED BY: MARY C. LEWIS REGISTER OF WILLS This receipt is voided new receipt is CD 0001521 REGISTER OF WILLS Cumberland County - Register Of Wills Hanover and High Street Carlisle, PA 17013 Phone: (717) 240-6345 Date: 7/03/2002 GOUDSOUZION STEVEN N 2955 WILLIAM PENN HWY SUT 301 EASTON, PA 18049 RE: Estate of BASS RAJAHN L File Number: 2001-00639 Dear Sir/Madam: It has come to my attention that you have not filed the Status Report by Personal Representative (Rule 6.12) in the above captioned estate. As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO. 103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after July 1, 1992, the personal representative or his counsel, within two (2) years of the decedent's death, shall file with the Register of Wills a Status Report of completed or uncompleted administration. This filing will become delinquent on: 8/26/2002 Your prompt attention tothis:matter will be appreciated. Thank You. Sincerely, ~c. ~tpt MARY C. LEWIS REGISTER OF WILLS cc: File vlPersonal Representative(s) Judge ~ y STATUS REPORT UNDER RULE 6.12 Name of Decedent: .Rajahn L. Bass Date 0 f Death: 8/26/2000 Will No. Admin. No. 2001-00639 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I repo~t the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes No X 2. If the answer is No, state when the personal representative reasonably beli~ves that the administration will be complete: Within 90 days - awaiting settlement proceeds. 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final" account with the Court? Yes No b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes No d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the :::::Of~:::~~hans' Court and may ~ to this report. Signature 74831 Counsel I.D. No. Steven N. Goudsouzian Narne (Please type or print) 2925 William Penn Highway, Suite 301 ~~.-1 Address Easton, PA 18045 .( 610) 253-9171 Tel. No. Capacity: . Personal Representative x Counsel for personal representative STEVEN N. GOUDSOUZIAN ArroRNEY AT LAw 2925 WILLIAM PENN HIGHWAY, SUITE 301 EASTON, PA 18045-5283 ----------- (610) 253-9171 FAX:(61O) 559-9281 E-MAIL GOUDSOUZIA@AOL.COM August 9, 2002 Attention: Ann Register of Wills Cumberland County Hanover and High Streets Carlisle, PAl 70 13 RE: Estate of Rajahn L. Bass Court File No: 2001-00639 (Cumberland County) Our File No: 2000-082 Dear Ann: Enclosed please find one original and two copies of an inventory and an inventory tax return in the above captioned Estate. Please file the original and one copy and return the remaining copy in the self-addressed envelope provided. Please also find a check in the amount of twenty-five dollars ($25.00) for filling fees made payable to Register of Wills and a separate check in the amount of three thousand and seven hundred and fifty seven dollars and forty cents ($3,757.40) to the Register of Wills as agent. Lastly, enclosed please find a Status Report under Rule 6.12. Please file the original and return the remaining copy in the self-addressed envelope provided. Thank you. Steven N. Goudsouzian SNG/dlh Enclosures: as noted cc: Tracie Montague (w/o enclosures) F:'ClicnlsIlOOO\KKIMONT AGVE.llS2'Jrt.regi.-tt:rofwil1..0l!.Ol!,(}2,dOC Register of Wills of Cumberland County, Pennsylvania INVENTORY , Deceased No. 21 - 01 - 0639 Date of Death 8/26/2000 Social Security No. 146-64-3474 Estate of BASS, RAJAHN L also known as TRACIE A. MONTAGUE The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities. Attorney: Steven N. Goudsouzian Personal Representative Signature: ~ t?t- ~ TRACIE A. MONT AGU 1.0. No.: 74831 Signature: Signature: Address: 2925 William Penn Highway, Suite 301 Address: 700 WOLF AVENUE APT IE EASTON, PA 18042 Telephone: __~lQL1~Q:'.2~~1_ Easton, PA 18045 Telephone: (610) 253-9171 Dated: Personal Property COURT ORDER DATED 6/10/02 (COPY ATTACHED) CONTINENTEL INSURANCE CO $100,000.00 ALLSTATE INSURANCE CO 15,000.00 LESS A TTTORNEY FEES (28,750.00) NET A WARD $ 86,250.00 COURT ORDER DATED JULY 12,2002 (COpy ATTACHED) PROGRESSIVE INSURANCE CO $15,625.00 LESS ATTORNEY FEES I ( 5,208.33) NET AWARD $10,416.67 86,250.00 . Ii' , l~ J 10,416.67 - i Total Personal Property $96,666.67 (Attach additional sheets if necessary) Total Personal Property and Real Estate $96,666.67 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT -- IN RE: RAJAHN L. BASS No. 2001-00639 DATE OF DEATH: AUGUST 26, 2000 : ~ER~ AND NOW, this _10 day of ~ ' 2002, upon '(:-<-.1:.; consideration of the attached petition, it is hereby ORDERED and DECREED that Petitioner, Tracie A. Montague, as Administrator of the Estate, on behalf of the Estate of Rajahn Bass, is hereby granted leave of court and is authorized as follows: 1. To settle the claims against the third party and the vehicle operated by . Rajahn L. Bass for the policy limits in the gross sum of one hundred and fifteen thousand ($115,000.00) dollars; 2. To sign the releases and agreements set forth as Exhibits "B" and "C" to the within petition to effectuate the settlement of the above claims; 3. To make payment ~f attorneys' fees to Attorney Steven N. Goudsouzian in ~i1 ~UI~ ~~ the amount of. tlllJ! t)-' eight thousand, ~ hundred and .m~ three ~3~} dollars in accordance with Exhibit "A" to the Petition) j- ~ GfJk- sf ')..'(,' S1) f'J_ ~~ tWJ.. 1 ~10. 4. To pay any additional costs and expenses of the estate; and 5. To proceed with the underinsured claim concerning Rajahn Bass's motor vehicle policy. . A TRUE COPY FROM RECORD In Testimony wherof. I hereunto set my hand and the seal of said Court at Carlisle. PA Cil~t!l::Ji&%~ lark of the Court Cumberland County 'I IN THE COURT OF COMMON PLEAS OF NORTHAMPTON COUNTY, PENNSYL VANIA CIVIL DMSION r"-,.t ESTATE OF RAJAHN L. BASS VS. PROGRESSIVE INSURANCE COMPANY 5053 RIITER ROAD, SUITE 101 MECHANICSBURG, PA 17055 . . No. -48-CV~266~';' .,.~ . c.o,y I 07'" : , I' , o'-V2a?~0c95D/~ . . . . ORDER OF COURT AND NOW, this ~ day of cJz./v / , 2002, upon consideration of the attached petition, it is hereby ORDERED and DECREED that Petitioner, Tracie A. Montague, as Administrator of the Estate, on behalf of the Estate of Rajahn Bass, is hereby granted leave of court and is authorized as follows: 1. To settle the claims against the underinsured motor vehicle policy of Rajahn L. Bass for the policy limits in the gross sum of fifteen thousand, six hundred and twenty five ($15,625.00) dollars; 2. To sign the releases and agreements set forth as Exhibits "B" to the within petition to effectuate the settlement of the above claims; 3. To make payment of attorneys' fees to Attorney Steven N. Goudsouzian in the amount of five thousand, two hundred and eight and thirty three cents ($5208.33) dollars in accordance with Exhibit "A" to the Petition; and 4. To pay any additional costs and expenses of the estate. BY THE COURT: p/~~ J. ~ i ~ I COMMONWEACrnOep",,,cv,,",^ ! INHERITANCE TAX RETURN WAR~~;~',~~~;VE'UE i RESIDENT DECEDENT _... ___________ HARRISBUf3G,PA 1?128-{)~___,~______",________________ __ ----~ECEDENT'S NAME (LAST. FIRST, AND -MlDDLE-INITIAlj---- -~ --,---- i ~~A~ESOS: D~~~;-~~-:EAR) ----:- OATEOFBiRTH{MM-OD-YEARj-- ---- ~ ~H~;l~:A~&~~RVMNGSPOUSESNi\ME 1~:~~~: l~:~DCEINITIAL) 'lEV _ lSD~ ~X. ('-liD/ . REV-1500 c)FF!C1A,_USEOM,\' :;;. 'I:J- ::l FILE NUMBER 21 01 .. COUNTY CODE ~YEAR SOCIAL SECURITY NUMBER 0639 NUMBER 146-64-3474 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE w ~ z:::!1IJ U~~ W~U ~Oo u~~ ~m ~ < -~ 1-. Original Retu~--~-U2-:- Supplemen~r Reiurn---------..-- o 4. Limited Estate 0 4a. Future Interest Compromise (date of death after 12-12-82) o 6. Decedent Died Testate (Attach copy 0 7. Decedent Maintained a Living Trust (Attach of Will) copy of Trusl) ~ 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death belween 12-31-91 and 1-1-95 1 o o REGISTER OF WILLS -..--..--.-----.----------,----- SOCIAL SECURITY NUMBER 3. Remainder Return {date of death Prior to 12-13-82) - 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes o 11.Election to tax under Sec. 9113(A) (Attach Sch O) ~ .. ~ u AME Steven N. Goudsouzian r---.------ IRM NAME (If applicable) STEVEN N. GOUDSOUZIAN 2925 William Penn Hig1J.way, Suite 301 Easton, P A 18045 El€PHONE NUMBER 610/253-9171 ,.------.----------. --.~.- --------.--,-.----.----. 1. Real Eslate (Schedule A) 2. Stocks and Bonds (Schedule B) :QF:FJC!AI. 'iSE ONI.Y (1) None None None None 3. Closely Held Corporation, Partnership or Sole-Proprietorship (2) (3) (4) z o ~ ~ ~ ~ ~ :l .. ~ 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G or L) 8. Total Gross Assets (total Lines 1-7) 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 13,302.32 (5) 96,666.67 (6) None (7) None (8) 96,666.67 10. Debts of Decedent, Mortgage Liabilities, & Liens (Scheduie I) (10) 11. Total Deductions (total Lines 9 & 10) (11) 13,302.32 12. Net Value of Estate (Line 8 minus Line 11) (12) 83,364.35 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election io tax has not been made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (13) (14) 83,364.35 SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) ---.