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HomeMy WebLinkAbout05-3077 SHIPPENSBURGI SOUTH HAMPTON MANOR, L.P. : Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2005- ..1077 CIVIL TERM JOHN C. SHATZER and TERESA J. RICKER, Defendants. CIVIL ACTION-LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance persona!ly or by an attorney and filing in writing with the court, your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAYBE ABLE TO PROVIDE YOU WITH INFORMA nON ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 SHIPPENSBURGI SOUTH HAMPTON MANOR, L.P. : Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO.2005- 3011 CIVIL TERM JOHN C. SHATZER and TERESA J. RICKER, Defendants. CIVIL ACTION-LAW COMPLAINT NOW, comes Shippensburg/South Hampton Manor Limited Partnership ("Shippensburg Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets forth the following: 1. Shippensburg/South Hampton Manor Limited Partnership is a Maryland limited partnership duly authorized to conduct business in the Commonwealth of Pennsylvania. 2. Defendant, John C. Shatzer, is an adult individual with a residence address of 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257. 3. Defendant, Teresa J. Ricker, is an adult individual with a residence address of230 Meadow Drive, Shippensburg, Cumberland County, Pennsylvania 17257. 4. Shippensburg Health operates a resident skilled nursing facility (the "facility") located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257. 5. On or about December 16,2004, John C. Shatzer sought to be admitted to the Shippensburg Health facility. I 6. On or about December 16, 2004, Teresa J. Ricker executed an Admission Agreement to have John C. Shatzer admitted to the facility. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "A" and is incorporated. 7. On or about December 16, 2004, John C. Shatzer became a resident of the facility and remains a resident as of the date offiJing of this Complaint. 8. A determination was made by the Cumberland County Assistance Office that John C. Shatzer did not qualify for medical assistance. A true and correct copy of the denial of medical assistance is attached hereto as Exhibit "B" and is incorporated by reference. 9. Upon information and belief, Teresa J. Ricker has been receiving the social security benefits of John C. Shatzer during the period of time that John C. Shatzer has been a resident of the facility. 10. At the time of filing, John C. Shatzer owes Shippensburg Health the sum of $23,870.93 in accordance with the Statement attached hereto as Exhibit "C" and incorporated by reference. 11. Demand has been made upon John C. Shatzer and Teresa J. Ricker to tender the amount due and owing to Shippensburg Health. COUNT I-BREACH OF CONTRACT SHIPPENSBURG HEALTH v. JOHN C. SHATZER AND TERESA J. RICKER 12. Plaintiff incorporates by reference paragraphs one through eleven as though set forth at length. 13. All conditions precedent to recovery under the Admission Agreement have been fulfilled. 2 14. Teresa J. Ricker, was obligated to use the assets and income of John C. Shatzer to satisfy the debt due and owing to Shippensburg Health for the services and care provided to John C. Shatzer by Shippensburg Health. 15. John C. Shatzer is obligated to pay the costs of his care provided by Shippensburg Health which were not covered by a third party payor. 16. John C. Shatzer and Teresa J. Ricker have, without justification, failed and refused to pay the amount due. 17. Teresa J. Ricker and John C. Shatzer have breached the Admission Agreement by failing and refusing to pay for the services rendered. 18. The Admission Agreement provides, in relevant part, as follows: "If you or your representative do not pay the money you owe us and we hire a collection agency or attorney you agree to be liable for their fees and court costs." WHEREFORE, Plaintiff requests judgment in its favor and against the Defendants for the sum of$23,870.93, interest, costs, expenses, attorney fees and any additional amount coming due to the date of award. COUNT II- QUANTUM MERUIT SHIPPENSBURG HEALTH v. JOHN C. SHATZER 19. Plaintiff incorporates by reference paragraphs one through eighteen as though set forth at length. 20. During the period of his residency at the facility, John C. Shatzer has enjoyed the benefit of care and services provided to him by Shippensburg Health. 3 21. John C. Shatzer has failed and refused to pay for the costs of his care and services provided by Shippensburg Health to him. 22. John C. Shatzer has been unjustly enriched by his use and enjoyment of the services and care provided by Shippensburg Health without making payment therefor. WHEREFORE, Plaintiff requests judgment in its favor and against John C. Shatzer for the sum of $23,870.93 plus costs, expenses and interest. COUNT III-MONEY HAD AND RECEIVED SHlPPENSBURG HEALTH v. TERESA J. RICKER 23. Plaintiff incorporates by reference paragraphs one through twenty-two as though set forth at length. 24. During the period of John C. Shatzer's residency at the facility, Teresa 1. Ricker has received the social security benefits of John C. Shatzer. 25. The proper use of those funds would have been to pay the costs of care accruing for the care of John C. Shatzer. 26. At the time of receipt of these funds, Teresa J. Ricker knew she was obligated to pay these funds over to Shippensburg Health for the costs of John C. Shatzer's care at the facility. 27. Teresa 1. Ricker gave no consideration for the funds of John C. Shatzer received by Teresa J. Ricker. 28. Demand has been made upon Teresa J. Ricker to tender the funds of John C. Shatzer to Shippensburg Health and she has failed and refused to do so. 4 . WHEREFORE, Plaintiff requests judgment in its favor and against requiring her to: a) return the subject matter in specie; b) pay over the value if Teresa J. Ricker has consumed the money in beneficial use; c) pay its value if Teresa J. Ricker has disposed of the funds received; and d) award costs, expenses and interest. Respectfully submitted, 07\N, BARIC ~ SCHE~,~2 0:a~y1)l (://a1_ , David A. Baric, Esquire LD. 