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Home My WebLink About06-1997 - IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by Shana Smith, Transferor No. ()(., - 1997 (}( uLl Y VL"'L and Symetra Assigned Benefits Service Company, Transferee JOINT PETITION FOR ORDER GRANTING APPLICATION FOR COURT APPROVAL OF A TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS FILED ON BEHALF OF Transferee COUNSEL OF RECORD OF THIS PARTY: NICHOLAS D. KRAWEC, ESQUIRE PA ID #38527 DEBORAH R. ERBSTEIN, ESQUIRE PA ID#86470 CHRISTOPHER M. BOBACK, ESQUIRE PA ID #91730 Bernstein Law Firm, P.C. Firm #718 Suite 2200 Gulf Tower Pittsburgh, PA 15219 412-456-8103 BERNSTEIN FILE NO. C0063031 Shana Smith, Transferor No. Of-. /tjtj1 G;;.J'-r;;... Approval for Transfer of Structured Settlement Payment Rights by IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA CIVIL DIVISION INRE: and Symetra Assigned Benefits Service Company, Transferee SHANA SMITH AND SYMETRA ASSIGNED BENEFITS SERVICE COMPANY'S JOINT PETITION FOR ORDER GRANTING APPLICATION FOR COURT APPROVAL OF A TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS COMES NOW Shana Smith and Symetra Assigned Benefits Service Company, Transferee, (hereafter "SABSCO"), pursuant to the Pennsylvania Structured Settlement Protection Act, 40 P.S. ~ 4001, et seq. (hereafter "the Act"), and file this Joint Petition for Order Granting Application for Court Approval of a Transfer of Structured Settlement Payment Rights, and state the following in support: I. Co-Petitioner and Transferor/Payee, Shana Smith, is an adult individual, who resides at 2205 Cedar Run Drive, Extended Apartment B, Camphill, Pennsylvania 170 II. Payee is By: Ni olas D. Krawec, squire Attorney for Symetra Assigned Benefit Service Company Suite 2200 Gulf Tower Pittsburgh, PA 15219 (412) 456-8103 1.0. No. 38527 NOTARIAl SEAl l CaIhv L Youngblood. Notary Public Lemayne Boro. Cumberland County i foh( Commission Expires June 22. 2006 i -_..~\ \. ~ . '., ~ ".; ,..,.. ,", - .. ~. .,. ,,' - ' , .. single. Payee has two dependents her children Ja'maury McKeithen age 3 1/2 and Promise Hill Age 8 months. 2. Co-Petitioner and Transferee SABSCO is a Washington corporation with its principal place of business in Bellevue, Washington, and is also the structured settlement obligor. 3. Concurrently with this Joint Petition, SABSCO filed an Application for Court Approval of a Transfer of Structured Settlement Payment Rights (the "Application"). A true and correct copy of the Application is attached hereto as Exhibit "A" and incorporated herein by reference. 4. Transferor/Payee, Shana Smith, has requested and concurs with the Application. WHEREFORE, Shana Smith and Symetra Assigned Benefits Service Company jointly request that this Court enter an Order granting the Application for Court Approval of a Transfer of Structured Settlement Payment Rights. ~~A/ ,~ BERNSTEIN LAW FIRM, P.C. Shana Smith 2205 Cedar Run Drive Extended Apartment B Camphill, Pennsylvania 17011 Sworn to and subscribed before me thisL'6 day of l'toWvcJ" , 2006 Notary 2 Shana Smith, Transferor ORDER APPROVING STRUCTURED SETTLEMENT TRANSFER IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA CML DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by No.: and Symetra Assigned Benefits Service Company, Transferee Upon an application for Court Approval of a Transfer of Structured Settlement Payment Rights ("Application") duly brought by Symetra Assigned Benefits Service Company as Transferee ("SABSeO"), and the Court having considered documents in support herein and written submissions, if any, filed by said interested parties named below: Transferor/Payee (and dependents): c/o Shana Smith 2205 Cedar Run Drive Extended Apartment B Camphill, Pennsylvania 17011 Structured Settlement Obligor: Symetra Assigned Benefits Service Company PO Box 34734 Seattle, W A 98124 ndkOl1712VOOI Annuity Issuer: Symetra Life Insurance Company PO Box 34690 Seattle, W A 98124 " The Court, upon said Application, hereby makes the following findings: I. That the transfer sought to be approved complies with the requirements of the Pennsylvania Structured Settlement Protection Act, PA St. 40 ~ 4001, et seq. (hereafter "the Act"), 26 V.S.C. ~ 5891, and does not contravene any applicable statute or order of any court or other government or responsible administrative authority; 2. That said transfer is in the best interest of Shan a Smith, TransferorlPayee, taking into account the welfare and support of Shan a Smith's dependents (if any); 3. That Shana Smith has been advised in writing by SABSCO, Transferee, to seek independent legal advice regarding the transfer and has received said advice or expressly and knowingly waived said advice in a separate written acknowledgment; 4. That SABSCO has provided the Disclosure Statement as required by the Act to Shana Smith; 5. That SABSCO has provided Shana Smith with a copy of the transferee's application, with attachments, a copy of the notice and proposed order; and 6. That SABSCO has provided written notice of said Application to the Annuity Issuer, the Structured Settlement Obligor, and other interested parties as required by the Act, none of whom have submitted written objections to said transfer. Based on the foregoing findings, it is hereby ORDERED, ADmDGED, AND DECREED that the transfer of the structured settlement payment rights, as described ndkOl1712VOOI It is FURTHER ORDERED that, pursuant to the Act, by making and .. in the "Purchase and Sale Agreement" filed with the Application herein, is hereby approved and no party to this proceeding shall hereafter refuse to honor this approved transfer. delivering the Transferred Payments to SABSCO, as set forth herein, the Annuity Issuer and the Structured Settlement Obligor will be discharged from all liability for these Transferred Payments due the Transferor/Payee under the annuity. Annuity Issuer and Structured Settlement Obligor are hereby ordered to remit the following periodic payments, to wit: $25,000.00 lump sum payment due October 28,2006 and $57,661.81 lump sum payment due October 28, 2008 to: Symetra Assigned Benefits Service Company (its successors and/or assigns) P.O. Box 34734 Seattle, WA 98124 Tax ID # 91-1246870 SABSCO shall service the payment and remit $48,611.81 to Payee. The Transferred Payments, as described in the "Purchase and Sale Agreement" filed with the Application herein, shall be paid to SABSCO regardless of whether Shana Smith is alive or deceased when the Transferred Payments become due. This Order is entered without prejudice to the rights of Symetra Life Insurance Company and/or Symetra Assigned Benefits Service Company and the Court makes no finding regarding the enforceability of any non-assignment provisions contained in the original settlement agreement or related documents. This Order in no way modifies or negates the ownership or control of the underlying annuity contract by Symetra Life InslU"llllce Company and/or Symetra Assigned Benefits Service Company. It is further ordered that the Structured Settlement Obligor and Annuity Issuer shall irrevocably change the beneficiary for the Transferred Payments to SABSCO ndkOll7l2VOOl DATED this _ day of ,2006. and no other individual or entity other than SABSCO, its successors or assigns, shall have the authority to change the beneficiary for the Transferred Payments. Symetra Assigned Benefits Service Company and Symetra Life Insurance Company shall provide formal acknowledgement of the terms of this transfer within 10 days of the date of receipt of this Order. The formal acknowledgement letter shall be delivered to SABSCO at PO Box 34734, Seattle, Washington 98124. This Order concludes the proceedings herein. BY THE COURT: JUDGE ndkOl1712VOOl Civil Action No. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by Shana Smith, Transferor and Symetra Assigned Benefits Service Company, Transferee CERTIFICATE OF SERVICE I, Nicholas D. Krawec, Esquire, hereby certify that a true and correct copy of the foregoing Application for Court Approval of a Transfer of Structured Settlement Payment Rights was served on the following by certified U. S. Mail, return receipt requested, this Lft~ day of Hm" , 2006, addressed as follows: Shana Smith 2205 Cedar Run Drive, Extended Apt. B Camp Hill, P A 17011 Symetra Life Insurance Company PO Box 34690 Seattle, WA 98124 Symetra Assigned Benefits Service Company PO Box 34734 S","I~ WA 98~ / -T~~ BERNSTEIN FILE NO. C0063031 .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by Shana Smith, Transferor No. and APPLICATION FOR COURT APPROVAL OF A TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS Symetra Assigned Benefits Service Company, Transferee FILED ON BEHALF OF Transferee COUNSEL OF RECORD OF THIS PARTY: NICHOLAS D. KRAWEC, ESQUIRE PA ID #38527 DEBORAH R. ERBSTEIN, ESQUIRE PA ID#86470 CHRISTOPHER M. BOBACK, ESQUIRE PA ID #91730 Bernstein Law Firm, P.C. Firm #718 Suite 2200 Gulf Tower Pittsburgh, PA 15219 412-456-8103 Shana Smith, Transferor APPLICATION FOR COURT APPROVAL OF A TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA CIVIL DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by No.: and Symetra Assigned Benefits Service Company, Transferee AND NOW comes Symetra Assigned Benefits Service Company, Transferee, (hereafter "SABSCO"), pursuant to the Pennsylvania Structured Settlement Protection Act, PA St. 40!i 4001, et seq. (hereafter "the Act"), hereby states as follows: PARTIES 1. Transferor/Payee, Shana Smith, is an adult individual, who resides at 2205 Cedar Run Drive, Extended Apartment B, Camphill, Pennsylvania 17011. Payee is single. Payee has two dependents her children Ja'maury McKeithen age 3 1/2 and Promise Hill age 8 months. 