-- -------,---,.. z 83,364.35 x .045 (16) 3,751.40 0 16.Amount of Line 14 taxable at lineal rate ~ _.,,-~- ._--~~~ ~ ~ 17.Amount of Line 14 taxable at sibling rate x .12 (17) ~ 0 ---....---..---.-..--- u x 18. Amount of Line 14 taxable at collateral rate ~ X .15 (18) --"---'-.--" .-----.- 119. Tax Due 120. 0 Jiiii\I~~~~~I\lifll1llilllillIIiMlIli!I!lIl11 (19) 3.751.40 -- CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) SHIPPENSBURG ----~- ----rTATE--~~-liIP-1 ;257- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 6. Prior Payments C. Discount Deced{mt's Complete Address: STREE'I ADDRESS 45 BARD DRIVE --.----. CITY Total Credits (A + B + C) 3. InteresUPenalty if applicable D. Interest 10. Penalty TotallnteresUPenalty (D + (0) 4. If Line 2 is greater than Line 1 + line 3, enter the difference, This is the OVERPAYMENT. Check box on Pag91 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. IOnter the total of Line 5 + SA. This is the BALANCE DUE. Make Check Payable 10: REGISTER OF WILLS, AGENT (1) 3,751.40 (2) 0.00 (3) (4) (5) (5A) (5B) 0.00 3,751.40 3,751.40 PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X"IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred;...... .............."................. b. retain the right to designate who shall use the property transferred or its income;. ................. c. retain a reversionary interest; or.................... ...................... ............................ d. receive the promise for life of either payments, benefits or care?... .................... ................. 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?... ..................... ................ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 4. Did decedent own an Individual Retirement Account, annuity, or other non~probate property which contains a beneficiary designation?.... ............... .................... ........................................ ................. '~ i o ~ o ~ o ~ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. 700 WOLF AVENUE APT IE EASTON, PA 18042 ---.-.-----------.--------- Under penalties of perjury, I declare that I have examined this return, Including llccomplmying schedules and statements, and to the best of my knowledge and belief, it is true. correct and complete, Declaration of preparer other than the personal representative is based on aU information of which preparer has any knO'Medaa. SIGNATURE OF PERSON RESPONSIBLE FOR FlUNG RETURN ADDRESS ~d. DATE "ADDRESS 'SlGNAniRE"ciF'PREP'- ---HER THAN REPRESENfA T1'JE' ADDRESS:' ?~ 2925 William Penn Highway, Suite 30 I Easton, P A 18045-5283 DATE- DATE For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3% [72 P.S. ~9116 (aj (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0% [72 P .S. ~9116 (a) (1.1) (ii)). The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving s~:';Jse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twentyMone years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparenl of the child is 0% [72 P.S. ~9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P .S. ~9116 1.2) [72 P.S. ~9116 (a) (1)). The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 99116 (a) (1.3}). A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. '. I COM\fONWEALTHOFPENNSYlVAN~ INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC, PERSONAL PROPEIUY ES1;.TE OF BASS, RAJAHN L I FILE NUMBER 21 -01.-0639 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorshIp must be disclosed on schedule F. ITEM NUMBER 1 DESCRIPTION VALUE AT DATE OF DEATH 10,416.67 COURT ORDER DATED JULY 12,2002 (COpy ATTACHED) PROGRESSIVE INSURANCE CO $15,625.00 LESS ATTORNEY FEES ( 5,208.33) NET AWARD $10,416.67 2 COURT ORDER DATED 6/1 0/02 (COPY ATTACHED) CONTINENTEL INSURANCE CO $100,000.00 ALLST ATE INSURANCE CO 15,000.00 LESS A TTTORNEY FEES (28,750.00) NET A WARD $ 86,250.00 86,250.00 .-- --~-~ 96,666.67 TOTAL (Also enter on lIne 5, Recapitulation) ,'. 1 COM'vlONWEAlTH OF PENNSYLVANiA. INI-lERITANCE TAX RETURN RESIDENT DECEDENT -- ----------- SCHEDULEH FUNERAL EXPENSES & ADI\IIINlSlRAllVE COSTS ESTATE OF BASS, RAJAHN L --~----I FILE NUMBER-- -~~~-- 21-01-0639 ----.- ----- ----------.._----- Debls of decedent must be reported on Schedule I. --ITEM~T-~--~-- NUMBER A. DESCRIPTION AMOUNT FUNERAL EXPENSES: DEVOE FUNERAL HOME 2,618.00 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions B. Social Security Number(s) I EIN Number of Personal Represenlalive(s): Street Address City Year{s) Commission paid Attorney's Fees STEVEN N GOUDSOUZIAN State Zip 2. 10,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address State Zip City Relationship of Claimant to Decedent Probate Fees REGISTER OF WILLS- PROBATE FEE REGISTER OF WILLS - FILING FEES 53.00 25.00 4. 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs CUMBERLAND LAW JOURNAL - LEGAL NOTICE HARRISBURG PATRIOT NF.WS - LEGAL NOTICE 2 KIDDER TOWNSHIP- POLICE REPORT 75.00 234.00 54.57 Total of Continuation Schedule{s) 242.75 TOTAL (Also enter on line 9, Recapitulation) 13,302.32 .~ ~ Schedule H Funeral ExpeII5eS & Adminislrative Cos1s continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT _~_~~--=~~IFILE ~~~_B~lR_ 063~~~==-~~- 95.00 ESTATE OF BASS, RAJAHN L 3 .,-- I ANDERSON INVESTIGATORS 4 PROTHONOTARY CIVIL DIVISION - MINORS COMPROMISE CARBON COUNTY CORONORS REPORT 97.75 50.00 ______l_____...__ Page 2 of Schedule H '.~.-' ~ I COMMONWEALTH OF PENNSYl "ANiA I INHERITANCE TAX RETURN I __'m_~ RESID~NT OEC~D_ENT ___.L-_ SCHEDULE J BENEFICIARIES L__ I FILE N~~~ 0639 -~------- -.-I----~-- -~-~-- - ~----.---~---IRELATIONSHIPTO --------,;:~OUNTORSHAR-- -~I~MBEl TAXABLE N:'::R::~T~:~:~::~~~~U~~~~~~:~:~:i:~~~~:~;OPERTY-----f-- no ~;~'~~;'~;'I'I_~_~F ESTATE__E_ .. 1 AALIY AH KAINA MONTAGUE-BASS Daughter 100% 700 WOLF AVE APT IE EASTON PA 18042 ESTATE OF BASS, RAJAHN L I I Enter dollar amounts for distributions shown above on lines 15 through 17, as appropriate, on Rev 1500 cover sheet II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Register of wills of CUMBERLAND County, pennsylvani, Certificate of Grant of Letters ,n"'''_ ,,,.,...,,. ,\) I '~, '.1,1. ,.....I,!, """ /..,....1...1 ''>'-', , i' .~ "" ,\.0/ " '-...,,,':j, 'f, '\ :..,,~ .n ..' ~ .. c. I ..::: r '.! ." <<.. ',-' .~. :-: , ",;' l; H,', ,,,.l....:.~...... . ~'\' ';:>""~ ~~\'::' " . ;,~ ~", '"..,{,I.:.\.\-,I,,,;.;- '\ No. 2001-00639 PA No. 21-01-0639 ESTATE OF BASS RAJAHN L (LAb 1 , rl~bl, M1UULb) Late of SHIPPENSBURG BOROUGH CUM~~KLANU CUU~lY, Deceased WHEREAS, BASS RAJAHN L (LAb 1 , rl~bl', M1UULb) CUMBERLAND COUNTY , died on Social Security No. 146-64-3474 , late of SHIPPENSBURG BOROUGH the 26th day of August 2000; and WHEREAS, the grant of letters of administration is required for the administration of the estate. THEREFORE, I, MARY C. LEWIS , Register of wills in and for the County of CUMBERLAND , in the Commonwealth of Pennsylvania, have this day granted Letters of Administration to MONTAGUE TRACIE A (LAb~, rl~bl, M1UULb) who has duly qualified as administrator (rix) of the estate of the above named decedent and has agreed to administer the estate according to law, all of which fully appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE, CARLISLE, PENNSYLVANIA. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of my Office on the 6th day of July 2001. ~~-'1/(J~~~@b'14{/-i~"u~y **NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHAN'S COURT INRE: RAJAHN L. BASS : No. 2001-00639 DATE OF DEATH: AUGUST 26, 2000 : ~ER~ AND NOW, this J 0 day of ~ ,2002, upon ~,~-.":,L consideration of the attached petition, it is hereby ORDERED and DECREED that Petitioner, Tracie A. Montague, as Administrator of the Estate, on behalf of the Estate of Rajahn Bass, is hereby granted leave of court and is authorized as follows: 1. To settle the claims against the third party and the vehicle operated by . Rajahn L. Bass for the policy limits in the gross sum of one hundred and fifteen thousand ($115,000.00) dollars; 2. To sign the releases and agreements set forth as Exhibits "B" and "C" to the within petition to effectuate the settlement of the above claims; To make payment ~f attorneys' fees to Attorney Steven N. Goudsouzian in .f~+'\ 'iW..... J.\~ the amount ot; tJ . If eight thousand, ~ hundred and thiI~ tiMt'- -<,3Bt'Q;J3>) dollars in accordance with Exhibit "A>> to the Petitionl j- ~ GfJk-. ~ ~'f,1 srJ "- ~..eO. ~ ~ 'z.Mo. 3. 