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Attorney for Plaintiff da b.dir/shcc/shatzer/complaint.pld ___'" ............0 111~495755 DES PAGE 08 VERIFICATION The statements in the foregoing Complaint are based upon information which has been assembled by my attorney in this litigation. The language ofthe statements is not my own. I have read the statements; and to the extent that they are based upon information which I have given to my cotmsel, thcy are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. S 4904 relating to unsworn falsifications to authorities. DATE: {f/~/ oS . .. ~ HEALTH CARE CENTER \21 Walnut Bottom Road Shippensburg, Pennsylvania 17257-9005 (717) 530-8300 FAX (717) 530-8304 TTY 1-800-654-5984 ADMISSION AGREEMENT This Agreement is between Shippensburg Health Care Center (the "Facility" or "we" and) Idll.J C. ~lf""'1' ta.. (the "Resident" or "you") and, if you or the court have designated an individual to act on your behalf, or there is another individual to act on your behalf, or operation of law, '1"-6:>4. -;r ~ .....J,"" ("your representative"). A checklist of the rights and responsibilities applicable to your representative is listed in Exhibit 1 and is incorporated into this Agreement. Payinl! for Your Care If you are applying to this facility as a private-pay resident, you must provide all financial information requested by us. If we later find that the information you or your representative provided was incomplete or inaccurate; we-will consider that as a breach of this Agreement which gives us the right to pursue all legal remedies against you or your representative. Who Can Be Reauired to Pay for Your Care Only you and your insurer can be required to pay for your care. No other person, (i.e. a family member, friend, neighbor, legal representative or guardian) can be required to pay from their own funds for your care, although he or she may knowingly and voluntarily agree to guarantee payment for the cost of your care. We require the person responsible for making payments on your behalf to pay for your care under the terms of this contract in a timely manner. If you are a beneficiary of Medicare, Medicaid or any other third-party payment plan, your representative agrees to make all necessary payments from your funds. Your representative could face a civil penalty for intentionally failing to pay required amounts from your funds and could face a criminal penalty for abusing your funds. Private Pay Residents The items and services included in our daily rate is basic room, board and general nursing care as required by your medical condition. Payment for items and services that are included in the daily rate and is payable one month in advance and due on the first of each month. Items and services included in your daily rate are listed in Exhibit 2.A. You will be charged separately for additional items and services not included in our daily rates such as special nursing care, special equipment, pharmacy charges, laboratory charges, medical transportation and additional services such as telephone expense, dry cleaning, beauty and barber services and newspapers. Items and services for which you will be charged are listed in Exhibit 2.8. Payment for these additional items and services are due after you have requested them, and; you have received and have been billed for them. Within 30 days of receiving an item or service, EXHIBIT "An " If you or your representative do not pay the money you owe us and we hire a collection agency or attorney, you agree to be liable for their fees and court costs. Private Duty Nurses Geriatric Aides If you want a private duty nurse or a private duty geriatric aide, you are responsible for selecting a person licensed and/or certified according to Pennsylvania laws and regulations. You are also responsible for paying him or her and for letting us know that you have hired one. The person you hire is not an employee or agent of the facility, but he or she must meet our standards and follow our policies and procedures. Employees of the Facility may not serve as private duty nurses or private duty geriatric aides. RoJdine Your Bed if You Leave the Facilitv If you are hospitalized or on leave from the Facility, we will hold your bed for you as follows: A. If you are private-pay resident, or are receiving inpatient care reimbursed under Medicare Program (and you are not covered under Medicaid), unless you notify us otherwise, we will hold your bed for as long as you pay for it at the daily rate you are currently being charged. B. If Medicaid pays for part or all of your nursing home care and you need to be hospitalized, we will hold your bed for up to the maximum number of days required by this state, currently 15 days. If you leave for any other reason, we will hold your bed for up to the maximum number of days required by this state, currently 18 days. You have a right to be readmitted to the facility to the first available appropriate bed. While we are holding your bed, you are still required to pay the Facility any amount for which you are liable as determined by the Medicaid Program. ,c. If you have applied for Medicaid, your bed will be reserved in accordance with Paragraph B. However, if you are found to be ineligible for Medicaid, then you are required to pay for the bed as a private pay resident as described in Paragraph A. D. Other third-party payers mayor may not have a bed hold policy. We will discuss this ifit applies to you. Your Rieht to Make ComDlaints and Suef!:est Chanf!:es in Policies and Services As a nursing home resident, you have many rights according to State and F ederallaw. These are described in detail in Exhibit 6, which is attached and is part of this Contract. You may make complaints about your care in the Facility and you may also suggest changes in the policies and services of the Facility. You will not be harassed or discriminated against for making a complaint or suggesting a change in a policy or service. You may present your complaints to facility, management company or to one of the following State agencies: Larry D. Cottle, LNHA Administrator Shippensburg Health Care Center 121 Walnut Bottom Road Shippensburg, P A 17257 717-530-8300 Peter E. Perini, Sr. President Magnolia Management, Inc. 1710 Underpass Way Hagerstown, MD 21740 301-745-8700 Ombudsman Office of Aging 16 West High Street Carlisle, P A 17013 717-240-6110 717-532-7286 Ext. 6110 Department of Health 100 North Cameron Street 2nd Floor Harrisburg, PA 17101 717-783-3790 Your Ril!ht to Make Decisions You have the right to make your own medical decisions and to manage your personal affairs. If you become disabled, it may be necessary for someone else to make decisions for you. For this reason, we recommend that you have a living will and/or advance directive for medical decisions and a financial Power of Attorney but you are not required to do so. See Exhibit 7 for a description of your legal rights to decide about your future medical treatment. Transfer, Relocation and Discharl!e You have the right to remain here, and you may not be transferred, relocated or discharged against your will, except for the following reasons: (1) A medical reason (i.e. the facility cannot provide the kind of care that you need, your condition has improved so that you no longer need Jhe care we provide, or a medical emergency arises; (2) Your welfare or the welfare of other residents or staff; (3) Nonpayment for a stay, or (4) the Facility ceases to operate. If we decide that you should be transferred or discharged, we will notify you, and an immediate family member or legal representative, by letter 30 days in advance. If you are transferred because of an emergency situation, we will provide the required notice as soon as practicable. The letter will contain the reasons for the transfer or discharge and its effective date. The letter will also tell you how you can appeal our decision to