2. The structured settlement annuity issuer is: Symetra Life Insurance Company (fka Safeco Life Insurance Company) PO Box 34690 Seattle, WA 98124 ndkOl1709VOOl FACTS , 3. The structured settlement obligor is: Symetra Assigned Benefits Service Company (fka Safeco Assigned Benefits Service Company) PO Box 34734 Seattle, WA 98124 4. Transferee SABSCO is a Washington corporation with its principal place of business in Bellevue, Washington. 5. Shana Smith is entitled to structured settlement payments as the result of a structured settlement agreement entered into on 24 August 1999 ("Settlement Agreement"). 6. The Settlement Agreement resolved claims by Payee for compensation for personal injuries or sickness. The Settlement Agreement provided for periodic payments as follows: $100.00 monthly payment due on October 28, 1999 and on the 28th say of each following month until 48 payments have been made, guaranteed; $20,000.00 lump sum payment due October 28, 2003, guaranteed; $25,000.00 lump sum payment due October 28, 2006, guaranteed; $57,661.81 lump sum payment due October 28, 2008, guaranteed. A true and correct copy of the Settlement Agreement is attached hereto as Exhibit A. 7. Liability to make structured settlement payments pursuant to the Settlement Agreement, was assigned, through a qualified assignment within the meaning ofIRC ~ 130, to SABSCO. 8. To fulfill its obligations under the qualified assignment, SABSCO purchased an annuity from Symetra Life Insurance Company, naming Shana Smith as Payee on the above described payments. ndkOl1709VOOl ndk01l709VOOl .. 9. Under the terms of the annuity, Symetra Life Insurance Company is obligated to make the periodic payments to payee but the Structured Settlement Obligor remains the owner of the annuity. 10. Shana Smith desires to sell a portion of the periodic payments, as follows: $25,000.00 lump sum payment due October 28, 2006 and $9,000.00 out of $57,661.81 lump sum payment due October 28,2008 (i.e. "Transferred Payments"). 11. After receipt of the Disclosure Statement, not less than 10 days beforehand, as required under PA St. 40 9 4003(a)(2), Payee entered into a Purchase and Sale Agreement with SABSCO on 14 March 2006, in which Payee agreed, subject to the court's approval, to sell the Transferred Payments. 12. Payee has represented that Transferred Payments have not previously been sold, assigned, encumbered, conveyed or pledged, and that Payee has all right, title and interest in the Transferred Payments. 13. Payee has agreed to irrevocably change the beneficiary of the Transferred Payments to SABSCO or its designee. 14. The Purchase and Sale Agreement complies in all respects with the requirements ofPA St. 4094001, et seq. A true and correct copy of the Purchase and Sale Agreement is attached hereto as Exhibit B. 15. Not less than 10 days prior to the date on which Payee executed the Purchase and Sale Agreement, SABSCO provided Payee with a disclosure statement setting forth in the information required by law. A true and correct copy of the disclosure statement is attached hereto as Exhibit C. 16. Shana Smith was advised in writing by SABSCO to seek independent legal advice regarding the financial, legal, and tax implications and ramifications of the ndkOll709VOOI . transfer, and she knowingly and voluntarily chose not to seek such advice in writing. A true copy and correct of waiver to that effect is attached hereto as Exhibit D. 17. Not less than 20 days prior to the hearing date, SABSCO provided notice through service on all interested parties, pursuant to PASt. 40 S 4004, identified in paragraphs I through 4 above, the following documents: a copy of the petition and rule to show cause, a copy of the application, a copy of the transfer agreement, a copy of the disclosure statement, a copy of the notice of date, time and place of hearing, a copy of the notice to all interested parties, and a [proposed] order, as set forth in Exhibit E. 18. Shana Smith intends to use the funds from this transfer to payoff a few collection accounts and fund a down payment on a home. The proceeds are not required for daily living expenses. A true copy of the Affidavit of Payee is attached hereto as Exhibit F. 19. The transfer of structured settlement payment rights is in the best interests of Payee, taking into account the welfare and support of Payee's dependents, ifany. 20. The transfer of structured settlement payment rights described herein and in the Purchase and Sale Agreement complies with the requirements of the Structured Settlement Protection Act PA St. 40 S 4001, et seq, 26 V.S.C. S 5891, and does not contravene any applicable statute, or the order of any court or other governmental authority. 21. SABSCO reserves its right to assign the Transferred Payments to another entity. 22. Shana Smith desires to irrevocably change the beneficiary of the transferred payments to SABSCO or its successors or assigns. BERNSTEIN LAW FIRM, P.C. /1 B~~ "Nicholas D. Krawec, squire PA LD. #38527 Attorneys for Symetra Assigned Benefits Service Company Suite 2200 Gulf Tower Pittsburgh, PA 15219 (412) 456-8103 ~ 23. SABSCO has provided notice to all interested parties as required by PASt. 40 S 4003(6). 24. Venue is appropriate in Cumberland pursuant to PA S1. 40 S 4004 as Shana Smith resides in Cumberland County. PRAYER FOR RELIEF WHEREFORE, Transferee, SABSCO, respectfully requests the Court enter an order approving this application and the transfer of structured settlement payments rights, described herein and in the Purchase and Sale Agreement, to SABSCO. DATED this 27th day of March, 2006. ndkOl1709VOO 1 ------ - s: tk,b.f h . "",,- EXHIBIT A . . . UNIFORM QUALIFIED ASSIGNMENT "CLAIMANT' Etfieda M. Smith as Guardian Ad Litem for Shana Delon:s Smith, a minor Yoric Insurance Company SAFECO AJslgned Bcnetil$ Service Company SAFECO Life Insurance Company 1\"....~...., "I~ In7 '-< , "ASSIGNOR" "ASSIGNEE" >>ANNUITY ISSUER>> "I!FFECTIVE DATE" TDJS AGREEMENT iJ made and entered into by and ~ lIle parties he<elo IS of the Effective Date willt ,"'lce to lIle rollowing facts: A Claimant ltas cxecuted a selIIcment agRCllIClIt or rekuc dated 'II. .. " .,.J'" . 19 -1L (the "ScItIemcnII+-.I_") thai provides rOt the As$ignof to maIce ccmin periodic plymcnls to or !'or the benefit or the Cbimant as stated in AddClldum No. I (the "Periodic Payment.); and B. The partic$ desire to cft'ecIa "qulllilicd assiJl1llMlll" within the .-nillll and JUbject to the conditionsoCSection 130(c) oCthe Internal R_e Code of 1986 (the "Code"). N ":! NOW, THEREFORE. in COIISi<lcotion of the ~ f~ and other good and valuable ;;..: eonsidcralion. lIle panics agree as follows: ..... ~1. :::a Co The Assisnor hereby usisns and the Assignee hereby _""" all of the As$isnor',lilbility 10 C' mike the Pc:rioclic Payments. The Assignee "" ISSlIlllCS no liability to mike my paymenl nOl specified in Addendum No. I. 2. The Periodic PJymentS COllSIilu1e ~es on acCOURl of personal injury or sickness in a case in~1vin& pltysicIIl injury or physical sickncs.s within the mcanin,s of Scclions I04{a)(2) and 130(c) oCthe Code. ,~ ). The Assignce's liability to mike the Perio<Cc P~ymcnu is no greater than tlm of the Assignor immedUately prccedilllltbis Apement. Assignee is not required 10 set aside specific lWCIS 10 _e Ihe Periodic Payments. The claimant bas no rishts agalnst tIM: Assignee greater than. general creditor. None of the Periodic Payments may be accdcrated, defcrn:d. inc:reased or de<:rcued and may not be anticipated, $Old, assigned. or encumbered 4. The oblilJltion as:sumed by Assignee with respect to any reQUired payment shall be discharged upon the mailill8 on or before thc due dale of. vIIlid cbcclc in the amountllpCCifled to lhe address of record. S. Thi. Agrccmcnt shall be governed by and interpreted in accordatlce with the Ia~ ofllle Stale of Washington. 6. The As$ignee may liInd th. Periodic Paymcnu by purchasing. "qualified funding _" wilhin the meaning ofScction 13O(d) of the Code in the form of an annuity conltacl iuuod !ly the A/lnuily ISSllet. All riglus of ownership and eomrol of SIleb lIlIlIIity conlracl shall be lIIld remain vested in the Assigm:c exclusively. 1 :' .":~'. - -. --:-i._~;-~ .'. il . < '/~ ",' .--.'r"'----. '....; I/O 1/.3 . . 7. Tho: AssigllCC may havc the Annuily IsllUcr SClld pa)'l1lClllS 1lIldC( III)' "quaJi6cd fundina aSSCl" pun:lla.scd henlutIdcr dinlelly to the payec(s} $p<lcified in Addendum No. I. Suc:b dircccioll of paymentS shall be solely for the Assignee's convenience Illd s1IallllOl provide the Claimant 01' any payee wit!I any riShts of ownership or conuoI overthc"~ funding _" or againstthc Annuity Issuer. 8. AsJigllCC', Ii&bIIily to malec lhe Periodic Pa)'lM1lls Wll COlIliauc wilhoul dimioudon reptdlcss ofany banktuplCY or insolvency or the Assignor. ASSt~R: Yil.rk hlsurance Company BY: ~ - TITLE: ~ - /~ -, ~w ~"~ <'> N '-" :ii "" 0' .. SO. In the _I the Sclllcmen\ Agrccmenl i$ dcc:lared terminated by a court of law or in lhe event that Scctlon 130(c) of the Code has not been $Ui$1le:l, Ibis Agl cement shalllerminate. The AsJigncc shalltllen assign ownership of any "qualilied I\Jtldina asset~ purdlased hcniunder to Assisnor, lL 1d AsJigllCC', "ability for III-. Periodic Pay. -.en15 shaJllcnninate. 10. This Asrecmetl. shall bc binding upon the rcspcclivc representatives, heirs, ..._n and assiam of the Claimant, the AssisItor and the Assiancc Illd upon any person or entity tlw. may _ lllI)' risbt hereunder or to any of the Pcriodic~ ASSIGNEE: SAFECO Assigned llaIefits Se7ice Company ;/. h.(" '" I ' {', a.r... 'If, : l!.~:.. :"~\ V'{ BY: TITLE: ~ IIO-ij,j, . P'-'~ .' . . . ADDENDUM 1'10. 1 DESCRIPTION OF PERIODIC PAYMENTS Payments of One Hundred Dollars ($100.00) monthly, for a period certain of four (4) years. starting October 28, 1999lhrough September 28. 