4. To pay any additional costs and expenses of the estate; and 5. To proceed with the underinsured claim concerning Rajahn Bass's motor -. vehicle policy. ~ J. . A TRUE COPY FAOM RECORD In Testimony wherof, I hereunto set my hand and the seal cq~fi.&~' lerk of the Court Cumberland COUnty IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT INRE: RAJAHN L. BASS : No. 2001-00639 DATE OF DEATH: AUGUST 26,2000 : ~ FOR COURT APPROVAL OJ? SETTLEMENI.OE AND NOW, comes Tracie A. Montague, Administrator of the Estate of Rajahn L. Bass and petitions the Court as follows: 1. Rajahn L. Bass was an adult individual born on April 13, 1974, with a social security number of 146-64-3474. 2. On August 26, 2000, Rajahn L. Bass perished in Carbon County, Pennsylvania in a motor vehicle accident. 3. At the time of his death, Rajahn L. Bass' mailing address was 56 Bard Drive, Shippensburg, Pennsylvania, 17257, in Cumberland County, Pennsylvania. 4. Rajahn L. Bass did not leave a will. 5. At the time of his death, Rajahn L. Bass was not married. 6. Rajahll L. Bass was survived by his minor child, his sole beneficiary, Aaliyah Kiana Montague-Bass (date of birth June 12, 1996) who resides with her mother at 700 Wolf Avenue, Apt. IE, Easton, Northampton County, Pennsylvania 18042. 7. Petitioner, Tracie A. Montague, is the natural mother of Aaliyah Kiana Montague-Bass. 8. The only individual entitled to receive any proceeds from the estate, both through a survival action and/or a wrongful death action is Rajahn L. Bass' minor child, Aaliyah Kiana Montague-Bass. 9. On July 6, 2001 Letters of Administration were granted to Tracie A. Montague. 10. The Petitioner retained the undersigned counsel on the behalf of her child as well as on behalf of the estate pursuant to the fee agreement attached as Exhibit "A". 11. Rajahn L. Bass perished in a motor vehicle accident. He was riding another individual's motorcycle when the motorcycle and another vehicle struck. There are three potential claims ( a) The Third party vehicle; (b) The vehicle Rajahn Bass was operating; and@Rajahn Bass's motor vehicle policy. 12. As of this date, no action has been filed. 13. The undersigned counsel has negotiated a settlement with the third party carrier for the policy limits of one hundred thousand ($100,000.00) dollars. Specifically, forty thousand ($40,000) dollars will be paid in a lump sum and the remaining sixty thousand ($60,000) will be paid over time. The letter and the agreements setting forth the terms of the settlement are outlined in the settlement agreement attached as Exhibit "B" to the within petition. 14. The undersigned counsel has negotiated a under insurance settlement with the carrier for the owner of the vehicle Rajahn Bass was driving for the policy limits of fifteen thousand ($15,000.00) dollars. A true and correct copy of the correpsondence outlining the settlement and the release are attached collectively as Exhibit "C" to the within petition. 15. Both carriers have provided the undersigned counsel with affidavits of no further insurance. In addition, undersigned counsel has obtained authority from the remaining underinsured carrier to settle the first underinsured claim. 16. Presently, the undersigned counsel is attempting to negotiate the under insurance settlement with the carrier for Rajahn Bass's insurllnce policy. 17. Petitioner requests that this Honorable Court permit Petitioner to accept the settlements set forth above and sign the releases and agreeements attached as exhibits to this Petition. 18. Petitioner has retained undersigned counsel to investigate the case, interview witnesses, and take appropriate stempts to prosecute the survival and wrongful death actions. Petitioner and counsel recommend the accepting of the proposed settlements for the policy limits of the respective insurance policies. WHEREFORE, Petitioner respectfully requests this Honorable Court permit Petitioner to settle the third party carrier claim as well as the underinsured claim for the vehicle that Rajahn Bass was driving for the policy limits as set forth above and to permit Petitioner to sign the appropriate releases and pay all relevant costs and attorney's fees. Steven N. Goudsouzian, Esq. J.D. No. 74831 2925 William Penn Highway Suite 301 Easton, PA 18045-5283 (610)253-9171 Attorney for Petitioner F~AGtI...i\CfOClOl'--"""" VERIFICATION The undersigned hereby states that the statements offact made in the foregoing document are true and correct to the best of my information and belief. The language of the document was prepared on the advice of my attorney and any legal claims or legal defenses asserted in the document, are pleaded on the advice of my attorney. If the document contains averments which are inconsistent in fact, then I have been unable after reasonable investigation to ascertain which of the inconsistent averments are true, but to the best of my information and belief, one of them is true. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S.A. ~4904 relating to unsworn falsification to authorities. ..iAfl<.; 6!. ~ Date: r /::':1/~ VERIFICATION I, Steven N. Goudsouzian, Esquire, counsel the Petitioner and the Estate in " the above-captioned action, hereby verify that I have investigated the facts of the incident as set forth in the attached petition, and the settlement of one hundred fifteen thousand ($115,000.00) dollars in this case is reasonable under the circumstances based upon the severity of the injuries causing death and the limits of insurance. I verify that the statements contained in the foregoing document are true to the best of my knowledge and belief. Said statements are made subject to the penalties of 18 Pa. C.S.A. ~4904, relating to unsworn falsification to authorities. ~ Steven N. Goudsouzian Date: April 22, 2002 STEVEN N. GOUDSOUZIAN ArroRNEY AT lAw 2925 WIWAM PENN HIGHWAY, SUITE 301 EAsToN, PAl8045-5283 -----..----- (610) 253-9171 FAX:(61O) 559-9281 E-MAIL: GounSOUZIA.@AOI.COM October 30, 2000 Barbara L. Montague 210 I Birch Street Easton, P A 18042 Tracie A. Montague 700 Wolf Avenue Apartment IE Easton, PA 18042 RE: Contingent Fee Agreement Letter Our File No: 2000-082 Dear Ms. Montague: You have asked me to represent you in connection with regard to the actions up to, including, and following the incident concerning Rajabn L. Bass on or about August 26,2000, and I am pleased to do so. My representation will include but will not be limited to any wrongful death, survivor, or any other type of claim. It is my practice to confirm in writing the identity of any client whom I represent, the nature of my undertaking on behalf of that client, and billing and payment arrangements with respect to my legal services. I understand that I was engaged to act as counsel for Barbara L. Montague, in her individual capacity; Tracie A. Montague, in her individual capacity; Barbara L. Montague and Tracie A. Montague as co-guardians for the Estate of Aaliyah Kiana Montague-Bass; and on behalf of Aaliyah Kiana Montague-Bass and for no other person or entity. The following paragraphs reduce our agreement to writing: You hereby constitute, appoint and retain, Steven N. Goudsouzian, Att;orney at Law, as lawful attorney tQ conduct all negotiations, make settlement, r:eceive payments, institute actions at law in. any appropriate forum, and in any and every proper and ethical manner to recover damages for injuries to my Exhibit "A" Barbara L, Montague Tracie A. Montague , Contingent Fee Agreement Letter , Page 2 October 30, 2000 person and my children from such persons as may be liable therefore resulting from or incidental to a happening on or about August 26, 2000. You understand that you shall be totally and solely responsible to pay any and all medical and hospital bills, witness fees, filing fees, deposition costs, costs for medical reports, long distance telephone calls, photocopying and all other costs, and any and all other expenses which may be incurred incident to the preparation for or conduct of litigation. You agree to pay to the attorney for services to be rendered pursuant to this agreement, 33 1/3 % of the total recovery on my claim and cause of action, if the recovery is obtained through settlement prior to trial, and 40% of the total recovery if the same is obtained after trial commences. Such fee is to be paid whether such recovery is obtained: (1) by the attorney directly; or (2) by any other person or agency whatsoever. You will reimburse Steven N. Goudsouzian, J.D. at the close of the case, the termination of representation or whenever funds are recovered in the case, whichever shall first occur, for any costs which he may choose to advance throughout the case, as listed above. If there is recovery, these costs will be paid out of the portion of the recovery which goes to the client, after the payment of attorney's fees. You understand that reimbursement of such costs must be made regardless of the outcome of my claim. My clients, of course, may terminate my services at any time. However, if my services are terminated by my clients, I reserve the right to charge for my time expended. My statements for professional services are substantially based upon my hourly rate for services on your behalf. My current hourly rate is one hundred fifty ~) dollars per hour. At noted, you may also be billed for disbursemetand other charges relating to my professional services. An,y remaining b ance not paid in full within thirty (30) days will accrue interest at the rate o!:, e percent (1 %) per month, (twelve percent (12%) per year). J JS~.a- 5_.