transfer or discharge you. If you are discharged involuntarily, we will attempt to make other appropriate arrangements for your care. However, if other arrangements are not available, your representative agrees to accept you into his or her custody if it is medically appropriate. Your Ril!ht to End This Contract If you decide to end this Contract and leave the Facility, you must pay your bill before you leave. You must give us five (5) days written notice to tenninate this contract. If you leave before the end of that time, you must still pay for each day of the required notice. In the event you die while a resident of the facility, your representative is responsible for making the funeral arrangements. We will notify your representative immediately. If we are unable to reach your representative, we will contact the funeral home of your choice to facilitate arrangements. Additional Documents It is not possible to cover everything that is important to your stay in our Facility in the body of this Contract. Therefore, we have included additional important documents as Exhibits. These Exhibits are part of this Contract. Please verify that you received the Exhibits and that the contents of the Exhibits were explained to you by placing your initials on the line next to the description of each Exhibit. '1J'~Exhibit 1. Rights and Obligations of Representatives. --t:J t. Exhibit 2. For Private Pay Residents: (a) Items and serVices covered by daily rate. (b) Items and services not covered by daily rate. U Exhibit 3. How to Apply For and Use Medicare and Medicaid Benefits. ~J.f. Exhibit 4. (a) Items and Services Covered by Medicaid. (c) Items and Services Not Covered by Medicaid. ~ Exhibit 5. Physicians Who Practice at the Facility. ~ Exhibit 6. Legal Rights of Pennsylvania to Decide Future Medical Treatment. .-e:S~. Exhibit 7. Policies and Procedures Concerning Your Personal Funds and Your Personal Property. ~ ~. R'Exhibit 8. Services Provided by Outside Health Care Providers. Chan2es in Law Any provision of this Contract that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Contract. If there are services we have agreed to provide that are later found to be impossible to render as a result of a change in State or Federal law, it is agreed that to the extent possible, the Resident and the Facility will continue to fulfill our respective obligations under this Contract consistent with the law. IN WITNESS WHEREOF, the parties have executed this Contract on this~, day of ~~~ ?~~~ Witness Witness Resident If the Resident has been adjudicated disabled or the Resident's doctor determines that the Resident is incapable of understanding or exercising his or her rights and responsibilities, the Facility may require the signature of another person on this contract. The other person may be: (1) An appointed healthcare agent under an advance directive for medical care; (2) A guardian or Power of Attorney ofthe person; @A surrogate or family member. ~A~{j.~ ResponsibleCParty (Name) ()) Title: Indicate whether you are (1), (2) or (3) EXHIBITS TABLE OF CONTENTS Exhibit 1 Rights and Obligations of Representatives. Exhibit 2 For Private Pay Residents: A. Items and Services Covered by Daily Rate B. Items and Services Not Covered by Daily Rate. Exhibit 3 How to Apply For and Use Medicare and Medicaid Benefits. Exhibit 4 A. C. Items and Services Covered by Medicaid. Items and Services Not Covered by Medicaid. Exhibit 5 Physiciatts Who Practice at the Facility. Exhibit 6 Legal Rights of Pennsylvanian's to Decide About Future Medical Treatment. Exhibit 7 Policies and Procedures Concerning YOur Personal Funds and Your Personal Property. Exhibit 8 Services Provided by Outside Health Care Providers. , EXHIBIT 1 RIGHTS AND OBLIGATIONS OF REPRESENTATIVE - The 'Representative shall-have the right to be notified by the Facility of any event or. occurrence , involving the Resident, which directly affects any obligation- of the1Representativeunder this .,,' "Agreement." Representative agrees to' assume y independently, ., under-' this"Agreement; the following, obligations and'is entitled to the following. rightS,r,as indicated~by,'Representative's initials accompanying any of the following provisions: '. . Representative agrees to be' responsible for ensuring, that any'payment "froni.'th'e"tesident to' which the Facility is. entitled'pursuant'to this Agreement shall.,be,paid,.ta,the>Eaeility in a timely maimer. In the event the Resident is a beneficiary of Medicare, Medicaid or any other third-party payment plan, Representative agrees to ensure that all co-payments, co-insurance or charges and fees for non-covered items and services, together with any late fees as . described. under this Agreement, shall be paid from the Resident's funds.. ,Representative is subject to' a: civil 'penalty. for willful violation' of theagreement~o"distribute'the'Resident' s funds to the facility. · (Unless the Representative voluntarily agrees to act as guarantor), Representative shall be responsible for any payments required under' this Agreement only to ,the extent. of the Resident's funds. .. ResidenUs applying for admission on private pay. basis, and Representative, agrees to, assist , the Resident in providing' all financial'infurmation required by the Facility. to detennine the extent of the Resident's resources. If it is ever detennined the Representative participated in the disclosure of incomplete or inaccurate information, the incomplete or inaccurate disclosure shall be deemed a material breach of this Agreement and the Facility reserves the right to pursue all available legal remedies against the Representative, including but not limited to an action for breach of contract. · Representative is signing this Agreement as a duly authorized agent such as an appointed healthcare agent under an advance directive or guardian appointed by a court. A copy of all supporting documentation for this representation is attached to this Agreement. · Representative, is signing this. Agreement on Resident's behalf; based upon a physician's certificate, a copy of which is attached to this Agreement, certifying that Resident does not possess the capability to understand his or her rights and responsibilities. · Representative agrees that in the event of the Resident's death, Representative shall take responsibility of all burial arrangements for the Resident and for removal of all personal property from the Facility. (Exhibit 1, Continued) . If it is the desire of the Resident or Representative to obtain the supplemental services of private duty nurses in accordance with the requirements described under this Agreement, , Representative agrees to be responsible fQJc arranging independently for those services, including ensuring any payment. . , Representative agrees. that in. the event the Resident's private funds ,are'. exhausted during the ,. , Resident~s.stay and,theResident is:eligible to apply for benefits undel'.theMedicaid'Program, , the Representative shall' assist the Resident and then Facility' with . any application for Medicaid benefits. " Representative, further agrees to. act; ;oTI;behalf':of-the',Resident,. to " , facilitate any Medicare; . Veterans Administration' or other third"party. benefits. which. may be available to cover the cost of Resident's care at the Facility. . ' In the event the resident seeks to terminate this Agreement, the Representative agrees to ensure that all notices required under this Agreement are provided to Facility. ,. In the event of an involuntary termination of this Agreement, if.other.arrangements acceptable to the Resident cannot be made, the Representative agrees to accept the, Resident into the Representative's custody, if medically appropriate. . Representative has.,the right to copies of the following documents and any amendment to them: Representative further acknowledges receipt of the following documents, which may be amended from tlme-to-time. 1. A copy ofthis Admission Agreement. 