2003; payable to Sbnna D. Smith. Payment of'Twenty Thousand Dollars ($20,000.00) payable to Sbana D. Smith on October 28, 2003. Payment of Twenty Five Thousand Dollars ($25.000.00) payable to ShaM D. Smith on 0c:t0ber28.2006. Payment of Fifty Seven Thousand, Six HuncliI:d Sixty One Dollars and Eighly One Cents (SS7,661.81) payable to Sbana D. Smith on October 28,2008. BENEFICIARY: Any payments to be made after death ofSbana D. Smith, pursuant 10 the tenns of the Settlement Agreement, sha11 be made 10 Ihe Eslate of Shalla D. Smith. TIle Payee shall have the righl to submit a request 10 chanllC the Beneficiary dcsigr.ation. No such designation, nor any revocation thereof, shall be effective W1less it is in writing. signed by the Payee, and delivered to the Insurer or the Insurer's Assignee. The designation must be in a fann acceptable to the Insurer or the Insurer's Assignee before such payments are made. N N 9 :3 (") N ~ c.' ", INlTIALS ASSIGNOR: ~ ASSIGNEE: 0,1/'''; . litr c,L:" '.' 3 "" ,12 . . '. GKNF.RAl. R.'F.L~ KNOW ALL PERSONS BY TIlESE ~'TS THAT El&eda M. SalitlJ. Adminislnolrix oftbc:Eswe of Shirley LoW" SmitlJ. D-=d; mfi'cda M. SalitlJ. Guardian Ad Litem for ShoIlaOclorcs SalitlJ. Icdivi4ualJy ar>d as AdaliDislr:1lrix oCtbc Eswc of Sharon Oclorles SmitlJ. O<:ccued; aDd El1mla M. Salilh, Adaliftisrnl:ix oCtbc~ oCSharoD Louise SmIth. D0cease4 (bcreiIlatI<< ''Rckasolsl. for Illd in COllSidcmiOll of the ems sum of 1'btee BIlIIIlrecI Tholl.cIIld Dolbn ($3OO,ooo) 60 bcreb i mDise, ",lease ODd toRvor 4isdwp J. Guy Nclt, Lee AIm Neff, Clyde D. 'Fulmer IlIll Beulah H. l'ulmcr,lDdMdually * IId1b1a City Limlu Rc:lIly (bcn=iDWr "Rdc>>m"), lIlcir illsurm. sulmdiarics. ]>OROl <:otpO<1ll-.1lllpIoyec$. ollio"ulId c1i1...r...lllIllllleirbeir$, -.." -. ..h.,;.olAlMOn: amlprinc:ipal$, W fie""" .._ I.....l~"" ti-'f>~ -J.-...... .....-... lilY * all otbcr~ 1ilm5. ~ and C01jN.lIl>O~ o!anlli'om all ar>d all_ of ri.f( acliollS lIlI4........ oflCliOll, SIlils. CcbII, d\lC$. aecoUlll$,!xI. oovocmts. oontracts, ~ivdpl<nl', claims lllld cIc::IIllllds ~ in law or equity, espc:Wlyall clam... Qr joinders for...~ liability, coDltibulio\l. In<IlIIlI1ity or olherwite lIrisln& 0Ilt of... incidl:llt _T - wbicballea<dlY~onorab01>tApri111, 1m III 1602lle&iml Strect,Hvrisburs. P~'l"aail, dle details of which inoidmlaDd dle diIpUtc arisiJlt tbctefrom beins COIllaincd ill a sui.! filed by R~rs.pn.t \he ReIe:uo.. in the tnuphin County Court ofCocmlon Pleas. gjd suit beori:Ig _ DO. 1196 S 1997, wbieh against th. said lll:loasees Releuots <NOr had, ,- ..- now have or wtIic:h Iheir 1$OIIts. employees, _, heirs, exetUlOrS. adminimllon. sw:cessors or usipIs, prilIcipals or ~ ,,{them, bcnilsaIlet =. shall..." may have, for or by reason of ~ ......., llIlluer or t.lling w!laIsocver, liom the begimIill& of Ill. workllO tbc dall$ of lbeu pmeots. IN FllJh I1U CONSlDERA "tION of!he payment ..1 ronh in this OOllCrtl Rekue, lI1c Releasim agree as folio...." , .... w o c" CI' liD 1/.3 -- .-*--"---,,. . . . I. The Releasots ~ that lhiI seItkmaIl bv bcClIap.:d 10 solely Cor 1M l""'P'* of ~ dilpulC<l obi"". ucI cy pa)'Dlmt raadepursum: to Ibis scttleraclllls JlOt 10 be COlkS".cd IS ... admission of tiabiJiIy, ncpgcncc. C'lIlpabilil}' or...y olhClI'3"l COt1Clusiou. 2. The RcIeuon lII\dmlaJI4 onclapcc tbat !be piljllllCIIl opccificolly IdeIIlifiaIlIlld set fonh herein is rhe CIlllrc IIl4 only COIlIi<\onIliolI fOr lhiI GcGetallW...... ucI it is im<:ndccl by \be lWeasotS 1baI1!lis GcIIcr.1I P.clcasc sba1I be comploCe and sba1I_ be subject 10 cy claim of misI1ka of &ct or law by the Releucm, ...d tbat it c.cpn:$>" aMIIl4 complClC settlemCl! oC lilbi1ily claimed IIl4 denied: ucI tbat 1llis ....cr.l! Release i> inll:llded to be ful4 finillll1d COUJ;llele. l. Iu pari ofthe~ lOr the paymoaIlO 1b<lReleo$ors oCdlllIlmWII"""'" above l:lICI>lioll8cl, !be ~ &Ie teleuiDS all ~ iDcIudiIlg all (bole ror knowo or _0_* Ollticipate Of """"ticipalcd iDjuries :lIld cbmqeo. The P.clcaso."S m:olDi%c lIl'Il IClalowlcdse tbat dlen: is a ri~ tbat subscqueDllO lbo c:r.ccutiOll oflhil GtDOllII ~ the Rclcasors,.;n daim or sua... Ill<IIItIary Of olilCllost, dIm1gc or any oflbese whidl arc in SOIIle way cl1lSCld by or rebtcd to the ill<:idCllt, but ..hidl.... \lnl(nown ucllII1""ticipatcd III the rime "f - - tllis 0cDcmI P.cl_ is $ipd; ucIll1nbe:, that 111.... is . risk tbat tbcda:xl'C'" ~......... may be or may become "'"'" mtllJivc lIIoD the Rdcasors '""" ccpec! or llIllic:ipatc. Tha Rclcuors IltCCpllbe abo",,1IlellIioncd risk * lhiI GeDcr.l! Relc:aK sba1I opply to oIIl1l1laloWll * ~ tcSUlt:; oflbe ineidem 1$ wc11 u lbosc kllown ond lUlticipalcd. 4. TlIo: 1l.cIeuors lilnaor undcttt:md :.zul AJI'CC the, the RcIcuo.. shall be 'npoIl$wle lOrtllep.)'DlCIll oChis ottomcy$' fees ontICO$lS. as...U.. >11 fec:s ""d expal$" :lrising m.m lIIIlI in <JltlIlCCIiOJl witllcy lt1m:tS Jelatod to the iDeidcn.. for ""d in cocsidtnlion of this G<.omJ . 'G c:> ..' c;' 2 J/Dl/.2, . . ~ S. Tbo l1<lr~ ape to bolcIlhe Rclasca lIalmIess !10m all dIlms, tiCll5 or actioar, il.<l.dil4. ~,M ' which arise out of Of aro in illY way relaled to anyiojuri.. or .......0$ die Rdouor. may !lave rw:tai:ned m, or as a resull ofllle iIIeld..., wlaich may be bIOUtbl apinst any of!lle Rel~ iDcJudill&, but 110' ..mired 10. .WIllS or li_ for paymear or reimbummcar o!'alIIdicaI oexpea$COS. woM', ~u\ina~. c!iaabilil}' ~ tII+4~~ paymcoIs, Of Ol!lerbcDcliu,lIld 10 <lef'end..:aoolind.....",;fy(b. Re!_ "i(bmpec;l1O aIll\Uc:h claims, U- or acUons. 6. Tbo ReIeMon 'Sf"" to COOJ><IlIlO filIly IIld 10"_ illY :aDd all supplemellary documl:lllS:aDdto like all addltioaal aclicns tlIal may be neeessary or Ipploprlale to give l\1Il fon:e IIld eIfcct to l!le buic _1llCI imeD4 oflhil Geo<nI RcIeue. md wllicl14te r.oe iIlc:mlslsIeal..w. ilS-. 7. P.-_.. b eonsider.llloll ofu.. re~ set forlh above, Yodc IDsu:.- ~y, 011 beIMlf oldie Rll\weos, aerm to pay to die iIldividllll(s) llIIllWl below {"hyco(a)j die S\llllS O<llllned hi lhiI Se.:lio1l 71le1ow: ... Paymeats clue 1Ilu.. IUIlC of SemeatenllS folJows: l'aymco! ofTwo Hundlcd Tlliny TIlO\lSZd Oou..s ($130,OOO.OO) payable to Elfreda M. Smilb, AdrnilliSll'lttbc of die Estll!e o!Shirloy Louiae Smitll, Deceased; El6ed2 M. - - Slllitb . Gwudi... Ad Ulem fot Shan.a o.lotcs Smith; 1tldi1lidusllj 2lllI IS AdmiJlismtrix of!lle EstIlcofSlwODDelormSmitll, Dcccasccl; llDCI E16-o:laM. Smitll, as ~of!lle Estaw I .- g C" .;I' ofSboron Louise Smltll, Dccdscd. llDc1ll1e La'" Oftl~ of AllciDo &. Rovner, llpOI1 ex_Ii.", of tIW~ b. I'do<!it: l'aymenlS tMde ~ to lbe ..bcdvJe as Co11>ws-:lhc 3 IIfl11.', - - .. -- - :, ~ , ... g c,-, ".. . . "Periodic P8y\DelllSj: (I) P&ymclIlS ocOne HIIl'lClrcd Dol!als ($100.00) monthly, lOT. periocl certailI oUour(4)yea:s. slllrtins Octobe:ZS, 1999 tJuooch ScpICIllbcr 28. 2003; payable to Shela D. Smith; (U) PiI)'nlCllt of rwCllty Thousand Dollars ($20,000.00) payable to ShwD. Smith 011 OclObcr28. 2003, (Iii) payment oftWCDtY 1m: Tbousand Dollars ($25,000.00) payable ro SbaDaD. Smilb 0.11 October 28, 2006; (IV) PaymClll ofF'lfty Sevca 1'hous:md. Six HUIIdrcd Sixty ODe Dollm aDd.El&bty Oaac_ (SS7,66Ul) payablttoSbauaD. Smith 011 o.~;!8. 2008. All SOII1S set fotTb bain COlISlillltC damages o:IlCl:01lIlt ofpb)'5ical iDju:ics and ~Ialess, within !he ~ o!~ 1000a)(2) oCtile IIllemal R.cvctmc: CocIe of 1986. a.s :III1Cllded. &. 11&)~' Ri.ht& 10 P2""'/mI~ Rel8l$Ol'S aclcoowJedce lilat the Periodic Payments _ be lCGlllcralcd. <Icfemd, incteasecl or decrOUlld by me RdCllSOlS; nor shill :lie Re1cason have the pewer to sell, mortgage, ellClImOe:, or aIlticip;ta the PerWdie P4)'mCOI$. or lilY part lh=t; l-Y 4SSignmClll or otherwise. 9. Blll"".ft~' B""'lIicillrV. ADy pa>_to be mllde all.:r dealb ofShana D. Smith. . pUl:ltla%lllO the terms of tbis General RcI_, shall be made to the Estate ofShlUlll D. Smith. The Payee sllaII hAv.lb. rig.'lt co Sllbmil3 ~uCSlIo cluuIsc the Beodlc:Wy <ICl1ismriOll. No such de$i1D"liOll, nor llllY =eation thettof. shall be e<<.ctivc1lllless it is in writing, signed by the rayee, ancIlIcli,'vcd \0 the L'ISIll'Cf or tbc ilIsurct's Asoiance. 1'lIc dc:sipation _ be in a bin ac:cpulblc to tho insurer crib. iasurer's Assignee before such payments are ~. 4 1/01/. , liIoo~ , . . '. 10. ~l/I"....t to o",liliod Assi,.,..,etll a. Rdcason ac:bowlcclp IIld agree lIlat the Rel_ aDdIor Yotlc lilsw':oD<:e Componymay make. ~ Assipnal~" willWl the meaning ofSectioa 130(.) oCthe lDtemaI a- Code of 19E6. as lIlllCIllled, o{!bc~' aDdIOf Yotk Illsuranc:c COlIIPIIIY', liability to make rhe Pcriodle P&ymalI$ sell'orlb lJl para;npM 7(b). (e). (d) and (e) to SAFECO A~ BeDCtits SeMe:o Compan,y (the ..Assign.....). !he Assignee's oblipllon forpaymenl of1be Periodic p~ lIbo1I1>e 1lO z._lbatI UI.$t oClbc ~ lIDIIIor Y<nlr; ~ Comp;lIy (whctb:tby judpleutor aptmeat) ~ ~ lbe wi,pzmc&lt oflbel'erioctic fl}'lDllltS ob1iplioD. b. ItJq mil ouilDlD"Ol. if made, ~ be ocecplCd by !bc Releuon w!thout ri,pl of tcjcccioa aDd shall eompl<::cly release aDd disc:lla:ge the Rcleaces aDd Yode WutlIuce CoItlpIIly ftvm the Periodic P1ymOllts obliplion ouipel 10 the Assignee. The Rel_ rococnize tIlol. ill doe _ of mil an uslgmnetlt. tbc Assip:.: itulllH 1he sol. obligor with tcSpoet1o the l'c:riodic Payn>oll\$ obliplion. aDd lIlat all oth<< rde.... with resr= ttllbe Periodic Paym<:tIt$ obliplion lhar. pett:lin to lIle liability of lIle R"'~ II1lI Yotlc; ~ C""'P"">' sballlh-....... beemne mw. irrevoeablellld absolulc. e. SAFECO Life 11lS"_ Company wiU iss\le lleltt:r ~ the .: paiomlmcc of the (lblill'ti_ asslpd to SAFECO Assiped Benefiu St:rvi" Company by W#:'f of. Qualificll AAiJlllDClll Agrcemecl ilIlld for which SAFECO Assi,clled Bc::lC1itI St:rvlce ,- ,-'" ;;:, ~,.... '" Compmy p1IIdwes III onuuity Uolll SAJollCO Lire !'2S1ll':l1lCe Compmy to eo_these $OIIlC obUptioDS. 