~J -. .' ..." . .. . Barbara L. Montague Tl'\lcie A. Montague . Contingent Fee Agreement Letter ,Page 3 October 30, 2000 , I will keep you informed as to the progress of my engagement, as appropriate, and I will send you copies of significant papers prepared or received by me. If you have any questions about my services or about the status of my engagement, please feel free to contact me at any time. If the foregoing does not comport with your understanding of my engagement in any respect, please contact me so that I may address your concerns promptly. Otherwise, please sign below to indicate your acceptance of the outlined terms and return to me in the enclosed, self-addressed, stamped envelope. A copy is enclosed for your record. If you have any questions, please do not hesitate to contact me. I look forward to serving you. ACCEPTED: ~k Barbara L. Montague Individually, As Co-Guardian of the Estate of Aaliyah Kiana Montague-Buss and On Behalf of Aaliyah Kiana Montague-Buss SNG/me ~t?~ Tracie A. Montague Individually, As Co-Guardian of the Estate of of Aaliyah Kiana Montague-Buss and On Behalf of Aaliyah Kiana Montague-Buss , ~> ~NCOMPASS~ INS U'R A N. CE P.O. Box 16203, Re4ding, PA 19612 Jury 23, 2001 FonnerlV knO\II1 as CNA P.rsonal Ins~ral1CO Jeffrey Miller.:lPCS ctalmo Representative T~ ' (610) 3z0.4300 (800) 936-4203)(4390 FBcsimile (800) 936-421J? /nI8rrIef js(frsys~com G!\CQflIplI$$ill$urance.com ATTORNEY STEVEN GOUDSOUZlAN 2925 WILLIAM PENN HIGHWAY EASTON, PA 16045-5283 VIA FAX ONLY, 610-559-9281 Our Claim Number: R12281 05 HE Your Client: Rajahn Leon Bass YourReference Number: Our Insured: Denise And Leona Evans Date of Loss: 0812712000 porte)' Number: US 219185267 Insuring ComP8TIY: Contfnentallns Co Dear steven Gaudsouzian: This will confirm that we have extended an offer of $100,000.00 to settle your client's claim. You wi" be contacted shortly by Jacl< Luke of Structured Financial Associates. , am enclosing a copy of our Insured's coverage showing the policy'limlt of $100,000.00 Sincerely, :Jeffrey !Millet' Ene: Exhibit "B" -' SETTLEMENT AGREEMENT !ii~'--" This Settlement Agreement is entered into between Releasor, Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague, and Continental "Insilrimcc. Company (hereinafter sometimes called the . "Obligor") as liability insurer of Releasee, Denise Evans, RECITALS A. On or about August 26, 2000, Releasor, Aaliyah Kiana Montague-Bass, a minor, sustained personal injuries as a result of a vehicular accident at or near Kidder Township, State of Pennsylvania (hereinafter called ''the Incident") which resulted in the wrongful death of Rajahn L. Bass. Releasee, Denise Evans, is insured by Continental Insurance Company and claim number US219185267 has been assigned. B. The parties desire to enter into a settlement in order to provide for certain payments in full settlement and discharge of all claims which are the subject of the Incident and/or Complaint on the terms and conditions set forth herein. NOW THEREFORE, it is hereby agreed as foUows: 1. Full Release of Liability. In consideration of the payments provided for herein, Releasor hereby releases and forever discharges the Releasee, Denise Evans, and the liability insurer, Continental Insurance Company, and their past, present and future officers, directors, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest and assigns, of and from any and all past, present or future claims, demands, obligations, actions, causes of action, wrongful death claims, claims for loss of services, comfort and society, rights, damages, costs, expenses and compensation of any nature whatsoever, which the Releasor now bas, or which may hereafter accrue or otherwise be acquired, on account of, or in any way growing out of, or which are the subject of, the Incident and/or Complaint, including, without limitation, any and all known or unknown claims for personal injuries to the Releasor, and the consequences thereof, which have resulted or may result from the alleged negligent acts or omissions of the Releasee. As a condition of this settlement, Releasor waives any rights to punitive damages. This release and discharge shall be a fully binding and complete settlement as to the parties to this Agreement and all parties represented by or claiming through such parties, except only the executory provisions of this Agreement. Releasor understands that injuries may have been suffered that are unknown at present and that unknown complications may arise in the future. Releasor acknowledges that the sums paid in consideration of this Agreement are intended to and do release artd discharge any claims in regard to such unknown or fuiute comp-Iications. . a:\ Bass.SA -1- 04/1012002 2. Payments. Obligor hereby agrees to make payment of the following amounts: , (a) Periodic Payments: For the-benefit of Aaliyah Kailla Montague-Bass, to be paid as the Court directs, or upon reaching the age of majority, to Aaliyah Kiana Montague- Bass, i) $2,405 annually for 8 years, guaranteed, beginning August 1,2002, increasing at a rate of2%, compounded annually; ii) $4,220 annually for 4 years, guaranteed, beginning August 1,2010, increasing at a rate of 2% compounded annually; and iii) $20,000 annually for 4 years, guaranteed, beginning August 24, 2017. (b) Forthwith Payments: To Releasor, Aaliyah Kiana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague, and her attorney, the Law Firm of Steven N. Gondsouzian, jointly, the sum of $40,000.00, to be disbursed as the Court directs. All payments set forth above constitute damages on account of personal injuries or sickness arising under the Complaint or as a result of the Incident, within the meaning of Section I04(a)(2) of the Internal Revenue Code of 1986, as amended. 3. Right ofOriBinal Obligor to Substitute Designated New Obligor. It is understood and agreed by and between the parties hereto that Releasee or Obligor may, as a matter of right, and in Releasee or Obligor's sole discretion, assign the duties and obligations as set forth herein with respect to the periodic payments to Releasor, to Allstate Assignment Company and that such assignment, if made, shall be accepted by the Releasor without right of rejection and in full discharge and release of the duties and obligations of the Obligor. In the event of such an assignment of the duties and obligations of the Obligor as authorized above, the payments and rights of the parties shall conform to Section 130 of the Internal Revenue Code. If an assignment is made, the Obligor shall be released from all such future obligations and the assignee shall at all times remain directly and solely responsible for the payment of all such sums and obligations. ~ 4. Purchase of Assets(s) to Fund Periodic Payments. To assure the ready availability to the Obligor or an assignee, should an assignment be made pursuant to paragraph 3 hereof, of Periodic Payments payable under paragraph 2 of this Agreement, the Obligor or an assignee, should an assignment be made, may, promptly upon the execution of this Agreement, purchase an annuity from Allstate Life . ,Insurance Company as sole owner. . Releasor aclmowledges that the periodic payments cannot be accelerated, deferred, increased, or decreased by the Releasor or any Payee; nor shall the Releasor or any' Payee have the power to sell, mortgage, encumber, or anticipate a:\ Bass.SA -2 - 04/1012002 the periodic payments, or any part thereof, by assigriment or otherwise. As a matter of convenience, Releasor may be designated as a payee and Releasor's estate designated as a beneficiary in applying for the aforesaid annuity. Any payments to be made after the death of the Payee pursuant to the tenns of this Settlement Agreement shall be made to such person or e,ntity as shall be designated in writing by said Releasor to the Assignee. If no such person or entity is so designated by said Releasor or if the person designated is not living at the time of the Payee's death, such payments shall be made to the estate of the Payee. The obligation of the Obligor, or of an assignee should an assigriment be made, to make each periodic payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of the Payee named in this Agreement. It shall be the obligation of said Releasor to keep Assignee advised of the address to which payments are to be tendered. Any change of address shall be supplied in writing at least thirty (30) days prior to the due date of any payment date. 5. Release of All Liens. In consideration of the payments provided for herein, the Releasor hereby releases and forever discharges the Obligor, Releasee, and their past, present, and future officers, directors, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, partners, predecessors and successors in interest, assigns, and all other persons, firms, or corporations, of and from any and all liens and/or expenses incurred as a result of, and reasonably related to the above-referenced Complaint and/or Incident. 