2. A list of the Facility's rates, subject to amendment on'thirty-(30) days notice, and a description of charges for services not included. 3. A list of health care providers offering services at the facility. . Representative acknowledges the Facility's right to any legal remedies available under law for Representative's breach of this Agreement. EXHIBIT 2.A Private Pav Residents A. Items and Services Included in the Dailv Rate The items and services included in the daily rate, and their related charges, are listed below: Description of Items and Services Included in the Dailv Rate 1. Room 2. Board 3. Social Services 4. Nursing Care, including: a. The administration of prescribed medications, treatments and diets. b. The provision of care to prevent skin breakdown, bedsores and deformities. c. The provision of care necessary to encourage the resident from accident, injury and infection. d. The provision of care necessary to encourage, assist and train theresident in self -care and group activities. 5. Other: Activities Total Dailv Room Rates (effective July 1, 2003) Special Care Program Private Rooms $179.00 $189.00 Semi-Private Rooms $164.00 $184.00 Triple/Quad Rooms $152.00 $174.00 Medicare co-pay: $105.00 EXHIBIT 2.B ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE The following items and services are not covered by the Facility's basic daily ,rate: Item or Service Physician Services Medications Prescribed Dietary Supplements Personal Dry Cleaning, Personal Linens Telephone Television Service Beauty/Barber Shop Services Clothing Sundry Pharmaceutical Ambulance Service, Medical Transportation IV Therapy X-Ray Services Medical-Nursing Supplies Dental, Podiatrist and Opthamology Services Physical, Speech and Occupational Therapy Services Oxygen Newspaper, Periodicals Lab Services Specialized and/or specially ordered medical services/equipment Guest meals (Exhibit 2.B, Continued) ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE (refer to the Ancillary Charge List for additional costs) Item Charge ' Telephone Direct bill from telephone company , Television/Cable per month $7.00 per month , BeautylBarber Shop Services: Permanent Haircuts and Blow-dry Hair Sets Cut Only Color' $35.00 $10.25 $8.25 $8.25 $30.00 Personal Laundry $45.00 per month Personal Dry Cleaning Same as billed by c1earier Physical Therapy Service Determined by level of care required Occupational/Speech Therapy' Determined by level of care required IV Therapy Charge list will be provided by contract pharmacy prior to delivery of services Aerosol Therapy Determined by level of care required *************************************~**************************************** Shippensburg Health Care Center cordially invites family members, guests and friends to join our Resident's at meal times. The prices for guest trays, effective July I, 2001 are as follows: Breakfast A Breakfast B Lunch A Lunch B Dinner A Dinner B $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 Will be sei-ved at 7:00 AM ($3.77 + .23 state tax) served at 7:30 AM Will be served at 12:00 PM ($3.77 + .23 state tax) served at 12:30 PM Will be served at5:00 PM ($3.77 + .23 state tax) served at 5:30 PM *The Resident's will be assigned their meal times upon admission. Meals can be paid for at the Receptionists' desk. In order to prepare sufficient quantities we require a 2-hour notice to prepare guest tray. EXHIBIT 3 The following summarizes the Medicare and Medicaid programs. It also tells you who to call for more detailed information. If you have questions, our staff will also help you. , What's Covered - Medicare 1. Care in a hospital 2. 100 days of skilled care in a nursing home. Medicare provides full coverage for the first 20 days. You must make a 'co-payment after that. Thefollowing services are, examples of skilled care: a. Injections & feedings given through an IV b. Tube feedings c. Application of a dressing that involved prescription medication d. Treatment of stage 3 or 4 bedsores 3. Medically necessary doctor's services. What's Covered - Medicaid Medicaid is a comprehensive program that will cover most of the costs 'of a nursing home stay. See Exhibit4 for information about covered and non-covered items. Your Contribution - Medicare ,'Medicare does not pay 100% of the cost of covered services.' You will be required to pay part of the charges. Your payment may be called a "co-payment", "deductible" or ."premiurn", depending on the type of care provided. If you receive Medicaid, Medicaid will pay for any payment that you are responsible for under Medicare. Your Contribution - Medicaid. Depending on your income and assets, you may be required to make a contribution toward the cost of your care. The amount of any contribution will be decided by the local Board of Assistance. Who's Elie:ible - Medicare People 65 years old orolderwho are eligible to collect old-age benefits under Social Security are eligible. PersonS who receive Social Security disability benefits for at least 24 months, or have been found eligible' for Medicare', by the Social Security Administration because they have end stage renal disease requiring regular dialysis or kidney transplant are also eligible. Who's Elie:ible ~ Medicaid, Eligibility depends on whether your income and assets are below certain levels: 1. Income: You should consult the local Board of Assistance to find out whether your income makes you eligible. That phone number is listed on the next page. If you qualify, $30 per month of your income is protected for your personal use while in the Facility. (Exhibit 3, Continued) 2. Assets: The Cumberland County Board of Assistance will also be able to evaluate your assets and tell you whether you qualifY. The following are examples of things not counted as assets. a. Your house if your spouse lives there. b. Household goods. c. A certain amount of cash. d. " Personal Property in your possession in the Nursing home. e. A certain amount of money for burial arrangements. How to Aoolv - Medicare Contact the local Social Security Office at