11. RHzht 10 Pmchuun Annllitv. Yode lnsuooec:~. lbrousb its AAiJll<<. 'm0l'ta the.rilht to fi4ld lbe liability Ie make the Pcriodie ~lS 1hro1Ish the purchuc: of lID S /J()JJ.1, . . OIII21lity polic> liom SAFl!CO Ufe Insunmce (".cmp>Dy. rile Assip:e shall be the sole __ 0( 1M lllllWityJlOlicy aDd rball have.U riaJlu of o~. !beAssigne;: may have SAFECO Life TDsm:loee Comp=y mllil paJll1l"Dls diIl:ctly 10 1bc J>'lya:(sJ. The Relcuors sb4ll be: responrible for m.ia"''';"B a eurmu mailJDg addms Illr paya:(r) willi SAFECO ASSiped llecclilS s.mee CoIDJlUY. 12. ~fOblitlltion. The obliplion of Il:e Assignee 10 mak. each Periodic: Pay:nent sllall be di'lClla."Jl'd opon the moiling of a Vlllid cbeck in the lIIIlOOIl: of such paymeot 10 1M desipted :oldra: of lb. pa)'<C u:n<d ill p....Jl'IPh 7 of <his Generol R.le=. 13. The Jlel_litrtbcr aclalowledgc W1W Jleleasors :lI'll Rpfcsemc4 by collllStl oflbe Re1_' choU:e with rqvd It> 1lIIlI<I> llriJil;g 0111 oflbe iDcidcol: thOlIhe eoolenl:wl lepI eIfccI oflllis GeIlenl Rei=- have bCClI eiq>laIlIed 10 die Releasors by 1M R.e!CUO/S' -.110 !he RelWOlS' satisfaetioa and !hat Ibe Relwors ":lYe m.d md un<lerstaod Ihe above Genenll!.ele;lSelJld &eel)' ""~ sam.. Da:ed lhis ~ V"f{.. dAy of A,'ro<S+- . 1999. ~~J!)~~ A.dmImstmnX ofllle Bs1a,. ofSllirl"l' touisc SlIulh, Dtcased: l!Ir..M. Smilh, 0.......... Ad Utem lor ShaM DcloNs Smilh, lzIdMdtally 3lId ll$ ~ oflhc Eslal< ofSlm.nxl Del""" SmlIb. Dcc:nscd; tIl<I Elfreda M. Smill:. ~ oflll< Bs1a:e ofSbatOll - Loom SaU1ll. o.e-.d ,.- S,,'Om to .no Subscribed Bofol.",e tllis~...u...<by of ;"~3"'$"- 1m. K-#'11I~1 , No' . '-:' :;; L " .... ~~ -; ~.J.HO.IHt.NOCaI1;r1'11_ I l..owwqen"wo..t'u~'lrUit4~ , ....--...,....._ I 6 IIDJ/.~ 1U'llJlDA.. SII1'ftI. AClJIl1.niaUllt'l.'~ o~ 1:.11. ES1'A1'E or nD.L~ t.Otl'ISE SHI'ftl. DJ:l:EASI>>; EU:REl)A K. SllI't'Il. CQaJ:lUan Il<S Li_ ~or SHAN'A DEll:>>'D SKITIS. XncUv1<llUllly. an4 /10. 1'196 S 1991 .. AdIIJ.n1l;tz:aui.x of tlle U'l.'ATE OF ~ D~ SII%'ZtC. D~Jll)l and ELI'JIEIa X. SII%'ZtC. Mminiatra- trlx o~ 1:.IIe ESt~u: OF S/INl.OIl LOUISE SKITll.' DECEASED, : J'lUlltitfs CIVIL ACTION - LAW v. J. GAar !/En'. LEE AIlN 1IZfT. CLYDE D. J'Ut.'I(ER. and ~ II. .lPLKER. Indi.vidually and t'd'b'~ en:'! LIHI1'S ~. D8~cmdan1:S J'OaY TlUAL DE:IIMlDED : : , AND NOW. ~. ~d UD ~D'~~ this d--I day o! . \ . , 1999. the . I- t..' C> (., '-', petition or XlfrB<lll II. SlIith for Appro".1 of a col:lpromilled S4tl:tl_t on behalf of decedenU IInd " ..il'lor i:J beroby approved. 1) 8J.fr....... H. Sait!> is hereby aln:borized to accept $300.000 in touJ se1:1:leIlent of "11 claills in the aboVe-capt1oned _ttcr anll to diC1:r.lbute this procM<ls in 1:1\. "'''''''.r .et torth in 'the Petition, pora9X'"pba 24-2(;. 2) s'\fr./14 II. Satth 1=11 Authorized and req",ired to pey oucb 1nberitancc taxes trOll ....cb !State required undar 1:1\0 ..llocation sat forth 11> l'ara91'apn 27. 31 EUr_ K. Sait:ll is 4Uthorhed to execute 4nY :r:el"IlC40 or strUcture4 s8tt1"'"'"'t dOC\ll\..ny~ ~ the ",;;t:t1eaent ....t ror1:b in the petition. / (. .)/ ~ Ill'll/.2, E;<h'lb1t B . . I I EXHIBIT B Initial: &S. Purchase and Sale Agreement I. Parties: This purchase and sale agreement is between Shana Smith ("SELLER"), 2205 Cedar Run Drive Extended Apartment B, Camphill, Pennsylvania 17011, and Symetra Assigned Benefits Service Company, ("PURCHASER") 777 IOalll Avenue, NE, Suite 1200, SC-IO, Bellevue, WA 98004-5135, a Washington Corporation or its designated assigns. 2. Definitions: 2.1 "Payee" means an individual who is re<::eiving tax free payments under a strUctured settlement and proposes to make a transfer of payment rights; 2.2 "StrUctured Settlement" means an arrangement for periodic payment of compensation for personal injuries or sickness established by settlement or judgment in resolution of a tort claim; 2.3 "Structured Settlement Agreement" means the agreement, judgment, stipulation, or release embodying the tenus of a strUctured settlement; 3. Recitals: 3.1 SELLER is the "payee" under a "structured settlement agreement" agreed to between SELLER and York Insurance Company. 3.2 York Insuranee Company assigned its liability to make the payments. through a qualified assignment within the meaning of Section 130 of the U.S. Internal Revenue Code, to Symetra Assigned BeneHt Service Company ("SABSCO") which funded its obligation by buying an annuity issued by Symetfa Life InsUl"<ll1ce Company ("Symetra Life"). 3.3 The "strUctured settlement agreement" is listed in Exhibit "A" of this agreement The payments being sold by this agreement are listed in Exhibit "B" of this agreement. A copy of the Disclosure Statement provided by PURCHASER to SELLER is attached as Exhibit "e" of this agreement. Pagel 5.3 SELLER acknowledges that this lI'llllSfer will take several weeks to complete and requires court approval. Seller agrees to cooperate to obtain eourt approval of this sale and to take steps in good faith to effectuate this agreement. Seller acknowledges and understands that Purchaser has no obligation to pay the purchase price unless and until a final court order approving the sale is granted. Initial:SS 4. Agreement: 4.1 THEREFORE, contingent upon court approval under applicable statutes, SELLER agrees to sell the payments listed in Exhibit "B~ of this agreement to PURCHASER, for the amount of T\venty-Eight Thou.<;and, Seven Hundred Forty-Nine Dollars and Ninet)'-Four Cents ($28,749.94). SELLER affirms that the pa}ments listed on Exhibit "B" to this agreement are free from all charges and encumbrances. 4.2 SELLER agrees that in the event SELLER receives any of the payments listed in Exhibit "B" from the annuity issuer or the structured settlement obligor prior to the closing and court approval of this agreement, PURCHASER may deduct the aggregate amount of the payments so received by SELLER Itom the agreed purchase amount. In the event one of the purehased payments is sent to Seller after the court approval of this agreement is received, SELLER agrees to hold the payment in truSt for Purchaser and to immediately turn over such payment(s) to Purchaser. 4.3 SELLER agrees to revoke any prior beneficiary designation related to the payments being sold, and agrees to name PURCHASER, or its designee, as irrevocable beneficiary. 4.4 In order to effectuate the purposes of this agreement, SELLER grants a security interest (lien) upon all the of SELLER's right, title and interest to the purchased payments to PURCHASER. SELLER further authorizes PURCHASER to file financing statements regarding the purchased payments to secure PURCHASER'S rights hereunder. 5. SELLER Acknowledgements and Warranties: 5.1 SELLER acknowledges that PURCHASER has advised that SELLER seek independent professional advice, including legal and accounting advice, regarding this lI'llllSfer. 5.2 SELLER acknowledges that this transfer is in his or her best interest, taking into account the welfare and support of his or her dependants. Page 2 A. Selllemenl Agreement B. List of payments PURCHASER is buying from SELLER C. Disclosure Statement Initial: ~ 5.4 SELLER warrants that he or she has the power and right to enter into this agreement and has not sold or assigned his or her right to receive the payments, listed in Exhibit "B~ of this agreement, previously and that the payments listed in Exhibit "B" are not affected by any mortgage, pledge, lien, charge, security interest, encumbrance, restriction or advcrse claim of any kind. 5.5 SELLER warrants that he or she does not owe any money to his or her spouse or former spouse for alimony, maintenance, and/or child support. SELLER also warrants that he or she is current in any child support obligation and does not owe any money to any guardians of children or state agency for back child support. 5.61f Seller owes any past child support, or has recorded judgments or liens which encumber the purchased payments, Purchaser may, in its sole discretion, pay those debts and deduct the amount paid lrom the purchase price at the lime of closing. This agreement in no way creates any obligation by SABSCO to pay such encumbrances, directly or indirectly. 5.7 SELLER is fully aware ofhislher rights under the "structured settlement agreement," and this purchase and sale agreement, and agrees that upon court approval, this purchase and sale agreement terminates any rights SELLER or any of hislher beneficiaries. heirs, spouse, assigns, agents or representatives have or claim to have in the payments sold. 5.8 SELLER agrees to provide, or assist PURCHASER in obtaining, the following documents. a. Settlement Agreement b. Annuity Contract c. SELLER's Affidavit d. Consent of Spouse (i I' applicable) 6. Controlling Law: This agreement is governed by the laws of the state of Pennsylvania. 7. Exhibits: Page 3 8. Signatures: By signing below, we agree to be bound by all ofthe terms of this Purchase and Sale Agreement. DATED this 1'1 day of Mu.-t'c.,h2006. _Jl~.~ Shana Smith STATE OF .."P1t ) 1. ) ss. County of (lU?1 be-12 k",,,,,' ) On this..1!:L day of 771 (f:&e It... , 2006, before me, the undersigned, a Notary Public in and for the State of 7> /I , duly commissioned and swom, personally appeared Shana Smith to me known to be the individual described in and who executed the foregoing instrument, and acknowledged that she signed the same as her free and voluntary act and deed, for the uses and purposes therein mentioned. GIVEN under my hand and official seal the day and Ye'dr first above written. C~~. H OF PENHSVl~ TARY PUBLIC in and for Statelf 'P ft- , CNlMaO J. ~,EALm siding at: 7 t 7 71JRI&f 5'../ r:l<~(!, 71I'7D<' ~ ...!-IllIC=I::~~ y commission expires: .... ......01 Fill. 27, 10 Symetra Assigned Benefits Service Company BY'~~P(~~ Cenita 1-. Williamson Assistant. Vice President Symetra Assigned Benefits Service Company Poge 4 EXHIBIT A . . -. ..... ....