6. Final COl1lPromise: No Admissions. The Releasor agrees and acknowledges payment of the sums specified in this Agreement are accepted as a full and complete compromise of matters involving disputed issues; that neither payment of the sums nor the negotiations for this settlement (including all statements, admissions or communications) by the parties and their attorneys or representatives, shall be considered admissions; and that no past or present wrongdoing on their part shall be implied by such payment or negotiations. 7. Integration Clause. This Agreement contains the entire agreement of the parties with regard to the matter set forth in it and shall be binding upon and inure to the benefit of the parties hereto, jointly and severally, and the executors, administrators, personal representatives, heirs and successors of each. 8. Jurisdiction. This Agreement is entered into in the State of Pennsylvania and shall be construed and intelJ'reted in accordance with its laws. 9. Advice of Attorneys. In entering into this Settlement Agreement, the Releasor represents that Releasor has relied upon the advice of attorneys, who are attorneys of Releasor's own choice, and that . they have completely read and explained tile tel111s'X)f this Agreement and iliat'Releasor fully ullderstands and voluntarily accepts these tenns. a:\ Bass.SA .) . 04/1012002 10. Tax Disclaimer. It is understood, between the parties that the Releasor and/or Releasor's attorney did not rely upon any representations, express or implied, made by Obligor and/or Releasee or any of their representatives, as 10 the tax consequences of this Agreement and that Releasor releases Obligor and Releasee from allY and al! liability in connection with. any such tax consequences. II. Indemnity Agreement. Further, in consideration of the payments provided herein, Releasor agrees to indemnifY and hold Obligor and Releasee hannless from all future claims, demands or actions that may hereafter at any time be made or brought against them or either of them by Releasor, or anyone on whose behalf Releasor enters into this Agreement, for the pmpose of enforcing a further claim for damages on account of any injury or damage sustained in or arising from the Incident. 12. Cooperation of Parties. All parties agree to cooperate fully and to execute any and all supplementary documents and to take all additional actions that may be necessary or appropriate to give full force and effect to the basic terms and intent of this Agreement, and which are not inconsistent with its terms. 13. Confidentiality. Releasor, Releasee and their attorneys agree that they, and each of them, will not disclose to any person not a party to the action described herein, including but not limited to, members of the press and media, government agencies or elective representatives, absent subpoena or applicable statutory provisions, or any other third parties, confidential reports for attorneys, either orally or in writing, the terms and/or conditions of this settlement and/or the dismissal or the amounts thereof. Releasor and Releasor's attorneys and each of them agree to take such steps as are necessary to assure their compliance therewith. Releasor and Releasor's attorneys, and each of them, also agree that this portion of this Agreement shall support an Order of any Court of general jurisdiction which shall include the above prohibition of disclosure of the terms of the settlement and violation of this provision shall subject violator(s) to civil fines and penalties according to proof. 14. Court Approval. This Settlement is subject to court approval and shall become effective (notwithstanding the date of execution hereof) upon such approval. .~~ Releasor, Aaliyah JUana MOllla -Ba~s, a minor, by and through her paren and natural guardian, Tracie Montague ~ This Agreement is effective as of a:\ Bass.SA -4 - 04/1 012002 ~~-c Steven N. Gondsouzian, Esq., Counsel for Releasor Continental Insurance Company as liability insurer of Releasee. Denise Evans By: Representative a:\ Bass.SA -5. 04/lOnooz r:; <. Uniform Qualified Assjgnmen~ ~nd Release "Claimant" Aaliyah Klana Montague-Bass, a minor, by and through her parent and natural guardian, Tracie Montague "Assignor" Continental Insurance Company as liability insurer of Releasee, Denise Evans "Assignee" Allstate Assignment Company "Annuity Issuer" Allstate Life Insurance Company "Effective Date' 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 executed a seWement agreement or release dated .20_ (the "SeWement Agreemenr) that provides for the Assignor to make certain perlodic 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 ass/gnmenl" within the meaning and subject to the conditions of Section 130(c) of the Intemal 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 payments not specified in Addendum No.1. 2. The Periodic Payments constitute damages on account of personai 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 Perlodic 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 vaild check In the amount specified to the address of record. 5. This Agreement shall be governed by and interpreted in accordance with the laws of the State of Pennsylvania. 6. The Assignee may fund the Periodic Payments by purchasing a "qualified funding asset" within the meaning of Seelion 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 assel" purchased hereunder diracliy to the payee(s) specifiea 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 SettJement Agreement is declared terminated by a court oi 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 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 asslgns 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. Assignor: Continental Insurance Company as liability insurer of Releasee, Denise Evans By: Authorized Representative TdIe: Claimant: Aaliyah Klana Montague-Bass, a minor, by and through her parent and natural guardian. Tracie Montague ~~;, ~ ~ Ry' ~~ Claimant's Attorney 11. The Claimant hereby accepts Assi! assumption of all liability for the Periodic Pay and hereby releases the Assignor from allliabi the Periodic Payments. . Assignee: Allstate Assignment Company By: Authorized Representative Title: NSSTA National Structured Settlements Trade Association Addendum No. 1 Description of Periodic Payments Periodic Payments: For the benefit of Aaliyah Kaina Montague-Bass, to be paid as the Court directs, Or upon reaching the age of majority, to Aaliyah Klana Montague-Bass, i) $2,405 annually for 8 years, guaranteed, beginning August 1, 2002, Increasing at a rate of 2%, compounded annually; ii) $4,220 annually for 4 years, guaranteed, beginning Augusl1, 2010, Increasing at a rate of 2% compounded annually; and IU) $20,000 annually for 4 years, guaranteed, beginning AuguSl24, 2017. ~1itialS ~'Im"".tA-<"; a. Pf2 . Assignor: Assignee: Allstate MARKET CLAIM OFFICE 6345'FlANK OFilVE HARRISBURG PA 17112 717-540-7555 Fax 717-540-7,54Q EMAIL cdgjp@a/lstate.com August 21, 2001 Steven N. Goudsouzian, Esquire 2925 William Penn Highway, Suite 301 Easton, PA 18045-5283 Reference: Your Client Estate of Rajahn L Bass Our Claim Number: 1553102227-827 Dear Mr. Gourdsouzian: This letter is to confinn the offer of our policy limits of $15,000 toward the Estate of Rajahn Bass. Enclosed please find the proposed UIM release and declaration page. As we discussed, once this is court approved and the release is executed, we win promptly forward the selllement draft As always, thank you for your cooperation with this matter. Sincerely, w- Tm Shaffer, SetA Staff Claim Representative Exhibit "C" o ALLSTATE INSURANCE COMPANY (hereinafter referred to as Allstate) o ALLSTATE INDEMNITY COMPANY (hereinafter referred to as Allstate) RECEIPT AND RELEASE UNDER o UNINSURED MOTORIST INSURANCE - Coverage SS ~ UNDERINSURED MOTORIST INSURANCE - Coverage SU SUBROGATION AGREEMENT CLAIM It 1553102227-827 1. In consideration of the payment of Fifteen Thousand Dollars by Allstate, the receipt of which is hereby acknowledged, the undersigned hereby forever releases and discharges Allstate from any and all liability and from any and all contractual obligations whatsoever under the coverage designated above of Policy No. 698411141 issued to John Weaver Jr. by Allstate and arising out of ~ bodily injuries, 0 property damages sustained by Estate of Raiahn Bass due to an accident on or about the 26th day of~, 2000. 