the following address: Social Security Office 401 E. Louther Street Carlisle, PA 17013 (800) 772-1213 (717) 243-0085 How to Aoolv - Medicaid Contact the local County Board of Assistance at the following address: Board of Assistance 33 Westminister Drive Carlisle, PA 17013 (800) 269-0173 (717) 249-2929 . Whom to Contact ifvou have a Ouestion or Problem - Medicare If Medicare denies a claim, you have the right to appeal the denial. You may appeal by writing to: Aetna Medicare Claim Administration 501 Office Center Building Fort Washington, PA 19034 (215) 643-7200 Whom to Contact ifvou have a Question or Problem - Medicaid If your application for Medicaid is denied, your coverage is tenninated, or a service is not covered, you may appeal in writing to: County Board of Assistance Office 33 Westminister Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 (Exhibit 3, Continued) Whom to Contact if yOU have Incurred Medical EXDenses Drior to your MA Effective Date Medicare - Not 'applicable '.;~vWhom to Contact if vou.' have 'Incurred Medical EXDenses Drior to.your:MA Effective,Date . - Medicaid ' ' . " Medical bills that you received in the 3 months prior to' receiving. Medicaid>may, be.'covered by Medicaid. Contact: County Board of Assistance Office 33 Westminister Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0'173 EXHIBIT 4.A A. Items and Services Covered bv the Medicaid Per Diem Rate " .. _ . : Regular ro01I1;ilietary. services, social services and othec'Services'required-tO' meet , certification standards, medical. and surgical supplies;' and the use of equipment and facilities. . '. _ ,;, GeneralnursingiserVices,' including but not.l.imited, to',',adrninistrationiQf':oxygen "and" related; medications; handfeeding, incontinency.:~car,e;\I,tray,,'serv.ice' and enemas. _ , Basic Beauty/Barber Services. The facility: must provide shampooing and hair care which is considered necessary for hygiene. The facility must infarin the resident of the types and frequency ofthe services provided. _ Items furnished routinely and relatively uniformly 'toall'residents, such as water pitchers, basins, and bedpans. -Items ,furnished, distributed, or used individually in':.small quantIties such as alcohol, applicators, cotton balls, bandcaids;antacids;' aspirin (and other nonIegend drugs ordinarily kept on hand), suppositories;ai1d tongue depressors.. _ Items used. by individual residents but which ,are reusable'and'expected to be available such as ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment, and other durable medical equipment. " _ Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diets, even if written as a prescription item by a physician. - Laundry services for other than personal clothing. _ Non-emergency.medical transportation services. _ Other special medical services of a rehabilitative, restorative, or maintenance nature, designed to restore or sustain the resident's physical and social capacities. - Personal care items including a patient gown, shampoo, skin lotion, comb, brush, toothpaste, toothbrush, and denture cream. EXHIBIT 4.B B. Items and Services Not Covered bv the Medicaid Per Diem Rate . Medical expenses such as, but not limited to: . Health insurance premiums. . ,Visits by a non-participating, physician. other than: appraved' by the, nursing care facility. . . Emergency ambulance services,' if the ambulance. company doeg;:not accept'MA. . Over-the-counter medications, which are a particular brand not supplied by the nursing facility. For example, the nursing facility must provide aspirin, but the patient:.may request and buy a specific brand of pain reliever, such as' Excedrin PM, or Tylenol. . Hearing aids and batteries. . . Specialized Beauty/Barber Shop services. . . Diapers, if the resident wants a style or brand.which" is,'not'provided, by the nursing care facility. . Personal care items of the resident's choice ifhe prefers them instead ofthe items provided by the nursing care facility. This includes items such as brushes, combs, toothbrushes, cosmetics, etc. EXHIBIT 5 PHYSICIANS WHO PRACTICE AT THE FACILITY Dr. Yogindra S. Balhara, M.D. 761 Fifth Avenue Chambersburg, P A 17201 (717) 261-2583 . Dr. William Kramer, M.D. 144 South Eighth Street Chambersburg;. P A 17201 (717) 264-6511 Dr:Paul Orange, M.D. 4225 Lincoln Way East Fayetteville, PA 17222 (717) 352-3616 , Dr,:BaxterDrewWellmon, n, D.O.,P.C. 127 ,Walnut Bottom Road Shippensburg, P A 17257 (717) 532~3211 Dr. Hong S, Park, M.D. 120 North Seventh Street Chambersburg, P A 17201 (717) 267-7735 EXHIBIT 6 LEGAL RIGHTS OF PENNSYLVANIANS TO DECIDE ABOUT HEALTH CARE . You Have the Ri!!ht to Decide About Your Health Care , Adults,generally'havc:' the" right- to decide if they want medicaL treatment,i,un1ess" they are not.. " .' . "competent.\" ThiS" right includeS" decisions about treatments that extend life;: Iife,:support machines,. or feeding tubes. .,,- SOIrletimes; 'an,accident'or; illness takes away' a'person'sability,tmmake,health.'care'clJ.oices,' But"... . ". . ,;.the 'decisionscstill:must be made,'. If you.' are'unableto;makecthem;.":OtheFS"~wilk,:;The):"wiThtdecide . . ", ,:.. based on your. wisheS", ,or your best interests if your wishes are'unknown. ,Pennsylvania law gives'you the right to make many health care decisions'in advance. One way . ,.. .., to do this is by using a written advance directive to name an agent to make your health care ' decisions if you cannot. A written advance directive can also state your treatment preferences, especially about life sustaining procedures. Namin!! a Health Care A!!ent You. can name' anyone to' be your health care agent. The"only"'exception is"that;. in, general, someone who works where you are receiving your care cannot be your agent. . Your agent can be a family member or a friend. . .,You 'choose:when. your agent-can decide for you - right away; jf'you.,want; ori only' after two ' ,', doctors agree that you arenotabJe.to.decide for,yourself 'Youalsd,choose.thc::kinds,KJfuecisions; ,",,, . your agentcan'make for you.' For example,. ifyou.want, you can ,give your, agent very broad' power to decide about life.sustaining treatment. Pick your health care agent very carefully.' Make sure your agent knows what you want. Your agent will then follow your wishes, even if your friends or family disagree. Usin!! Advance Directives There are many ways to use an advance directive. A living will is a type of written advance directive that states your wishes on life-sustaining treatments. It usually comes into affect when a person will die very soon from an incurable condition. It can also be used when a person is permanently unconscious (Ill a vegetative state). You can make a broader written advance directive for other health care issues too. For example, you can decide whether you want life-sustaining treatment if you are in an end-stage condition:. An end-stage condition is an advanced, progressive, and incurable condition resulting in complete dependency. What Happens HYou Do Not Make an Advance Directive? No one can deny you health care because you do not have an advance directive. But you should know what happens legally if you do not. (Exhibit 6, Continued) . , Pennsylvania law allows a surrogate to make medical decisions for you if you have not named a health care agent and are no longer able to decide treatment issues yourself. Then, your closest ,," . relative, would be asked' to' make health. care' decisions' for you. . Y OUC'.spouse;. 