>>..... . ..... . ,.. ... ....,.... .....-. . . UNIFORM QUALIFIED ASSIGNMENT Effi'eda M Smith as Guardian Ad Litem for Shana DeIon:s Smith, a minor yotlc Insurance Company SAFECO Assiped 8cnefiu Sa'vlceCompany SAFECO Life Insurance Company A ~ \r.....".. T ... ~ IT 11 l.: , "C1.AlMANT" -ASSIGNOR" "ASSIGNEE" "ANNUITY ISSUER" "EFFECTlVE DATE" THIS AGREEMENT i. made and entmd into by and '*- the pu!la benlto U of the Effectiw Date wirh Icfcoellco to the f'ollowins ruts: A. CWmant has elCecuted a settlement l&1eeme1l1 or rei_dated "'~".'}'f .19-1L(the "Settlement ~1CIIl' that proVidllf for the APIpor to malee cmain periodic: payments to or !'or the benefit of the Claimant all ftated in AddeDdum No. t (the "Periodic Payment."); and B. The parties desin: to effiIct . "qualified ~t" within the lMaIlina and IUbject to theconditiOllf of Section 130(41) of the Internal RewIIue Code of 1916 (the "Code,. N ~ NOW, THEREFOR.E, in consideration of the S toreaoina and other &ood and valuable S considemion. the patties agree as follows: ..... ~. The AssiJllOT hereby UJijllf &lid the Afsisnee ~ hereby assumes all of the Aalgnor'slillbllity to ~ make the Periodic Paymentf. The Auisnee ISCIlllIeS no IIIbUity to make any payment llOl JPCCitled in AddelIdum No. I. 1. The Periodic Payments COllflitute damaaes 011 accoum of panonal iqjwy or sicIaleu in 1 cue involvlna physical lDjwy or physical sldmesJ wlthln the meanina of SccclOllf 104(1)(2) and 130(41) of the Code. tot 3. The Auipee'. liabinty to male. the Periodic Pliymems is no greater than tlw of the Assignor immediately preceding this Asr-t. Asslgnee is not required to set u1de specific wets to secure the Periodic Payment$. The claimant has no rigllt. against Ihe AJsignee lIIUter than. geaeral creditor. None of the Pcriod'lC PaymentS may be accelerated. deferred, increased or deereued and may not be ltnticipaled. told, aaslsned. or erlCUmbercd. 4, The obllllltlon assumed by Aslisnee with rospcc:t 10 any reQuired payment shall be discllaried upon the mallina 011 or before tile clue date of. VIIlId cbeck in the amount llpeCified to the address ofrecord. S. This Agreement sbalI be governed by and interpreted in llCCOI'lIattce with the laws of the Stete of WubingtOll. 6. The Auignee may I\lnd \lie Periodic PaymeMJ by purcbuing a "qualified fundina asset" within the meaning of Section 130(d) of the Code In th~ form of an annuity Corttract issued by the Anllllity Issuer. All riglIts of ownersbip and control of such &IIIl\lity contrBtl shall be and remain vested in the A.uignoe exc1usively. 1 . . . 7. TM Asaipcc may ~ the Annuity J$Iuer Rnd payments uncle( any "qua/ifIed ftmdlns wet" purcbased hcr1undet direcdy to the payell{s) spoci&ed in Addcodum No. t. Such direc:tion of paymentS IbIlI be IOIely for the Asligpee's eonvenieDce and IbIl1 not provide the CIIlmant or any payee with any rIaJlls of oWlletSbip or control over the "flUIIificd fimdina wet" or apinst the AIlnlIity __. 8. Assigpee's iabiIil.y 10 make tbe Periodic Payments WIl eorttillUe without diminution resanII- ofany bankruptcy 0( insolvency of the Assignor. ASSI1)R: Y~rk mSlIJ'llnee Compall)' BY: ..~- TITLE:~ /~ -, r'" ;"..J.< N N C, - .- :.!: <'> N ~ c:r'> 0" ,. q ..-. ,.. "._...__ ~.._.... __. u_._ ___., _. .. 9. In the CVCII% the SettIclncnt ~ is deellred lerminated by a court ofl,w or in the event that Seetlon 130(e) of the Code bu not been satWie:I, tIlis ^stllell_ shall termi1llle. The Assiple sbaII then U$iJII owncrWp or any "qualified IImdina asset" purdlued bereunder to Assignor, a.w Assigpee's liability !'or 1M Periodic PlY, ~.enlS shalllerminate. 10. This Aarecmeni shall ~ binc!ilIi upon tbe respcalw repnlnnlatiVC$, heirI. sueeeaon and U$igm orlM Oaimant, the Assignor and 1M Assignee and upon any person or entity tb3t may assert any right hereunder or 10 any orllle PcriodicPayItlI!nlS. ASSIGNEE: SAnCO Assigned Bellellt1 5e?'ice Company ~. M.l" ~ J.~:.: ,;,,;.....'" V'{ . BY: TITLE: 2 IIDiJ.~ , .. . . . ,." . , ADDENDtIM 1'10. t DESCRIPTION OF PERIODIC PAYMENTS Payments of One Hundr:d Dollars ($101>'00) monthly, for a period certain of four (4) years, starting October 28, 1999 through September 28, 2003; payable to Sbana D, Smith. Payment of Twenty Thousand Dollars ($20,000.00) payable to Shana D. Sntith on October 28, 2003. Payment of Twenty Five Thousand Dollars ($25,000.00) payable to Shana O. Smith on October 28, 2006. Payment of Fifty Seven Thousand, Six H1JIIdted Sixty One Dollars and Eighty One Cents ($57,661,81) payable to Sbal'la O. Smith on October 28, 2008. BENEFICIARY: Any paymcnls to be made after death of Shana O. Smith, pursuant to the temJS oftbe SettlementAsr=nenl. shall be made to the Eslate ofShana D. Smith. The Payee shall have the right to submit a request to change the Dene6ciary desigr.ation. No such designation, nor any revocation tbelcot; sbaI1 be cfFcctive un\esi it is in writing, sipld by the Payee, and delivered to the l'1Istnr or the Insurer's Assiguee. The designation must be in a form acceptable to the InsInr or the Insurer's Assignee before such payments are made. N N 9 == .....: ... N ~ c:,' '" INlTIALS ASSIGNOR:~. o.Y'-;'.. . ASSIGNEE: . ",r ~l...: " ~..' 3 I.... .,'" --~ .:r - ..... , ,.... g ..,., '" . . '. ~RAI. 'RJ"T "..n KNOW AU PERSONS BY1'D!SE PRESEl'o"l'S THAT Elhla M. SmilII. ~ ofelle &we ofSlll%ley LouII. SlIlilll, o-ascd; lillI'Cda M. Smitb, Gwu:dilll\ Ad LItem for SboIlaOdotllS SlIlilll, IlldMduaUy aDd as ~ of!beENtcorSbaron Dololl=s Smitb, Dec:cued; aDd mhlI M. SmitIl. AdllliIlIstmriXoftllt Estalc ofSlwoDl.olli$e SlIlilll, Deceased (hOllliDa1Ier"lleIeasonj, for aDdinOCllSickra1ioc orl!lel\fllsu\IIll oCTh= Hwldred "I'ho1lsIDil Dollm ($300,000) do hcrobi rem.iP.llOIaseand!olever disWrpJ. Gary N~ LCD Am N~ Clyde D. l'uL....., IIlId BoulDl1 H.l'ullr1cr, IndivlduaJly and tld/bIa City Limits 1l.caI1iY (bcrelDa1tor "Roleams"), their il>surcrs, sub$idllrics, pllRIll COIyO.~ ~ otl'lClll'S and direclors and their heirs, __ SUWl$SO,.I, ac!milllJlrIIor and principalS, and 11.""'" .._I"!~"';I-.I~,,_;.......... ~... a:ry and.u "lilor~ &ms. pIIIlMnbipslllld oozpoqzi~ oftll4/ion.u aa4.u~oC oi\.f( IClioas llIId _ oflCllOll, IlliIs, dcbls, duos, a=olIlltJ, boDds, ~ ccmtnIOtS, "11""'"....... j1~. cbIm:s llIICl dr:D>llds w~ ill low or co.uity, espocWly all cWm.s. U\' joindcn for $O!e liability, COl11ril>uliou. indormu'ly or olhctwi1e IIiWlg lOut of m iDl:id.e3ll whlch1lllegedlyoecumdoDOubollt April 17, 1m 1lI1l502Regi1la Stteet. HurislNrg, ~ivImi.. 111. delllils ofwhich iI:cid=t and the dispute arisillgueliom belag COlItai:Aed ill a wit filed by ReIasors ~ 1he RoIll~..es in the DauplIill Coumy Cowt ofCotmnon PI... r.ald tuit beoriIl& doclcot 1>0. 1796 S Lm, whlch apiIm!be said RcIf::uccs.Releuo<s -lDd, llOW!lave OI'wllich their.tpllS, employeel, _. hIlirJ, a_tors,~. suc:cnsors or usips, l'rilll:ipals Of a:ry cf1hcrll, hcreiDa&r c:m, IlIall '" may baY#, 1'or Of by reason of a:ry 0Il.lS1I, _ Of Wog wlmsocver, fromlllo be$imliIls oClbe.....md 10 lb. dates o!then pmcz>lS. 1N .t' ua.JAII..R CONSlJ)Ul.AYIOr;- ofllle pa~Uel1inlhilllbls Gcm::aI Rdeuc, !be Aeleasol:s a&l'U as follows: ,_~"_"__,->,~_,,,,,_,'d h'~ .: - - r'o; -- - -, g . . 1. 1'be RclwoIs aclaIowlodp!llat tills S4II\emeDI bu beClI as-d to solely lOr the JIIl'1lON of~diapulcd eJo.iqp, lIIIIllID)'pI)'III4lDI....~to this JCIII_is llOtto beCOll.llnled II lIII "<lmiilJWft oflilbilily, "'l8lWlICe, culpabitityor lIIIy otIw: legal COllCllIsioo. 2. Tht llclcason lIlllIcmalld II'l4 ~ chI! the pa)'Illoot apcci6Wly idtmti.cd lIIIIl act lbrIh hc:eiD is thelllllho: Illd O1Ily COIIIiderat\on lOr tills GmerallW-. =4 il is iJlleadcclby the 1l~!IIat tills GalcaI Rol... JIIall be 00IllP1<<e II'l4 JIIallnot be IlIbject to lID)' daim of miJtUie of filet or law by ebe RcleasoIS, lIIIIl!llat II ~ . fall ancl.:omplcto actd_t of liabIUty eWmIld aIld daaicd; ancl tIW tills pacrat Ra.e is ~ to be ~lIl. !inAllIIIIl coatpltte. 3. AI pitt ofthc COlIIldmIion lOr tllo paymant to lbe 1leIea$ors oflha _ bcnIm aboYlIlIV"'i........ tllo Rei_ere rcloulag all olaims, iIlc:ludiDc all diose for lmOWll or lIIllalowllllllll mIicipate or UIIlll3Iicipatcd lDjllrie$ :IIlll damopI. The Rclcaso:. =<Iplizt n1 aclalowle<Iaelhal there is a riole lllaI subseq\IellI Ul the =tiOll of this GculraI Release \be ll'lMo_ will cIalm or $lllJi:r IIIllml1Iy or othc:r 1oss, cIamaic or lID)' of these Which lie in SOllIe _ycmsed by orrcl4tocl to lIlc iacidct, butwbic.h..... W1Icnown:lllll vm:lIlcipllhlCllllllc1lmeof this GaIonII Rd_ is sipml; aDd Illrthe:, 1bal1bcn is a riIk 1bat dlc MM.... ~ WWl1 may be or may beoom. tr.OII! ~ve!bllD thcRdcuon _ expecl or lllticijlllc. TIle ReI" "If IICC<:pt the above ~ Iisk ancl tills GeIIml Rolc.ue sIWl :spply to alIl11lla1own aDd .....ticip;\ed rcauIts orebe iDeidellt u wcII u diose known lIIll1 utlcipalcd. 4. nw ReI_ AinIler UlIdent:md lIIIIl ~ tIW the Rclcuols shall '00 n:spollSl'olc g~ 10< tho paymcal ofbi$ auomeys' fees IIIld COSlS. as well AS 011 fees ODd eocpellSCS orisina tom lIIIIl in OOlIIlClCIirm with llIlY mII\CZ$ rclatcd to tllo illeidan.1o< lIIIIlln ~ ofthi. GcacraI 2 .# .. - .- .- ....: "i ,- g C" <>, . . Release. S. The :~ "1'= 10 hold the hleasces llIlmless hmllll cIalmI, 1= or llClions. a..:ll>dll. . wlliellxm. out of or are ill my way mllled 10 any iDjuria or damaps !be lld_ may have snslIintd is!, or lIS . mull oClIle izlcjdllllt, wlliell mily be bIvugbt 1,pins!myoCl!le 'Releucaillcllldilla, balllC\..mlted 10, claims orlieas rorp~cr reimburscmcm of llledical el\peII5CI, woda:r's compcnl1licm ~ disal>ill1Y Wurmcc lIti4~~ p~ or odletbeadits, and to detaKl."ud ;"d.....,;fylH ll.el........ ",itb mpecllO llIlllllCh clllims, licIIS or ac1icm. 6. Tbe bleaIors agrtelO cOCl)CllllC 1bIlv and to ...cute my IIIld llIl supplllInIlllOl)' ~ lIDd to like III aclditioasllCllcm5lbat llI87 be -..,. or IppRlprim to Jiw 111II tcn:e lIIId efI'cct to the buic tcmIS lIIld iDtcud ortbls Geaetalll.el-.Illcl wllich are not ~_1Irithits_ 7. 'P:mD- III COIlS!deralloll oftberelasc set C<lrdl above, Yo:ll:lDs\nDcCl Company, 011 behalf oCtbe ll.el-, au- to JllYto the ilI4ividual(s) nazne4 below ("Paycc(a)'') tbc _ 0Ullined ill 1hia Scclloa 7 below: .. PaymonlJ due Gl the lime ofScttlcmClll U CoUowa: !'ayalCllt of Two lillIldrecl TGiny ~ Do1lars ($130,000.00) pa.yaItIc to ElhcIa M. SmltlI, ~ oCthe J!.slate ofSIW:lty LoIllR SmltlI, Decand; E1iiecIIl M. SlOb!>. Gu.ll:dillll Ad LilUll tot SblIIla DeloreI Smllll; lDllividusUi alld U AdmiJllslralrix oCtile 8slllIe orSlwoll Delores Smith,])cccasccI; and B1hda M. Smilh, os ,6.~~lr oflhe EIlIlC ofSbIl'Oll Louiae Smllh, Dec.ucd, and the Lcow Ol!llces of N>P>o &. Rovner, IlpOI> exllC1ltiotJ of tbis.~ b. l'eriodic l'aym1lllS made ac:cor1lia& to the Il:hedu1c as Collilws (the 3 .:r .. - ~ _or I g <" '" , . . "Periodic PI)!lIIfllllS"); (i) Paymc:lltS of'OIIeHllIldrocl Do!bl$ (5100.00) 12lOlIlllly, for "period cert2in of'iOur(4)years, ct.artin1l0c:t00er2S.1999 dwughScpt<llllberZS, 2003; payable to SbGaD. Smilll; (u) Paymcntofl'wclIlyTholl$andDoIMI ($20,000.00) payable 117 Shallal). Smith 011 October 28,2003; (m) PIi)'!lleIIt ot"Twl:ll1y FIVe nollWld I:lolIm ($25,000.00) payable to SbaII.a 1>. Smith 011 October 28, 2006; (iv) l'aymCllt o(Fitly SevCll Thousmd, Six Iitmdred Sixty One Dollm IIlCI Ei&/lty0llt CCIU(SS1,66Ul)p.wyablero SheaD. Smi1IlOll CXtober28. 2008. AlI_ let forth hemD CON!i_ damIcu 0lI1CCOl1l.l1 ot"p/I>'SieaJ injuries aad siclcness. withlD rile mcan.':Ig ofSceriOll104(a)(2) oItIlo ItIRmal ~ Code of' 1986, lIS 1IIIl.\:lIdcd. 8. ~"'-o:s' Ri_ to PoVl'lll!ntS. RtIoucn acIcIIo~ d1at the :Periodic ~ _ be ~dc:f'c:md, lDc:reascd or dea'eucd by 1hc J.d..,sOI$; lIOl'sbIl11hc ~ have 1he JlC'I"U 10 sell, ......l8'a<r, "'O"...mWl, or utic:ipatc tbe PorWdic PQ)'IMlItI, or any part therI:oI; by uslgllmCllll or otherwise. 9. RplM..,... .1l<:ne6cl...... AJIy pa)1llCQ1S III be lIIlICIuk dc:ttb ofShma D. Smi1h. ' pIlllIUIIIt 10 thotclllllofthis Gonmll.l.cl_,.un bemadclo rlIeEmteofSh8lla D. Sn:lth. 'IMl'a)w sllaU have tho rig.\t to submit 11. request 10 damge1heBeDd!cWy~ No 5Udl desl_OlI, llOI' any nmcatiOll tbmo~ shall be cft'eaive llIllm it is in writing, sipd by rlIe Pa)'OCl, aad 4elh'VCII to the i_ or tbe iIuutU', Aaoipce. The ~lIlI1UIt be ilia 1ilrm ~lc to the 1_ or tho lulrer', Asaiple before SllCb pa)'lllftU _1III!Ie. 4 Qloos ..::- ~ '. ,- <-, "" "" v' '. . . 10. C........t to Oualifled AssI_f!Ilt a. RelcuorsacllDcrwledJelllCl ape 'IbaI tlleJlJ:l_lIldIor YoU l'llsuzaDce ~ mayllllll:e. "QUIlliliedAasipast. n wilhiD the maniD; of Section 13O(e) oftht llltcmIl ~ Code of 19tG, as lIlllCIldtd, oftlle lI.e1cu,*' and/or YOU 1ll.sunlnec CompllIY's MbililY to make lhcPcriodIc:?aym_ sat tbrtlI InJl~ 7(b), (c), (d) IIl<I (e) to SAFECO Assipcd Balelits ScMCfI Company(thc nA&sis-i. 'Ihe Asslpce's obliptiOll tbrp&)'lDl1\t ofthc 1'criadlc Paya::mts sI::llU lie DO 1-_ than 1bat ofthc Rel_ and/or YOlk hlsarallee c-,my (~by j""r-IOt ap=cat) """""Iill'tly prIll*tiq the assi&amcat ofthePeriodlc ~ obllplloll. b. Arty $UCh ~ iflDldc, shall be ICCcp\lld by llIc ~w!Ihout !isht of zejectlOl1llll1lh1lll complo:clyrcl_ ad die L It llIc Rc~ IlllI YoU 1.............. Compmy 1lvIII tile Periodil: PlyDlCIllS obIipIiOll 1SSlp4 10 tlle Aslipcc. 'Ihe Rclcasors ~ lbIf, In 1!Ie CVCft ofsucbaussigmneat, thcAsslpecshltlll>l!M $OlcobliJOl'with IlIII]ICQ to tlle l'criodic P&)'IlIlllIt$ ob1JgllloD. Dllllal all Olbu nleascs witb respccl to 1!Ie Pcriod1c paymmu obli&alkm 'IbaI 'jlClU:il1 to thc lial>ilityottbo Rc~ and Yodt ~ C~ sbaIIthtol..q.oA become llDaI, irrcvocablc :mol :absolute. e. SAl'ECO Life lns:m:Il:t Company \\in issue . letter ~ the pcd'onDIDcc oftbe o'bJiaatiom lllipod 10 SAl'ECO Asslped 1l<<letils Scrvi= c-pmy by way or. QoIIified AssipllllCllt Agn:calfolllftd for wllidl SARCO Assipcd Bcnclils ServIce O>mpmy~ Ill. amuity liom SAt'ECO u.-rc ~~ Company to COVCl:'d:Icse_ obJlprioDs. 11. Ritlrt to Purcllose an Annuitv. YoUlIls1mmce Comvmy, 1hroush itsAsslJllCe, __the rl;bllo fUnd the tlabillly 'Ie make tile Periodic PlI)II:MIIlllI tbroqh the plk<:Du. of... 5 - -- - I ,- a f"-' ~.t . . . .. IIIlDUily poUq.'1l"om SAFECO Life lnsurIIlcc Compmy. 1he Asslan.- .baIllM tllc sole """,or of the IlIIlUitypoJicy IIIld .baIl have all riaJlts of -w;.. ne AssiplClC!MY!law SAFECO ure lDsur.mco Compm:y moll p4l)'IlICIIlI dIJcctly to lbc pay<e(s). The RclCUOl'S sbloll be tapotlll1>le tilrm.u...l""'ll cu:mu mallbII addreu .tl>r pa)-ee(.) willi SAFECO ~ BCIICliI$ Savice Olmpmy. 12. Discbln!e oCOOlintion. The obliplioll of t!l.c AssiplClC 10 ll\IICll each Periodle !'t.y:IICIltsllalllM dUcbarpd IlJlOII t!l.c moi\ins of I valid check ill t!l.c amllIln: of such JllIYlDCIlt to the dwiptcd addtcoftho payee lI;llIlCd m J'lRMk 7 oflhis Gcne:rol1l.clcasc. t3. '1bc Rc~ lUnbct aclalowledCC lIlll the lllltaSOlt ::n l~plII$llIItC4 by colmHl ofthe~' <:boice with tllJIld 1<>_ arislQsOlltoft!l.cllldcleat: lhattheCoalfllllMd lqpI dfecfoflhis GaunI ~ havcbCQI cxplaiDed '" tllc Rclcucml by the~. ~ 10 the Rcleuots' satisf:u:lioaMd WI rheRclwots hilY. md Md uoclcrmDd the Above Gmet81 Rcl_a heir eocccIlle same. Da:cdthls ~'f"/(A. "Yor..lrurt- .1999. ~t1 jJ. .\.~ M. SMITH. Admimll1'llrix oftllcEstote ofSlrirlcy l..oWc SmiIb. Doc......; ilflodaM. SIIIldl, ~ M lJtcmfor SbooaDclam Sall\b, ~ "'u~.(tllc EswolofSbaroa Dclola.Slllldl,J)c:ensed; IIlCIEICioda M. Smltll, ~oftllc Eswe ofSbaroo Lou. Smicb. De c =ued s_ to IPcl S1lbfc:rlbed llelilcule lIIis 0l.~"Y of"'~ tm. K'~tIr'IA~1 ~ . lie I -.... ... ..!!..~~'IOI!'~eo_ ! 6 .:t:' - - - ~ - .. l- "-" <;;I C" lot' JlL'B1lDI.. x. SHX'lB. J.dlW\isuat:dx of t:tuI J:SDD OF ~ r.ov:tSZ SHID. DlC.J:I\SI:l)I ZLJ'Ul)A X.$IlUK, : ~Ul U u- tor SlWQ. JlELOPBS SH%U:, %ntivic!wllly. .aJl4 as UldniRz'au.ix oS: the '.E$'1'An 07 : SBABOIf 1)I:LQPl!S S!I%':ll.. DECEA$ZP I ana J:LJ':RInA X. llICtD. ".4oIh'~1I1:ra- : uU: of the ZS'rW OF SBKR.Olf : r.ov:tSE SHrlIl.' DEC:ElSED. P1Wt:l.:tfs , : NO. 17.' S 19" , . . : CIVIL AC1'%O!I - lAW , v. . . . . ;r. Gl\1tt NDT, :t.J:It AIOl mrET. (:L'YJ)'J; D. 1"lJ:tXER, aM uuu.1I1I. ~ IB41viclWllly .na ~/d/h/" en I.IJtttS RWIrY. :Defendants : .7tlRr ~ D1lHAm)ED : . . : , '1'11%8 D!P~ .~. Q!l;;II1':"(V'. r~'IfJ AND BOW, this )).--1 day of ~ \,~ ' 19"; the ,peU1;10n or ZUZ'8<Ia K, Smith tOft /lpprOval of . ~ SetU_ on l:>e.ba].t of decedenU Ilnd II minor .l."mn,c1>y tJiP%O'ftd.. 1) Bltredp H. Sllith b he:-eby &u1:llor1:ed 'to Ilcccpl: $300,000 in total se1;tl_t of all claiU in the Ilbove-cqticne4 _e1:cr aJl4 1:od1c1:r1bu;t", thoa proce448 in the .anner Ht fcrtll in 1:11.. Pe1:ition, l?an!JX'aphs 24-2&.. 2) 1B.\fJ:eda JS, SIlith is authorized. end req\1.l.nd 'to pay auch inberii:ance tax.. frOlll ....ch !:Rata required. uMer the llllocaticn _t forth 11> l'aragrapb 1'7. 3) Elfreda. X. Smith is authorbed 'to executa lUlY relell1le or $t:ructure4 ..ett.J._t <klcWoent?~ ef ~e the >;;,e1:l8lllen1: $C1: torth in the l' 11:1.on. / I ~ ......., ~ EXHIBIT B Exhibit B List of payments to be purchased by SABSCO Payee Name: Shana Smith Date: February 28, 2006 Payment(s} to be sold: Due date(s): $25,000.00 $9,000.00 October 28, 2006 October :28, 2008 lI'/m8Ir' ~ - SeMce CGfnpeny' m 1_1,_, Suite 1200 .1IelIewe. W8ahington 98004 Mlllllnll _.....: PO ec. 30\734 'llulIIe. WA 8lI124-1734. ~ 1-&00-427-1304. TTYntlD I~ -------- - f)Zk,b'+ C EXHIBIT C Payment(s): Due date(s): DISCLOSURE STATEMENT NAME: Shana Smith Date: February 28, 2006 1. DESCRI.PTION OF TRANSFERRED PAYMENTS I am transferring the following structured settlement payments: 525,000.00 October 28, 2006 59,000.00 October 28, 2008 The aggregate amount of these payments is 534,000.00. 2. DISCOUNTED PRESENT VALUE The calculation of current value of the transferred structured settlement payments under federal standards for valuing annuities is $32,166.85. The applicable federal rate used to calculate the discounted present value is 5,40%. Signature: j~"~~;if"" /' Dated: ;S-.y-(',(~; Page 1 of 1 Pennsylvania I 3, GROSS ADVANCE AMQUNT In exchange for these payments, I will receive a gross amount of $28,749.94. Funding will not occur until all conditions required under the transfer agreement have ~curred. 4, TRANSFER EXPENSES The following fees and expenses wi1l be deducted from the Gross Advance Amount payable to me or my account: Legal Fees (estimate): $0.00 Broker Commission: $0.00 Itemize all other fees/charges: $0.00 S. t ' ~ Igna ure:, /;,,'. " / . .... . " " ",,, /"'<</. Dated:) . ) (Y. Page 2 01 2 Pennsylvania 1". ~ Signature: (~L., /i(r'<I/ S. NET ADVANCE AMOUNT I understand that the Gross Advance Amount, as described above, shall be reduced by the Transfer Expenses described above, resulting in the Net Advanee Amount below: Net Advance Amount: $28,749.94 I understand tbat 1 will reeeive tbis Net Advance Amount, minus a) any advances made to me or on my behalf by Symetra Assigned Benefits Service Company for notary fees, for cash advances related to attorney fees to seek court approval; and b) any amounts necessary to satisfy any outstanding liens, judgments, and credit-based obligations, pursuant to tbe terms of the transfer agreement. 6. QUOTIENT The quotient, expressed asa percentage, obtained by dividing the Net Advance Amount by the Discounted Present Value of the payments is 89.4% %, Dated: ~. J, . () ( v Page 3 013 Pennsylvania Signature, ",di>4t.d. ,61 ~?/) Dated; .