2. The undersigned hereby assigns, transfers and sets over to Allstate any and all claims or causes of action for bodily injury and/or property damage which the undersigned now has, or may hereafter have, to recover against any person or persons as the result of said accident and loss above stated to the eXlent of the payment above made; the undersigned agrees that Allstate may enforce the same in such manner as shall be necessary or appropriate for the use and benefit of Allstate, either in lis own name or in the name of the undersigned; that the undersigned will furnish such papers, information or evidence as shall be within the undersigned's possession or control for the purpose of enforcing such claim, demand or cause of aclion; that the undersigned will do whatever else is necessary to secure such rights of recovery on behalf of Allstate and do nothing aller loss to prejudice them; and 3. The undersigned covenants that no release or settlement of any such claim, demand or cause of action has been made. IN WITNESS WHEREOF I have hereunto set my hand this day of (Seal) Witnesses: C56O-6. SS-SU Receipt & Release-Subro Agreement Page 1 011 rev.06l28/00 IN RE: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 01-00639 ORPHAN'S COURT ESTATE OF RAJAHN L. BASS IN RE: PETITION FOR COURT APPROVAL OF SETTLEMENT OF ESTATE'S CLAIMS ORDER OF COURT AND NOW, May 2, 2002, hearing on the Petition for Court Approval of Settlement of Estate's Claims is set for Monday, June 10, 2002, at 2:30 p.m. in Courtroom 3 of the Cumberland County Courthouse; counsel to notify all interested parties. By the Court, Steven N. Goudsouzian, Esquire 2925 William Penn Highway, Ste. 301 Easton, PA 18045-5283 For the Administrator . 'U l:J . ;) A TRUE COPY FROM RECORD In Testimony Wherof. , hereunto set my hand anc/ the seal of said Court at CarHsle PA . n.~doyd ~i~..f ~~i::c). . Cumbel1and L;> i:~d [ '~'II Z[J - A!, '. . < ., IN THE COURT OF COMMON PLEAS OF NORTHAMPTON COUNTY, PENNSYLVANIA CIVIL DMSION ~' ..' ESTATE OF RAJAHN L. BASS VS. PROGRESSIVE INSURANCE COMPANY 5053 RlITER ROAD, SUITE 101 MECHANICSBURG, PA 17055 . . No. -48-CV ~166~':' CoOL! &'CvzOf~0<:0 50 '7 !).. . . . . . . . . ORDER OF COURT AND NOW, this !Y' day of eft/v / , 2002, upon consideration of the attached petition, it is hereby ORDERED and DECREED that Petitioner, Tracie A. Montague, as Administrator of the Estate, on behalf of the Estate of Rajahn Bass, is hereby granted leave of court and is authorized as follows: 1. To settle the claims against the underinsured motor vehicle policy of Rajahn L. Bass for the policy limits in the gross sum of fifteen thousand, six hundred and twenty five ($15,625.00) dollars; 2. To sign the releases and agreements set forth as Exhibits "B" to the within petition to effectuate the settlement of the above claims; 3. To make payment of attorneys' fees to Attorney Steven N. Goudsouzian in the amount of five thousand, two hundred and eight and thirty three cents ($5208.33) dollars in accordance with Exhibit "A" to the Petition; and 4. To pay any additional costs and expenses of the estate. BY THE COURT: .h/.;5I;;-~ J. ", IN THE COURT OF COMMON PLEAS OF NORTHAMPTON COUNTY, PENNSYLVANIA CIVIL DIVISION ESTATE OF RAJAHN L. BASS VS. PROGRESSIVE INSURANCE COMPANY 5053 RITTER ROAD, SUITE 101 MECHANICSBURG, PA 17055 . . No. 48-CV -2002- . . . . . . . . rETITION FOR COURT APPROVAL OF SETTLEMENT OF ESTATE'S CLAIMS AND NOW, comes Tracie A. Montague, Administrator of the Estate of Rajahn L. Bass and petitions the Court as follows: 1. Rajahn L. Bass was an adult individual born on April 13, 1974, with a social security number of 146-64-3474. On August 26, 2000, Rajahn L. Bass perished in Carbon County, Pennsylvania in a motor vehicle accident. 2. At the time of his death, Rajahn L. Bass' mailing address was 56 Bard Drive, Shippensburg, Pennsylvania, 17257, in Cumberland County, Pennsylvania. 3. Rajahn L. Bass did not leave a will. At the time of his death, Rajahn L. Bass was not married. 4. Rajahn L. Bass was survived by his minor child, his sole beneficiary, Aaliyah Kiana Montague-Bass (date of birth June 12, 1996) who resides with her mother at 700 Wolf Avenue, Apt. IE, Easton, Northampton County, Pennsylvania 18042. 5. Petitioner, Tracie A. Montague, is the natural mother of Aaliyah Kiana Montague-Bass. 6. The only individual entitled to receive any proceeds from the estate, both through a survival action and/or a wrongful death action is Rajahn L. Bass' minor child, Aaliyah Kiana Montague-Bass. 7. On July 6, 200 I Letters of Administration were granted to Tracie A. Montague. 8. Along with her mother who was appointed co-guardian concerning insurance proceeds, Petitioner retained the undersigned counsel on the behalf of her child as well as on behalf of the estate pursuant to the fee agreement attached as Exhibit "A". 9. Rajahn L. Bass perished in a motor vehicle accident. He was riding another individual's motorcycle when the motorcycle and another vehicle struck. There are three potential claims (a) The Third party vehicle; (b) The vehicle Rajahn Bass was operating; and (c) Rajahn Bass's motor vehicle policy. 10. The claims against the third party vehicle and the vehicle Rajahn Bass was operating have been settled. 11. The undersigned counsel has negotiated a settlement with the underinsured carrier, Progressive Insurance, for the policy limits of fifteen thousand, six hundred and twenty five dollars (15,625.00). The letter and the release are attached as Exhibit "B" to the within petition. 12. As the settlement is for the policy limits, Plaintiff has exhausted its ability to recover. 13. Petitioner requests that this Honorable Court permit Petitioner to accept the settlement set forth above and sign the release attached as Exhibit "B" to this Petition. 14. Petitioner has retained undersigned counsel to investigate the case, interview witnesses, and take appropriate stempts to prosecute the survival and wrongful death actions. Petitioner and counsel recommend the accepting of the proposed settlements for the policy limits of the underinsured motor vehicle policies. WHEREFORE, Petitioner respectfully requests this Honorable Court permit Petitioner to settle the underinsured claim as well for the policy limits as set forth above and to permit Petitioner to sign the appropriate release and pay all relevant costs and attorney's fees. ,~~~.."-""--~ ---<1-..... Steven N. Goudsouzian, Esq. J.D. No. 74831 2925 William Penn Highway Suite 301 Easton, P A 18045-5283 (610)253-9171 Attorney for Petitioner VERIFICATION The undersigned hereby states that the statements of fact made in the foregoing document are true and correct to the best of my information and belief. The language of the document was prepared on the advice of my attorney and any legal claims or legal defenses asserted in the document, are pleaded on the advice of my attorney. If the document contains averments which are inconsistent in fact, then I have been unable after reasonable investigation to ascertain which of the inconsistent averments are true, but to the best of my information and belief, one of them is true. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S.A. ~4904 relating to unsworn falsification to authorities. ~((~ Tracie A. Montague Date: ,/,,fdJ . , VERIFICATION I, Steven N. Goudsouzian, Esquire, counsel the Petitioner and the Estate in the above-captioned action, hereby verify that I have investigated the facts of the incident as set forth in the attached petition, and the settlement of fifteen thousand six hundred and twenty five ($15,625.00) dollars in this case is reasonable under the circumstances based upon the severity of the injuries causing death and the limits of insurance. I verify that the statements contained in the foregoing document are true to the best of my knowledge and belief. Said statements are made subject to the penalties of 18 Pa. C.S.A. ~4904, relating to unsworn falsification to authorities. ~~ Steven N. Goudsouzian Date: July 10, 2002 STEVEN N. GOUDSOUZIAfI. ArroRNEY AT IAw 2925 WIll.IAM PENN HIOHWAY. SUITE 301 EAsToN, PA 1804.5-5283 ....