'adult:chi1dren,"., ,," parents,or adult brother~ and sisters;' in that order, are considered' your closest relatives;' If these .' relatives.lare not available, another.relative or' close friend . can 'make. decisions for.you.. .A . " .. ,surrogate;" though,'mighthave less" authority to :. decide. against: life"Sustainiilg procedures,than ' a'. " ' health care agent. ;..,. . i' IJ[.there. is 'nooneto be. a :surrogate, .a' court. might have .to:;' appoint 'a" guardian ,to:'inlikeyour. .,. "medical decisions: The guardian,might' be. somebody who does'not-:.know''Y0u'personally-,.','''' " HowDoYon Get More Information? This summary. does not cover every issue.' If you have legal questions about your rights, please speakto a lawyer. Also talk to your health care provider aboutthe.medical.issues imrolved,in ,. , " .".' .,.<".youc,care:; Tell those "caring for you about your 'decisions'anckgive:.them.Ja;lcopy;;Of"any.:advance " ,', difective. For a free copy. of a Living Will or Advance Directive form contact: State Representative Jeff Coy 39 West King Street Shippensburg; P A 17257 (717) 532-1707 or Cumberland County Office of Aging Human Service Building 16 West High Street Carlisle, PA 17013 (717) 532-7286 Ext. 6110 (717) 240-6110 EXHIBIT 7 POLICIES AND PROCEDURES CONCERNING YOUR PERSONAL FUNDS AND YOUR PERSONAL PROPERTY A Your Rights: L ' You" have the right to ,keep and use your"personaL.property,..:incIuding some furnishings and clothing, so long as there is emlUgh:spac~and':othefI:esidents are . not inconvenienced. ' You also have the' right" tosecurfty'for your-personal possessions. 2:.' . , . ,You have'the'rightto:manage' your financiai.1lffaiFssunless~a'/eolJrt)-detennine&. that you, are", incapacitated ,.. or the" Social ..Security\~.<AdII1inistfatiotil'llSelects a . representative to receive Social Security funds'for your use and benefit. 3. We cannot require you to deposit your personal funds, with us. You may, however, choose any person to manage your funds, including the Facility. 4. If you decide to have us manage yourpersorial.funds,you'may,withrlni.w-your money that .we keep in the Facility. during. the;'FacilityZs; ,business: hOurSL "If we . have deposited any of your funds in a bank, 'YOli':may obtain' those 'funds within three bankingdays,providedthe funds have cleared. 5. If you. ,need help to' perfonn y:our bankingAransactions,i you', may.; give, the ,administrator.. of ;,ourFacility legal, authority. to '.access' your' account. This authority. is called "representative' payee," To give the administrator this authority, you will need to complete a special form. 6. You and your personal representative have the right, during normal business hours, to inspect our written records that concern your personal funds. ' 7. You and your personal representative have a right to file a complaint if either of you believes that your funds, valuables or other assets have been stolen or damaged. The agencies to contact in order to make a complaint are listed below: a. The Cumberland County Office of Aging Attn: Ombudsman Human Services Building 16 West High Street Carlisle, PA 17013 (717) 532-7286 Ext. 61I0 (717) 240-6110 (Exhibit 7, Continued) b. Cumberland Caunty Board of Assistance 3 3 Westminster Drive . P.O. Box 599 Carlisle, PA 170'13 (717) 249-2929 . (80'0') 269-0'173 c. . The Department of Health Divisian of Nursing Care Facilities 100' Narth Cameron Street 2nd Floor Harrisburg, PA 1710'1 (717) 783-3790' B. Our Responsibilities: ,.If'''' ,We, will! provide a' reasonable. amaunt aft'secureispaced'ou,'you.ta,ikeep.:yaur "clothing and other personal property.: We must; investigate .anydamage,to:'orJoss afyour persanal property. , '2.' :.""If'you'want us to manage $5D:DO"or.:.Jess;of'youriperscfualduridsy,we. wilLdeposit. . ". , this moneym ,a non-interest bearing' account orapettyea-sllifund: ',' 3;... m'yau"want'us :to'. manage' more' than-.:$50:DO'.Of>,youI"'personahfundsp'\Ve..will' , depasit this 'money in an interest bearing, accauntthat.. is insured, by the. federal. government. This account will be separate fram the accaunts we use to operate the facility. In addition, we will credit you with all interest earned on your maney. 4. We will maintain a full, complete and separate accounting of your personal funds. We will alsO' provide you with a quarterly statement af the activity af your account. 5. If you' receive, Medicaid benefits, we will natifY yail if yaur account balance becomes too high. If you are to' remain eligible for Medicaid, your account balance must be under a certain dallar limit that is established by the Federal government and changes periodically. . . 6. We may not use your personal funds to' pay for an item or service that Medicare ar Medicaid cavers. 7. We will maintain adequate fire and theft coverage to protect your funds and personal property that are kept at the Facility. We shall also abtain a surety bond or otherwise assure the security of your personal funds that are deposited with the Facility. (Exhibit 7, Continued) 8. If you are discharged, there are several things we must do: a. .We will ensure the return of your personal funds in our, possession. If we have depositedyour..personal funds in a bank account;. we will, ensure. that ' this' money is made available to you' o.your, authorized 'representative within 30 days. " b," ',!f;we are. your' representative payee;for~Social"Sec,urity., benefits;"",we will , ,promptly ask 'the Social Security' Administration": to'nlune a new , " . representative payee and'we will transfer-'younnoneytothat'personi' 9. In the event of your death, there are several things we must do: a. We will convey your personal funds and a final accounting of those funds to the,person'in charge of administering,your-:estate within.30 days. We will;immediately notifY, any' govemment'agencyAhatpaid.:,for,alLor.,part' of your care in our Facility. That agency, 'shall have the right to assist us in , determining what to do with your property. . b. ..': Ifa' government agency, did not pay for your care;' wewill,immediately . notifY,.your. representative or next of Icin,todeterm:it1e'.what..to.do'with your , property. c. If we have your funds, valuables or otheI: assets, in our possession, we will hold them until. the appointed personal representative of your estate presents a copy of the certified Letters of Administration to us. All conveyance of personal funds will be by check made payable "To the Estate of. . . ". d. We will make reasonable attempts to locate your personal representative and your heirs. If no claim is made on your funds, valuables or other assets in our possession within six weeks of your death, we will write the State Office of the Comptroller for direction. 