~ -;;>...c,0 7. PENALTY IN THE EVENT OF BREACJI OF CONTRACT The amount of any penalty or liquidated damages payable by me in the event I breach the transfer agreement is $0.00, 8, RIGHT TO CANCEL I understand that I have the right to cancel the transfer agreement without penalty or further obligation if I do so not later than the third business day after the date that I have signed the transfer agreement. Page 4 of 4 Pennsylvania EXHIBIT C 525,000.00 October 28,2006 DISCLOSURE STA~~I NAME: Shana Smith Date: February 28, 2006 1. DESCRlPTIQN OF TRANSFERR~D P,4. YMENTS I am transferring the following structured settlement payments: Payment(s): Due date(s): 59,000.00 October 28, 2008 The aggregate amount of these payments is 534,000.00. 2. D]SCQYNTEDfB~NT VALUE The calculation oCcurrent value of the transferred structured settlement payments under federal standards for valuing anDuitles is $32,166.85. The applicable federal rate used to calculate the discounted present value is 5.40%. lit} ~i' Signature: J<:/{4...,t1- ..~.;/ Dated: 11-1-1')((; Page 1 of 1 PenIl$ylVanIlll Signature:" jj;!~ -", ;../;~:HF~" Dated: ,:":;,;J(?{.1" 3. ~R9SS ADVANCE AMQlLm' In exchange for these payments, I will receive a gross amount of $28,749.94. Funding will not occur until all conditions required under the transfer agreement have occurred. 4. TRANSFER EXPENSES Thefollowing fees and expenses will be deducted from the Gross Advanu Amount payable to me or my aecount: Legal Fees (estimate): $0.00 Broker Commission: $0.00 Itemize all other fees/charges: 50.00 Page2of2 Pennsylvania Dated: 6~ (), . !) l.p 5. JIIET ADVANCE AMQ\1~T I understand that the Gross Advance Amount, as described above, sball be reduced by the Transfer Expenses described above, resulting in tbe Net Advance Amount below: Net Advance Amount: $28,749.94 I understand tbat I will receive tbis Net Advance Amount, minus a) any advances made to me or on my bebalf by Symetra Assigned Benefits Service Company for notary fees, for cash advances related to attorney fees to seek court approval; and b) any amounts necessary to satisfy any outstanding liens, judgments, and credit-based obligations, pursuant to tbe terms of the transfer agreement. 6. Ql!OIlE~T Tbe quotient, expressed as a percentage, obtained by dividing tbe Net Advance Amount by the Discounted Present Value ofthe payments Is 89.4% %. Signature: (JiZ",,~~ x:f1;:~1f Pag.3of3 PllOll$YIvanla 7. fENALTY IN THE EVENT OF JJ~EACB OF CQNTRACT The amount of any penalty or liquidated damages payable by me in the event I breaeh the transfer agreement is $0.00. 8. RIGHT TO CANCEL I understand that I have the right to eaneel the transfer agreement without penalty or further obligation if I do so not later than the third business day after the date that I have signed the transfer agreement. ~ r Signature; Ji~ ,A~6 Dated: (3 ~~-60 Page 4 cf4 Penm;ylvllnia f )(h\ k, t .:D % \ .. EXHIBIT D ~ Symetra Assigned Benefits Service Company SEEK INDEPENDENT PROFESSIONAL ADVICE IMPORTANT NOTICE: You are stroDgIy urged to consult with an attorney who can advise you otthe potential tax consequences of this transaction, In order to make oertain that the transfer of !\Ome or all of your structured settlement payment(s) is advisable for you, it is important that you have independent and objective advice about whether the transfer is in your best interest. Please seek independent legal advice from an attorney regarding the implications of this transfer, including consideration of the legal, financial, and .t:a.lc ramifications of this transfer. Show that person the DiscIQSUre and the Purchase and Sale Agreement prepared for you by Symetra Assigned Benefits Service Company ("SABSCO"). By signing the agreement below, you acknowledge that SABSCO has advised you In writing of your right to seek-and you have bad the opportunity to seek- Independent legal advice from 11I1 attorney regarding the legal, financial, and tax consequences of this Agreement. I, Shana Rmith, HAVE CHOSEN NOT TO SEEK INDEPENDENT PROFESSIONAL ADVICE. I have been advised by SABSCO, in writing, to seek independent professional advice from an attorney regarding the implications of transferring my future rights to structured settlement payments, including consideration of the legal, financial, and tax consequences of this transfer. I have chosen to forego the advice of an independent legal professional r.egarding this transaction. ~ ~/;# Signed YANlA N 10 and for the State of Printed Name: Commissions Expires: Pennsyl_ia f)(h. ~ ,+ G: ~ ffi " 8 "' " "5 if, 15 u ~ if ii: ~ 1\ "' ~ w p < " tt W '" ~ " ~ D ,. u '" "' rP} \:'>:9 ~ ~ I ~ EXHIBIT E Shana Smith, Transferor ORDER APPROVING STRUCTURED SETTLEMENT TRANSFER IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL V ANlA CIVIL DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by No.: and Symetra Assigned Benefits Service Company, Transferee Upon an application for Court Approval of a Transfer of Structured Settlement Payment Rights ("Application") duly brought by Symetra Assigned Benefits Service Company as Transferee ("SABSCO"), and the Court having considered documents in support herein and written submissions, if any, filed by said interested parties named below: Transferor/Payee (and dependents): c/o Shana Smith 2205 Cedar Run Drive Extended Apartment B Camphill, Pennsylvania 17011 Structured Settlement Obligor: Symetra Assigned Benefits Service Company PO Box 34734 Seattle, WA 98124 ndkOl1712VOOl Annuity Issuer: Symetra Life Insurance Company PO Box 34690 Seattle, WA 98124 The Court, upon said Application, hereby makes the following findings: I. That the transfer sought to be approved complies with the requirements of the Pennsylvania Structured Settlement Protection Act, PA St. 40 94001, et seq. (hereafter "the Act"), 26 V.S.C. 9 5891, and does not contravene any applicable statute or order of any court or other government or responsible administrative authority; 2. That said transfer is in the best interest of Shana Smith, Transferor/Payee, taking into account the welfare and support of Shana Smith's dependents (if any); 3. That Shana Smith has been advised in writing by SABSCO, Transferee, to seek independent legal advice regarding the transfer and has received said advice or expressly and knowingly waived said advice in a separate written acknowledgment; 4. That SABSCO has provided the Disclosure Statement as required by the Act to Shana Smith; 5. That SABSCO has provided Shana Smith with a copy of the transferee's application, with attachments, a copy of the notice and proposed order; and 6. That SABSCO has provided written notice of said Application to the Annuity Issuer, the Structured Settlement Obligor, and other interested parties as required by the Act, none of whom have submitted written objections to said transfer. Based on the foregoing findings, it is hereby ORDERED, ADJUDGED, AND DECREED that the transfer of the structured settlement payment rights, as described ndkOl1712VOOl The Transferred Payments, as described in the "Purchase and Sale Agreement" in the "Purchase and Sale Agreement" filed with the Application herein, is hereby approved and no party to this proceeding shall hereafter refuse to honor this approved transfer. It is FURTHER ORDERED that, pursuant to the Act, by making and delivering the Transferred Payments to SABSCO, as set forth herein, the Annuity Issuer and the Structured Settlement Obligor will be discharged from all liability for these Transferred Payments due the Transferor/Payee under the annuity. Annuity Issuer and Structured Settlement Obligor are hereby ordered to remit the following periodic payments, to wit: $25,000.00 lump sum payment due October 28,2006 and $57,661.81 lump sum payment due October 28,2008 to: Symetra Assigned Benefits Service Company (its successors and/or assigns) P.O. Box 34734 Seattle, WA 98124 Tax ID # 91-1246870 SABSCO shall service the payment and remit $48,6l1.81to Payee. filed with the Application herein, shall be paid to SABSCO regardless of whether Shana Smith is alive or deceased when the Transferred Payments become due. This Order is entered without prejudice to the rights of Symetra Life Insurance Company and/or Symetra Assigned Benefits Service Company and the Court makes no finding regarding the enforceability of any non-assignment provisions contained in the original settlement agreement or related documents. This Order in no way modifies or negates the ownership or control of the underlying annuity contract by Symetra Life Insurance Company and/or Symetra Assigned Benefits Service Company. It is further ordered that the Structured Settlement Obligor and Annuity Issuer shall irrevocably change the beneficiary for the Transferred Payments to SABSCO ndkOl1712VOOl DATED this _ day of ,2006. and no other individual or entity other than SABSCO, its successors or assigns, shall have the authority to change the beneficiary for the Transferred Payments. Symetra Assigned Benefits Service Company and Symetra Life Insurance Company shall provide formal acknowledgement of the terms of this transfer within 10 days of the date of receipt of this Order. The formal acknowledgement letter shall be delivered to SABSCO at PO Box 34734, Seattle, Washington 98124. This Order concludes the proceedings herein. BY THE COURT: JUDGE ndkOll712VOOl fxhik,it r:: I;; o ~ 0< ~ ~ " o " ~ w o ~ " [5 " ~ "- " l;:j " 1:; w " ~Fh "',,'Y 1 ~ Ii; , ~ EXHIBIT F AFFlDA VIT I, Shana Smith, of full age, being duly sworn according to law, upon my oath depose and say: I. I currently reside at 2205 Cedar Run Drive, Extended Apartment B, Camphill, Pennsylvania 17011. 2. I am the recipient of certain guaranteed payments under a strUctured settlement dated 24 August 1999. The entity presently obligated to make payments due under the structured settlement is Symetra Assigned Benefits Service Company. In order to fund its payment obligations under the structured settlement, Symetra Assigned Benefits Service Company purchased an annulI}' contract AA076637S from Symetra Life Insurance Company. 