---...---.- (610) 253-9171 FAX:(61O) 559-92.81 E-MAfu GoUDSOUZiA@AOl.COM October 30, 2000 Barbara L. Montague 2101 Birch Street Easton, PA 18042 Tracie A. Montague 700 Wolf Avenue Apartment IE Easton, PA 18042 HE: Contingent Fee Agreement Letter Our File No: 2000-082 Dear Ms. Montague: You have asked me to represent you in connection with regard to the actions up to, including, and following the incident concerning Rajabn L. Bass on or about August 26, 2000, and I am pleased to do so. My representation will include but will not be limited to any wrongful death, survivor, or any other type of claim. It is my practice to confmn in writing the identity of any client whom I represent, the nature of my undertaking on behalf of that client, and billing and payment arrangements with respect to my legal services. I understand that I was engaged to act as counsel for Barbara L. Montague, in her individual capacity; Tracie A. Montague, in her individual capacity; Barbara L. Montague and Tracie A. Montague as co-guardians for the Estate of Aaliyah K.iana Montague-Bass; and on behalf of Aaliyah Kiana Montague-Bass and for no other person or entity. The following paragraphs reduce our agreement to writing: You hereby constitute, appoint and retain, Steven N. Goudsouzian, A~rney at Law, as lawful attorney tQ conduct ~11 negotiations, make settlement, . receive payments,. institute actions at law in any appropriate forum, and in any and every proper and ethical manner to recover damages for injuries to my Exhibit" A" Barbara L. Montague Tracie A. Montague 'Contingent Fee Agreement Letter Page 2 October 30, 2000 person and my children from such persons as may be liable therefore resulting from or incidental to a happening on or about August 26, 2000. You understand that you shall be totally and solely responsible to pay any and all medical and hospital bills, witness fees, filing fees, deposition costs, costs for medical reports, long distance telephone calls, photocopying and all other costs, and any and all other expenses which may be incurred incident to the preparation for or conduct of litigation. You agree to pay to the attorney for services to be rendered pursuant to this agreement, 33 1/3 % of the total recovery on my claim and cause of action, if the recovery is obtained through settlement prior to trial, and 40% of the total recovery if the same is obtained after trial commences. Such fee is to be paid whether such recovery is obtained: (1) by the attorney directly; or (2) by any other person or agency whatsoever. You will reimburse Steven N. Goudsouzian, J.D. at the close of the case, the termination of representation or whenever funds' are recovered in the case, whichever shall first occur, for any costs which he may choose to advance throughout the case, as listed above. If there is recovery, these costs will be paid out of the portion of the recovery which goes to the client, after the payment of attorney's fees. You understand that reimbursement of such costs must be made regardless of the outr.ome of my claim. My clients, of course, may terminate my services at any time. However, if my services are terminated by my clients, I reserve the right to charge for my time expended. My statements for professional services are substantially based upon my hourly rate for services on your behalf. My current hourly rate is one hundred fifty .) dollars per hour. At noted, you .may also be billed for disburseme imd other charges relating to my professional services. Any remaining b ance not paid in full within thirty (30) days will accrue interest at the rate of ne percent (1 %) per month, (twelve percent (12%) per year). v I jS<>.a. ~ ., . . . . ~.--r> Barbara L. Montague Tracie A. Montague 'Contingent Fee Agreement Letter Page 3 October 30, 2000 I will keep you informed as to the progress of my engagement, as appropriate, and I will send you copies of significant papers prepared or received by me. If you have any questions about my services or about the status of my engagement, please feel free to contact me at any time. If the foregoing does not comport with your understanding of my engagement in any respect, please contact me so that I may address your concerns promptly. Otherwise, please sign below to indicate your acceptance of the outlined terms and return to me in the enclosed, self-addressed, stamped envelope. A copy is enclosed for your record. If you have any questions, please do not hesitate to contact me. I look forward to serving you. ACCEPTED: ~k Barbara L. Montague Individually, As Co-Guardian of the Estate of Aaliyah Kiana Montague-Buss and On Behalf of ." . Aaliyah Kiana Montague-Buss SNG/me ~ti.~ Tracie A. Montague Individually, As Co-Guardian of the Estate of of Aaliyah Kiana Montague-Buss and On Behalf of AaIiyah .K.iana Montague"Buss , PROGRESSIVE 5063 Ritter Road. Svita 101 Mechanicsburg, PA 170SS Telephone' 1-800-PROGRESSIVE Facsimile: 717691-6711 June 13,2002 progressive. com STEVEN GOUDSOUZIAN, ESQ. .2925 WillIAM PENN HIGHWAY, STE 301 EASTON, PA 18045-5283 OUr Insured Our Claim Number Date of Loss Your Client Rajahn Bass 016965010 8f26IOO Estate of Rajahn Bass Dear Mr. Goudsouzian: This will confirm my offer of $15,625, which represents our pro-rata portion of underinsured motorist coverage, to seWe your c1ienfs underinsured motorist claim. Enclosed is the pertinent part of the policy which deals willi non-stacked underinsured motorist coverage. Please call me willi any questions you may have in regards to this offer. As you are aware, oourt approval of lIIis selllement is required. Enclosed is the release I propose for this toss. The selUement draft will be issued once a court order is provided to Progressive. Progressive Northern Insurance Co., !k~ Patricia F. Faller Senior Claims Specialist (717)791-5141 enclosures UNDERlNSURED MOTORIST RELEASE & INDEMNITY AGREEMENT Page I of 2 KNOW ALL BY THESE PRESENTS: That the undersigned, Tracie A. Montague, individually and as Administratrix of the Estate ofRajahn L. Bass, (hereinafter "Releasor"), for the sole consideration of Fifteen thousand six hundred twenty-five dollars ($15,625), receipt of which is hereby acknowledged, has remised, released, and forever discharged and covenant to hold harmless Progressive Northern Insurance Company, its agents, employees, subsidiaries and affili4Ues (hereinafter "Releasee") and Releasee's successors and a."-"igrI'l, ftom any and all claims, actions, and causes of action, demands, costs, and expenses arising under the above-numbered policy for bodily uyury or dAfTUlges of any kind sustained, or that may be hereafter sustained by or on behalf of the undersigned. on account of or in any way arising out of an accident caJJSOO by an underlnsured motorist at or near SR 940 and T-524 (Moseywood Road), on or about August 26, 2000. To procure the payment of the stated consideration, the Releasor hereby declares: that no representations about the nature and extent of the said iJ:Yuries, disabilities or damages made by any physician, attorney or agent of Releasee, nor any representations regarding the nature and extent oflegalliability or financial responsibility, have induced the Releasor to make this Release; that this Release is entered into in consideration of all known and unknown i$ries, disabilities and dAtnlIges, and also the possibility that the injuries sustained may be permanent and progressive and recovery tbereftom uncertain and indefinite, so that consequences not now anticipated may result ftom the said accident. Releasor agrees to indemnifY and hold harmless said Releasee from any additional sum of money that Releasee may hereafter be compelled to pay on account of the iIYuries to said Re1easor because ofsaid accident. The Releasee is hereby authorized to take any action which may be desirable or necessary in law or in equity, either in the name of the Releasee or in the name oCthe Releasor, against any person or orgllni'TMion who may be liable for such injuries or damages who has not been heretofore released with Releasee's written consent. The Releasor covenants and agrees to cooperate fully with the Releasee in the presentation of such claims and to furnish all papers and docUlDQIlts necessary in such proceedings, submit to such physical or testimonial examinations as may be required in such procee(l"'gs, and to attend court and testifY if the Releasee deems it to be necessary. UNDERINSURED MOTORIST RELEASE & INDEMNITY AGREEMENT Page 2 of 2 I have read this release and understand it. Signed: date Tracie A. Montague date Administratrix of the Estate ofRajahn L. Bass Wrtness State of: County of On this _ day of , 2 , before me personally appeared , to me known to be the person(s) who executed the foregoing instrument, and acknowledged this as a free act and deed. IN TESTIMONY WHEREOF, I have hereto subscnDed my name and affixed my seal this day of ,2_. My commiR'>ion expires Notary Public Claim No.: 016965010 (Ed. 11/94) - 2 - "11608 197 37- Illm"IIWBI~IIIIID 1 ~ ... /Y PROGREJJlVEe /' ON . PENNSYLVANIA MOTOR VEHICLE POLICY i ., This policy, the deciarationspage, and anyappli- cable endorsements contalntha tenns of the eon- tract .of insuranc;e between. 