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010170353080 SG
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JUDGMENT NOTE
Mechanicsburg
(place)
, Pennsylvania, Augus t 26, 1998 , $ 4000.00
(date) (amount)
FOR VALUE RECEIVED, I1we promise to pay to the order of Erie Insurance
the sum of Four Thousand and------------------------00/100
said sum to be payable said sum to be as follows: Twenty-Five
dollars, ($ 25.00
) on the
1st
day of
October
19 98
and
Twenty-Five
dollars, ($ 25 .00
) on the __.ls~____ day
of every month thereafter until the entire amount is paid in fulL
UPON FAILURE to make payment as herein agreed in this note, I/we hereby authorize and
empower any attorney of any Court of Record of Pennsylvania or elsewhere, to appear for and
confess Judgment against me for the sum due and payable hereon, pursuant to Pa. RC.P. 2951
(a) (1) with or without declaration, with costs of suit, interest at the rate of 6% per a.nnum, an
attorney's fee, release of errors, and without stay of execution; and I1we also waive the right
of inquisition on any real estate that may be levied upon to collect this note; and I/we do hereby
voluntarily condemn the same and authorize the Prothonotary to enter said voluntary
condemnation upon any Fieri Facias that may be issued to collect said Judgment; and I1we
further agree that said estate may be sold on a Fieri Facias, and I/we do hereby waive and
release all relief from any and all appraisement, stay of execution, exemption or bankruptcy laws
of this or any other state now in force or hereafter to be passed.
xQ;:~:y ~~ (L.S.)
** (L.S.)
K~l.J'>. GL ay
This note is given executed without duress or coercion and with full and complete understanding
that upon failure to make payment as agreed, that a judgment will be entered agpinst rre/U3.
Further, I do hereby acknowledge that the damage incurred in the accident of
March 5th, 19 98 , for which this note is given resulted from my lIt,bl;b(.u~" IlBG
fault, and I do hereby acknowledge and waive my right to any hearing or trial on that issue.
. DATE OF BIRTH (- ,J.. \ - to I~ X ~ ~ (L.S.)
Tina Gray .
DATE OF BIRTH
.**,
Kirlt Cray
(L.S.)
C".;.
~..
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010170353080 SG
DISCLOSURE FOR CONFESSION OF JUDGMENT
J/We Tina Gray
,
Four Thousand
Judgment Note forn-n----nOO / 100
, am executing this JJ ~ day Of.sSep.t, 199i, a
($ 4000.00
) DOLLARS, obligating me to
repay that amount.
INITIALS: X 11'-'1
T.G.
INITIALS:
It has been explained to me by representative of the Erie Insurance Group that the Note
contains wording that may permit them or their attorneys to enter Judgment against me at the
I&- =ai~d
Courthouse, . aill Note is in defuult, without notice to me and without offering me
. an offering me an opportunity to defend against the Entry of Judgment, and that the Judgment
may be collected by iny legal means.
INITIALS: X r( G-
T.G.
INITIALS:
In executing the Note, IIWe am knowingly, understandingly, and voluntarily waiving any
rights to resist the Entry of Judgment against me at the Courthouse, and am consenting to the
Confession of Judgment.
INITIALS: X 11;-.
T.G.
INITIALS:
,~
'.
AFFIDAVIT TO ACCOMPANY JUDGMENT NOTE
L
JJWe are over twenty-one years of age, not within the military service of the United States
and its allies nor otherwise within the civil relief provisions of the Soldiers and Sailors Civil
Relief Act of 1947 as amended.
2.
3.
JJWe have deliveced to Erie Insurance a Judgment Note containing a confession of judgment
to secure certain payment obligations. . . ., &LJ.t
JJWe understand that a confession of judgment ~llcws for the entry of a jU~'ri~~ chiJ
, ccnfc;;sion again;;t them alld that said judgment encumbers all real estate that they own.
4.
The note is not related to a consumer credit transaction.
IN WITNESS WHEREOF and intending to induce Erie Insurance to complete the transaction as
provided, the undersigned have affixed their hands and seals on this d I .5 -r day of
X-/fo,....J,'~ ,19 qt' .
~tL~
(Seal)
(Seal)
Sworn to and subscribed ~fore me
this ). 1'1" day of f- ....., "fE-...... ~-./ 19.-iY.
I
rLt7/C~~ ~c--{
Notary Public
_....-...,..,................
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f>.(-);~.....:::';.L ;:>\'.. .
l'i"CHAto L \....~ij.St;~, JR.. riot'J, . Pl. :~,i(
New~ &1'0, C"",b<<f~nd Co""'Y. PA
My Co.rwnbolon Eap/Ifi """" 6, ZOO2
..
....
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CERTIFICATE OF RESIDENCE ~
~P.:udIO""--~N~~ tr~\, s\ *- j)A
Ad""" . ~ m. 4D
Name
Address
I certify that these are the last known addresses of the parties to this matter.
By:
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