10. Ifwe are in possession of your funds, valuables or other assets for more than one year from the date of your transfer or discharge, we will transfer your funds, any interest on your funds, and your valuables or other assets to the State Office of the Comptroller's Office of any account(s) in your name of which we have knowledge. EXHIBIT 8 SERVICES PROVIDED BY OUTSIDE REALTIi CARE PROVIDERS , , ,,' . Some. ofthe. services available.in the Facility; such'as pharmacy, services, are, pro.v.ided by outside ' ','healtlr careproviders:"These services; and information about the' providers; , appear below. . You ' are free ta pick your own provider or to use one of those listed below: _ Type'of Service Provider's Name, Address and Telephone Number , Whether we have a'finanCial . , . ,Interest in the Provider Physician Dr. Y ogindra Balhara 761 Fifth Avenue Chambersburg, PA 17201 (717) 264-6185 No X-Ray Services Mobil X-Ray Services The ChambersburgHospital 112 N. Seventh Street Chambersburg, P A 17201 (717) 267-6356 No Lab Services The Chambersburg Hospital 112 N. Seventh Street Chambersburg, P A 17201 (717) 267-7153 No Phannaceutical Pharmacare Route 3, Box 3-A Cumberland, MD 21502 (301) 777-1773 No Podiatrist Dr. Peter Holdaway 1936 Scotland Avenue Chambersburg, PA 17201 (717) 264-5211 No Podiatrist Dr. Kirk Davis, D.P.M. 601 Wayne Avenue Chambersburg, PA 17201 (717) 267-2255 No (Exhibit 8, Continued) TVl'e of Service Dentist Hospital fupatient or Emergency Room Provider's Name, Address and Telephone Number Whether we have a financial Interest in the Provider Health Drive . 928JaymorRoad Silite C-190 'Southampton, PA 18966 (215) 942-9950 FAX (215) 942-9954 No Carlisle Hospital Chambersburg Hospital Fulton Co. Medical Center Hershey Medical Center Waynesboro Hospital No No No No No pAiF~2. 4-04 NOTICE TO APPLICANT ~., BENEFIT , I 31ST ANCE L vrlECK B.JGlBLE B.J~Jt..e: PENDING 1-800-269-0173.717-240-2700 DEPARTMENT OF PUBUC WElFARE CUMBERlAND COUNTY ASSISTANCE OFFICE 33 WESTMINSTER DRIVE P. o. BOX 599 CARLISLE, PA 17013-0599 fi YOUR RECENT APPLICATION HAS BEEN REVIEWEO ANO YOUR ELIGIBILITY HAS BEEN DETERMIIJED FOR THE BENEFITS SHOWN BELOW o MEDICAL ASSISTANCE Mertha first check which may be a special am~1 you wm ~eive $ o Twice a Month 0 Once a Month. [J In the Mail o You have a patient pay liability of $ for the period beginning and ending D At the Bank o Effective Date o FOOD STAMPS YouwiD~eive$ a month from for the month(s) of then you will receive food stamps in the amount of $ to 0 In tf:Ie Mall 0 At the Bank '>4 Level of care authorized a month toward your care. , R","~,o'5S Pa.Cal.. \;Is.. \i ('r\ ~o:as.iW1iJ nc:tl?l.l',,~ l'~off'\LlrSV\lj ~((.'L~CUJ.ll.'\'IlLfd\Cc.<Mc. VI ~ ~ !)at- r ckJ \ c..,~,l'Prc.Cotl PA-'-I; tM.do~ M~~cf a..~\f'Isxo...lti.' QwI'lPb:V\<J pLotl CoP'i of Scw;USu..tJ~ ~'~,~arcl; {Y) d ~K :;.~15Gr ~ 2COQ or.d ~~b1 Q..H~d~~~t&Dk. t\.SSISItr>u..:WG.S :10 s;hrl-;~ Wr~tfqfl)$1!x>$'"p~<;\);n. . , ' . " "'. ,,' , " . ;' . "'.' .... . . Name $ $ $ $ $ $ Name" $ $ $ $ $ $ r-- \ TOTAL GROSS MONTHLY INCOME GROSS MONTHL V.DEPENDENT CARE COSTS GROSS MEDICAL COSTS Telephone Electric Gas Oil Water/Sewage GarbagelTrash Utility Installation Other $ $ $ GROSS UTIUTV COSTSlUTILITV STANDARD. RENTIMORTGAGE TAXES INSURANCE COST ON HOME TOTAL SHELTER COST Name $ $ $ TOTAL GROSS MONTHLY INCOME $ NET MONTHLY INCOMElNET SEMI.ANNUAL INCOME $ INCOME LIMIT $ L1 '6Q 45< I P:~ J CTRDlG I OIST (Y)(J ll\lr~ i\.,.}'u-, Worker's Signature .' ~ 711-;;)f-l").;n'\l/' Telephone Number (, ---- ~ -~---- --- - --- -~-- -- --- ---- t _ _ __ _ _ ~ ,'':! _ ; "- '__ ~ _ _ _ ...:: <:"\'.~..~~Ca,t ~"':fl~\ \~I C:h\nW' 1Oo~ RJ Ct;..i:\-\&\J.., (li\ n;}\~ . -,:;"" ,. LEGAL SERVICES. INC. , 8IRIiINEJ~OW , CARLISLE, pA17013-3019 "717-243-9400 717-766-8475 EXHIBIT "B" L .J, c..' . .' - - , ;,,",' - -.;. ~);.,. CU"ENT-b6R":,:;. .~...\";::.:,~. ~ ':':::\~t~~~~{~r~:~~€i~~i:S~~~~{~;~> STATEMENT. (' SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD SHIPPENSBURG, PA 17257 Facility Phone: 717-530-8300 Resident: JOHN SHATZER Statement Date: 05/19/05 Teresa Ricker 230 MEADOW DRIVE Shippensburg, PA 17257 Date Service Through Qty Description Amount Sub Total as of 04/30/05 14,338.73 Charaes 05/31/05 Sub Total Balance 4,898.00 4,898.00 19,236.73 05/01105 05/31/05 31 Room Charges (~ Cash Receipts/Adiustments Sub Total Balance -11.80 -94.00 -105.80 19,130.93 05/12/05 05/12/05 01/16/05 01/16/05 01/16/05 01/16/05 Payment Payment Proiected Prebill Charaes 06/01/05 06/01/05 06/30105 30 Prebill Room Charges Sub Total Total Amount Due 4,740.00 4,740.00 23,870.93 EXHIBIT "e" Paa.. 1 ~ ~~ \\ ~/~ ,~ ~ \ '\, ~ - , ~ ~~ <:;;;- '^' ~ ~~ ~ ~ ~ o ,"'- -;;~-: ~ ~ '0~::P e;- -\''-'\'0'; ~.:~~\ :: L~{n ':~ -CC ,'\'" ,...> .g, i,;..rl <c:~ ~ \-..' C'- ~/ ._.i., ...<. r- eo I SHIPPENSBURGI SOUTH HAMPTON MANOR, L.P. : Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2005- 3077 CIVIL TERM JOHN C. SHATZER and TERESA J. RICKER, Defendants. CIVIL ACTION-LAW PRAECIPE TO ENTER DEFAULT JUDGMENT PURSUANT TO Pa.R.c.P. 1037 TO THE PROTHONOTARY: Please enter judgment in favor of the Plaintiff, Shippensburg/South Hampton Manor, L.P. and against the Defendant, John C. Shatzer, for failure to file an answer to the Complaint of Plaintiff. A true and correct copy ofthe Notice of Default is appended hereto as Exhibit "A." A true and correct copy ofthe Certificate of Mailing for the Notice of Default is appended hereto as Exhibit "B." I certify that the Notice of Default was given in accordance with Pa.R.C.P.237.1. Plaintiff requests judgment in the amount of$23,870.93 as set forth in the Complaint. Respectfully submitted, O'B~EN BARIC WERER :aliA David A. Baric, Esquire 1.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 dab.dir/shcc/shatzer/default-john.pra I , I Ii ! SHIPPENSBURGI i SOUTH HAMPTON MANOR, L.P. : ,I Plaintiff, I' Ii Ii 'ri II I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2005- 3077 CIVIL TERM JOHN C. SHATZER and TERESA J. RICKER, Defendants. CIVIL ACTION-LAW II TO: !i , ,I John c. Shatzer 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257 Date of Notice: July 14,2005 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAYBE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE i THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. " Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone: (717) 249-3166 David A. Baric, Esquire 19 West South Street Carlisle, P A 17013 (717) 249-6873 I I I !I \I I', Exhibit "A" u.s. POSTAL SERVICE CERTIFICATE OF MAILING ",..--. or~ 'J ) :l ~~o\..'>/ ~.-/~~ ~ ~ "'Fie::;) .