1,1$ and the policy- holder. 1 NOTICE: IF YOU BUY COWSION COVER- AGE, IT DOES NOT APPLY TO VEHICLES . RENTED FOR BUSINESS USE OR FOR 6 MONTHS OR. MO!,!E.. . Progressive Northern Insurance Company Madison, Wisconsin Fonn No. 9606 (07/97) PA C 1997 The Progressive Corporation. All Rights Reseoved. "11606 797 37- IIIIIIIIIIII~IIII~D l;:;l;:; .cocno:t.,.. 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Z Z LIJ Q.. , o A Ill: o U 1&1 Ill: Ill: =:) o > Ill: o II. Z o H t- Ill: o A.~ Ill: III 3: o -' Z H C t- III Ell: , 1111 zl HI -,I I 0: HI %1 t-: I (!II ZI 0: -'I C. I t-' =:), U: COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 2806011 HARRISBURG. PA 17128-0601 REV-1162 EX(II-96) RECEIVED FROM: PENNSYLVANIA INHERITANCE AND ESTATE TAX OFFICIAL RECEIPT GOUDSOUZION STEVEN N 2925 WILLIAM PENN HWY SUT 301 EASTON, PA 18045 -------- fold ESTATE INFORMATION: SSN: 146-64-3474 FILE NUMBER: 2101-0639 DECEDENT NAME: BASS RAJAHN L DATE OF PAYMENT: 10/02/2002 POSTMARK DATE: 09/30/2001 COUNTY: CUMBERLAND DATE OF DEATH: 08/26/2000 NO. CD 001679 ACN ASSESSMENT CONTROL NUMBER AMOUNT 101 I $11.23 I I I I I I I I TOTAL AMOUNT PAID: REMARKS: STEVEN N GOUDSOUZIAN ESQUIRE CHECK# 2482 SEAL INITIALS: AC RECEIVED BY: REGISTER OF WILLS $11.23 MARY C. LEWIS REGISTER OF WILLS ~ STATUS REPORT UNDER RULE 6.12 Name of Decedent: Rajahn L. Bass Date of Death: 8/26/2000 Will No. Admin. No. 2001-00639 Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with respect to completion of the administration of the above-captioned estate: 1. State whether administration of the estate is complete: Yes x No 2. If the answer is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to No.1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes No x b. The separate Orphans' Court No. (if any) for the personal representative's account is: c. Did the personal representative state an account informally to the parties in interest? Yes ~ No , d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be filed with the Cerk of the Orphans' Court and may be attached to this report. .,.- ~ Signature D.ate: '1;)0/'::?:L / / Steven N. Goudsouzian Name (Please type or print) 2925 William Penn Highway Ste 301 Easton, PA 18045 Address (610) 253-9171 Tel. No. Capacity: Personal Representative x Counsel for personal representative (MAH:rmf/AM3) STEVEN N. GOUDSOUZIAN ATTORNEY AT LAw 2925 WILLIAM PENN HIGHWAY, SUITE 301 EASTON, P A 18045-5283 (610) 253-9171 FAX: (610) 559-9281 GOUDSOUZIA@AOL.COM September 27,2002 Mary C. Lewis Register of Wills Cumberland County Hanover and High Streets Carlisle, P A 17013 RE: Estate of Rajahn L. Bass Court File No: 2001-00639 (Cumberland County) Our File No: 2000-082 Dear Ms. Lewis: In accordance with the enclosed Commonwealth of Pennsylvania Department of Revenue Notice, please find payment in the amount of eleven dollars and twenty-three cents ($11.23). Enclosed please also find a status report indicating this estate has been settled. Enclosed please also find a status report time stamped on August 12, 2002 indicating that the Estate was awaiting settlement proceeds. Please file the originals of these documents and return time stamped copies in the self addressed stamped envelope provided. Thank you. SNG/crs Enclosure: as noted cc: Tracie Montague (w/out encl.) F:'CliCllu.I2000\KK\MONT AGUE.082\REOWlLL.M04 I / ~ - C>:;~.2 - .:2J '\, BUREAU OF INDIVIDUAL TAXES INHERITANCE T~X OIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 09-30-2002 BASS 08-26-2000 21 01-0639 CUMBERLAND 101 STEVEN N GOUDSOUZIAN STE 301 2.925 WILLIAM PENN HWY " EASTON PA 18045, '* REV-1547 EX AFP IDl-D2l RAJAHN L Allount Rellitted (1) (2) (3) (4) (5) (6) (7) .00 .00 .00 .00 96,666.67 .00 .00 MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE, PA 17013 CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV=is47-E;f-AFP--COY:02Y-NO'ficE-OF-YNHEifiTANCE-TAX-A-PPRAisEHENT~--ALD)WANCE-OR----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF BASS RAJAHN L FILE NO. 21 01-0639 ACN 101 DATE 09-30-2002 TAX RETURN WAS: ( ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Stock/Partnership Interest (Schedule C) 4. Mortgages/Notes Receivable (Schedule D) 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H) 10. Debts/Mortgage Liabilities/Liens (Schedule I) 11. Total Deductions 12. Net Value of Tax Return 13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax 13,302.32 .00 (11) (2) (3) (14) (9) UO) NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. (8) 96,666.67 13.302.32 83,364.35 .00 83,364.35 NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will re~lect ~igures that include the total o~ ~ returns assessed to date. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate 16. Allount of Line 14 taxable at Lineal/Class A rate 17. Allount of Line 14 at Sibling rate 18. Allount of Line 14 taxable at Collateral/Class B rate 19. Principal Tax Due TAX CREDITS: (15) .00 X 00 = .00 (16) 83,364.35 X 045 = 3,751.40 (17) .00 X 12 = .00 (8) .00 X 15 = .00 (9)= 3,751.40 ~..,-... ... -., l'tJ AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-12-2002 WRITEOFF .00 321.66 08-09-2002 CDOO1521 6.00- 3,757.40 BALANCE OF UNPAID INTEREST/PENALTY AS OF 08-10-2002 TOTAL TAX CREDIT 3,751.40 BALANCE OF TAX DUE .00 INTEREST AND PEN. 11.23 TOTAL DUE 11.23 . IF PAID AFTER DATE INDICATED, SEE REVERSE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.) REV-1470 EX (6-88) INHERITANCE TAX EXPLANATION OF CHANGES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES DEPT. 280601 HARRISBURG PA 17128-0601 DECEDENTS NAME Bass, Rajahn L. FILE NUMBER REVIEWED BY Daniel Heck ACN 2101-0639 101 ITEM SCHEDULE NO. EXPLANATION OF CHANGES Interest is abated in the amount of $321.66 from the delinquent date OS/27/2001 to 07/12/2002, the date of receipt of the proceeds of litigation. Interest is effective 07/13/2002. ROW Page 1 \ /6-02Y02-c2- BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION DEPT. Z8060l HARRISBURG, PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE INHERITANCE TAX STATEMENT OF ACCOUNT * REV-UD7 EX AFP 101-021 STEVEN N GOUDSOUZIAN STE 301 2925 WILLIAM PENN HWY EASTON PA 18045, DATE ESTATE OF DATE OF DEATH FILE NUMBER _COUNTY ACN 10-15-2002 BASS 08-26-2000 21 01-0639 CUMBERLAND 101 RAJAHN L Allount Rellitted MAKE CHECK PAYABLE AND REMIT PAYMENT TO: REGISTER OF WILLS CUMBERLAND CO COURT HOUSE CARLISLE. PA 17013 NOTE: To insure proper credit to your account. subllit the upper portion of this forll with your tax paYllent. CUT ALONG THIS LINE .. RETAIN LOWER PORTION FOR YOUR RECORDS ~ REV =i60j-'EX-AFP--('oY=02Y------...--iNHEiiTANC'E-fA3f-STAYi~irtif-ifF-AccoijNf--.j(.------------------ --- ESTATE OF BASS RAJAHN L FILE NO.21 01-0639 ACN 101 DATE 10-15-2002 THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW IS A SUMMARY OF THE PRINCIPAL TAX DUE. APPLICATION OF ALL PAYMENTS. THE CURRENT BALANCE. AND. IF APPLICABLE. A PRO~ECTED INTEREST FIGURE. DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 09-30-2002 PR I NCI PAL TAX DUE: ...............................................................................................__.................................................................................................................. 3.751.40 PAYMENTS (TAX CREDITS): PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID DATE NUMBER INTEREST/PEN PAID (-) 07-12-2002 WRITEOFF .00 321.66 08-09.-2002 CDOO1521 6.00- 3,757.40 09-30-2002 CDOO1679 11.23- 11.23 TOTAL TAX CREDIT 3,751.40 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 IF PAID AFTER THIS DATE, SEE REVERSE TOTAL DUE .00 . SIDE FOR CALCULATION OF ADDITIONAL INTEREST. ( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ, vnll MAV R" nil.. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J