~_:;j_:g' m.; ""'0(/)_"'0 -~ ~ -roo ... -I 'W!T1 Vl ~- ~~i! N ~ C'l m MAY BE USEO FOR DOMESTIC AND INTERNATIONAL MAIL DOES NOT PROVIDE FOR INSURANCE-POSTMASTER ;/ &riCl* Scnmt" ';;: PS Form 3817, January 2001 Exhibi t "BII :1 t SHIPPENSBURGI SOUTH HAMPTON MANOR, L.P. : Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2005- 3077 CIVIL TERM JOHN C. SHATZER and TERESA J. RICKER, Defendants. CIVIL ACTION-LAW CERTIFICATE OF SERVICE I hereby certifY that on July t 1 ,2005, I, David A. Baric, Esquire, of O'Brien, Baric & Scherer did serve a copy of the Praecipe To Enter Default Judgment Pursuant To Pa.R.C.P. 1037, by first class U.S. mail, postage prepaid, to the party listed below, as follows: John C. Shatzer 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257 Teresa J. Ricker 230 Meadow Drive Shippensburg, P nnsylvania I David A. Baric, Esquire C) '" (.J ~ , c;;J ~ ~ .'- c::;) -n c~(\ ~ .-1 -,- h1 ~ ~ !') ~ ~ ...f-.': ~. "- ~. ~ , "1\ ~ I..) ~ ~ en c:.' il " i SHIPPENSBURGI SOUTH HAMPTON MANOR, L.P. : Plaintiff, V. JOHN C. SHATZER and TERESA J. RICKER, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2005- 3077 CIVIL TERM CIVIL ACTION-LAW NOTICE OF JUDGMENT PURSUANT TO Pa.R.C.P. 236 TO: John C. Shatzer 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257 Notice is hereby given to you of entry of a judgment against you in the above matter. Date: 9/11.;l~ ~.a'!)- " notary II SHIPPENSBURGI SOUTH HAMPTON MANOR, L.P. : Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2005- 3077 CIVIL TERM JOHN C. SHATZER and TERESA 1. RICKER, Defendants. CIVIL ACTION-LAW PRAECIPE TO ENTER DEF AUL T JUDGMENT PURSUANT TO Pa.R.c.p. 1037 TO THE PROTHONOTARY: Please enter judgment in favor of the Plaintiff, Shippensburg/South Hampton Manor, L.P. and against the Defendant, Teresa J. Ricker, for failure to file an answer to the Complaint of Plaintiff. A true and correct copy of the Notice of Default is appended hereto as Exhibit "A." A true and correct copy of the Certificate of Mailing for the Notice of Default is appended hereto as Exhibit "8." I certifY that the Notice of Default was given in accordance with Pa.R.C.P.237.1. Plaintiff requests judgment in the amount of$23,870.93 as set forth in the Complaint. Respectfully submitted, David A. Baric, Esquire J.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 .I .. SHIPPENSBURGI " SOUTH HAMPTON MANOR, L.P. : Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2005- 3077 CIVIL TERM JOHN C. SHATZER and TERESA 1. RICKER, Defendants. CIVIL ACTION-LAW TO: Teresa J. Ricker 51 Gutshall Road Shippensburg, Pennsylvania 17257 Date of Notice: August 10, 2005 IMPORTANT NOTICE YOU ARE IN DEF AUL T BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAYBE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LA WYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone: (717) 249-3166 ; Ii " i: !I , " :1 !I I " 'I :1 I David A. Baric, Esquire 19 West South Street Carlisle, P A 17013 (717) 249-6873 EXHIBIT "A" U.S. POSTAL SERVICE CERTIFICATE OF MAILING MAY BE USED FOR DOMESTIC: A~D INTERNATIONAL MAil. DOES NOT PRO\JIDE FOR INSURANCE POl;TMASTER Received From: liBrltil 't &triC'/ cr Scherf%' J.:j WESt .SO\l~f.,,* c.arlis\~1 1'1'1 nD\~ ~iece of ordinary mail addressed to: \f.rt,So...j. t<:\c.&r 0\ Gutshall r\oo.d ~tn~\?UJ"I fA I1OlS7 PS Form 3817. January 2001 EXHIBIT "B" o o o = = g~ en~ ~Lc b~ en I Affix fee here in stamps ail ~" .~ i~ u ~a ~ " c: :to . :t> :t> tn ::J: -,'''C. O_-.J_D c.OOV'l-""O z. -,':::lO -l 'w'" (/) o. -< U1 "'tl ~ :to '" '" II I CERTIFICATE OF SERVICE I hereby certify that on August 25, 2005, I, David A. Baric, Esquire, of O'Brien, Baric & Scherer did serve a copy of the Praecipe To Enter Default Judgment Pursuant To Pa.R.C.P. 1037, by first class U.S. mail, postage prepaid, to the parties listed below, as follows: Teresa J. Ricker 51 Gutshall Road Shippensburg, Pennsylvania 17257 David A. Baric, Esquire .-.> c.;.::> 0 t:~','::\ -n '\ ~ ~ ~.n, .> ~'''' ;::;.l r'~':: r\1~ ~ ~ G") ,,) ~,,~ c;--, ~ U\ .'''iC) ~ ~ >:(') "":TO' " ,', "- "",1 -\-;..- ---.J ~ > ~. ':' . <2 /~, rrl ~ ." t>(\, '\ --, -.. "", :ss ~ .~:: Iv .-< - II 'I I SHIPPENSBURGI SOUTH HAMPTON MANOR, L.P. : Plaintiff, V. JOHN C. SHATZER and TERESA J. RICKER, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA NO. 2005- 3077 CIVIL TERM CIVIL ACTION-LAW NOTICE OF JUDGMENT PURSUANT TO Pa.R.c.P. 236 TO: Teresa J. Ricker 51 Gutshall Road Shippensburg, Pennsylvania 17257 Notice is hereby given to you of entry of a judgment against you in the above matter. Date: 'if .X' OS /<:;/ ck.k? ~ Prothonot //lZL.- SHERIFF'S RETURN - REGULAR CASE NO: 2005-03077 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHIPPENSBURG SOUTHAMPTON MANOR VS SHATZER JOHN C ET AL ROBERT BITNER , Sheriff or Deputy Sheriff of Cumberland County,pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon SHATZER JOHN C the DEFENDANT , at 1550:00 HOURS, on the 17th day of June 2005 at 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 by handing to JOHN C SHATZER a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 18.00 14.40 1. 75 10.00 .00 44.15 r~~-"t:~ R. Thomas Kline 07/27/2005 OBRIEN BARIC SCHERER me this I?-rll day of B~~A \(,~ Deputy Sherlff - Sworn and Subscribed to before A.D. SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2005-03077 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHIPPENSBURG SOUTHAMPTON MANOR VS SHATZER JOHN C ET AL R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: RICKER TERESA J but was unable to locate Her in his bailiwick. He therefore deputized the sheriff of FRANKLIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On July 27th , 2005 , this office was in receipt of the attached return from FRANKLIN Sheriff's Costs: Docketing Out of County Surcharge Dep Franklin Co 6.00 9.00 10.00 39.40 .00 64.40 07/27/2005 OBRIEN BARIC So an~ ~,.,::'Y .~;"..-~~' C._-';';- R. Thomas Kline ( Sheriff of Cumberland __-;."'0'" County SCHERER Sworn and subscribed to before me this 1,,1" day of 4t(G <>700 -5 A'a ~ Frot~ ~ ? "In the Court of Common Pleas of Cumberland County, Pennsylvania Shippensburg Southampton Manor VS. John C. Shatzer et al SERVE: Teresa J. Ricker No. 05-3077 civil fS-.j{)i)T 1t..6-V~ Now, June 15. 2005 , I, SHERIFF OF CUMBERLAND COUNTY, P A, do hereby deputize the Sheriff of Franklin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. ~~~/~~~ Sheriff of Cumberland County, PA Affidavit of Service Now, TW',cy' 0 &; , ,2005"', at -s.:'O 5 o'clock ~M. served the within Ct::/~~/,4-r ~~<"LU- ~rG-7y C~/f'?~,;;looS- 5'077/ upon TE/?E JA tJ: JP/CA/~ /,#~ R-1'~L/,<.- dQC//P7,;Y' J..#/'P/~/"J- o..c-r:-/c <:' at / S'? .c:.. c:.v <'r -:, ~.....-7' --7"/;1~/PSO"'c:..?f'4 ~ ,/ ;7;2.0 / - ~ by handing to /CA"~ 'iT" /f"/6\cC7? //iC/C-, copy of the original c:::.:?c:yy /f?/? ~ a and made known to/UtJp? X ~/CKC/iC /Z-~/? zr;. /f k Kc:-7<' t:?o.6'. /;2. -~7- /93"9 L/yC:3 p7 S I (]. ClT.5?V -4l L. L.. /f"oPPP S'/-/#J'!P;'k5O'Q;[>G; 172 /z:6"7 Ct?'A 'ML.A-v/:) ~~v T7j/11. u\c .!fj, <---..: Sworn d subscrib ore me this 0 ~ day 0 , 20 ~ S the contents thereof. So answers, ~4 ~ AWo~ a~ Sheriff of /"",~^L"/Z..--- County,PA/7";;>u/ t/~7Y 6&"S /""P.c.:~X/oq COSTS SERVlCE MILEAGE AFFIDAVlT $ Noe.iIl:seal . Rj,hardD._.NobryPubIi, $ Cbambersburg Boro. Franklin County My Commission Expires Jan. 29,2007