3. I voluntarily entered into a Purchase & Sale Agreement (the "Agreement") with Symetra Assigned Benefits Service Company ("SABSCO"). Under that Agreement, which is attached as Attachment A, 1 agreed to sell and assign to Symetra Assigned Benefits Service Company the following payments due to me under the structured settlement; $25,000.00 lump sum payment due October 28, 2006 59,000.00 out of$57,661.8llump sum payment due October 28, 2008 (the "Assigned Payments") 4. I understand that I will forego receipt of the Assigned Payments under the Agreement. I understand that I will continue to receive the Assigned payments until Symctra Assigned Benefits Service Company receives court approval. 1 understand that my beneficiarieslheirs and I will no longer receive any of the Assigned Payments or any portion of the Assigned Payments. I desire to change the beneficiary of the Assigned Payments to SABSeO or its designee. I understand that the Assigned Payments will go to Symetra Assigned Benefits Service Company or the assigns of Symetra Assigned Benel1ts Service Company. 5. I also understand that this Affidavit is submilled for use in the court- approval process initiated by Symetra Assigned Benefits Service Company and myself to seek court approval of the transfer ofpayments to Symetra Assigned Benefits Service Company. 2 6. At least 10 days before I signed the Agreement, I received a Diselosure Statement from Symetr;l Assigned Benefits Service Company detailing the terms of the Agreement, which I signed and returned to Symetra Assigned Benefits Service Company. I carefully reviewed the Disclosure Statement and fully and completely understand all terms of the Disclosure Statement. 7. In the Disclosure Statement, Symetr;l Assigned Benefits Service Company advised me in writing to seek independent professional advice regarding the Agreement from an attorney, accountant or other licensed professional of my choice. I have received said advice or knowingly waived said advice in writing. A true and correct copy of the verification or waiver to that effect is attached to this doeument as Attachment B. 8. 1 am an adult who is single and employed as a Certified Nursing Assistant with Messiah Village Nursing Home. My dependents are my children la'maury McKeithen age 3'1.. and Promise Hill age 8 months. Other than the future structured settlement payments that I wish to lI'llllSfer and assign to SABSCO,I have sources of income. 9. I have thoroughly considered this transaction, my alternatives and the use to which I will put the proceeds of this sale. 1 have considered the impact of this transaction on myself. I found an affordable home that is perfect for my family but I am having a diffieult time establishing credit because I have several small collection accounts. My collection accounts total less than two thousand dollars. I want to clear the collection accounts up so that 1 qualify for a home loan. I intend to use the proceeds 1 receive from Symetr;l Assigned Benefits Service Company to payoff a few collection accounts and fund a down payment on a home. I believe this is an efficient use of my money and that I will be investing in my own future. Therefore, I have decided 10 pursue this transaction with SABSCO. After considering these factors I believe that this transaction is in my best interest and in the best interests of my dependents. 10. I will not be using any portion of the proceeds from the Agreement for day-to-day expenses. I have never assigned, sold, or pledged any of the slnJctured settlement payments that 1 am proposing to transfer herein and that I am receiving from the aforementioned structured settlement, to any party or entity. I have determined that completing this transaction with Symetra Assigned Benefits Service Company is in my best interest and will improve my quality of life. NOTARlAl CARMElO J. Cl.AIJDIO, m"'" I.IInIlyM 8oro, tumbIrIMII My CommIsIIoII Er/Jhs ... ?:1. 0 I declare under penalty ofpeljury under the laws of the state ofPennesylvania that the foregoing is true and correct. Dated this tl day of Mareh, 2006, at CamphiIl, Pennsylvania. x6j~ ~- -- Shana Smith - ~ State of 7j! . I County of L ):.J - ~..ft ["...... J..... //. On this day personally appeared before me c ~ j;;..N# .JIM ' -;0 m~ k.nown to be the individual(s) described in and who executed the within and foregoing instrument and acknowledged that helshe signed the same as hislher free and voluntary act and deed for the uses and purposes therein mentioned. Given under my hand and official seal this I C{ day of )%:?/t ~ A . 20 b G.. II Notaty d for Residing at 'J171/1~l1t. LftKt '{fib-YII !7()v'3 co 3 B)(lllB It II . . 4 . . AFFIDAVIT I, Shana Smith, of full age, being duly sworn according to law, upon my oath depose and say: 1. I currently reside at 2205 Cedar Run Drive, Extended Apartment B, Camphill, Pennsyl vania 17011. 2. I am the recipient of certain guaranteed payments under a structured settlement dated 24 August 1999. The entity presently obligated to make payments due under the structured settlement is Symetra Assigned Benefits Service Company. In order to fund its payment obligations under the structured settlement, Symetra Assigned Benefits Service Company purchased an annuity contract AA0766375 from Symetra Life Insurance Company. 3. I voluntarily entered into a Purchase & Sale Agreement (the "Agreement") with Symetra Assigned Benefits Service Company ("SABSCO"). Under that Agreement, which is attached as Attachment A, I agreed to sell and assign to Symetra Assigned Benefits Service Company the following payments due to me under the structured settlement: $25,000.00 lump sum payment due October 28,2006 $9,000.00 out of$57,661.81 lump sum payment due October 28, 2008 (the "Assigned Payments") 4. r understand that I will forego receipt of the Assigned Payments under the Agreement. I understand that I will continue to receive the Assigned payments until Symetra Assigned Benefits Service Company receives court approval. I understand that my beneficiaries/heirs and I will no longer receive any of the Assigned Payments or any portion of the Assigned Payments. I desire to change the beneficiary of the Assigned Payments to SABSCO or its designee. r understand that the Assigned Payments will go to Symetra Assigned Benefits Service Company or the assigns of Symetra Assigned Benefits Service Company. 5. I also understand that this Affidavit is submitted for use in the court- approval process initiated by Symetra Assigned Benefits Service Company and myself to seek court approval of the transfer of payments to Symetra Assigned Benefits Service Company. I . . . . . 6. At least 10 days before I signed the Agreement, I received a Disclosure Statement from Symetra Assigned Benefits Service Company detailing the terms ofthe Agreement, which I signed and returned to Symetra Assigned Benefits Service Company. I carefully reviewed the Disclosure Statement and fully and completely understand all terms of the Disclosure Statement. 7. In the Disclosure Statement, Symetra Assigned Benefits Service Company advised me in writing to seek independent professional advice regarding the Agreement from an attorney, accountant or other licensed professional of my choice. I have received said advice or knowingly waived said advice in writing. A true and correct copy of the verification or waiver to that effect is attached to this document as Attachment B. 8. I am an adult who is single and employed as a Certified Nursing Assistant with Messiah Village Nursing Home. My dependents are my children Ja'maury McKeithen age 3 Yz and Promise Hill age 8 months. Other than the future structured settlement payments that I wish to transfer and assign to SABSCO, I have sources of income. 9. I have thoroughly considered this transaction, my alternatives and the use to which I will put the proceeds of this sale. I have considered the impact of this transaction on myself. I found an affordable home that is perfect for my family but I am having a difficult time establishing credit because I have several small collection accounts. My collection accounts total less than two thousand dollars. I want to clear the collection accounts up so that I qualify for a home loan. I intend to use the proceeds I receive from Symetra Assigned Benefits Service Company to payoff a few collection accounts and fund a down payment on a home. I believe this is an efficient use of my money and that I will be investing in my own future. Therefore, I have decided to pursue this transaction with SABSCO. After considering these factors I believe that this transaction is in my best interest and in the best interests of my dependents. 10. I will not be using any portion of the proceeds from the Agreement for day-to-dayexpenses. I have never assigned, sold, or pledged any of the structured settlement payments that I am proposing to transfer herein and that I am receiving from the aforementioned structured settlement, to any party or entity. I have determined that completing this transaction with Symetra Assigned Benefits Service Company is in my best interest and will improve my quality of life. 2 , , . 1 ~. . I declare under penalty of perjury under the laws of the state ofPennesylvania that the foregoing is true and correct. Dated this \ Y day of March, 2006, at Camphill, Pennsylvania. ~)~ -~~)~ Shana Smith State of ]/ /J . County Of-C-u. -- c; ~ r(,. S__//A. On this day personally appeared before me c ,,/Ih'/l ~~ to me known to be the individual(s) described in and who executed the within and foregoing instrument and acknowledged that he/she signed the same as his/her free and voluntary act and deed for the uses and purposes therein mentioned. t~7< L''J-h I Given under my hand and official seal this / I{ day of ~l/;; /1 e J. , 20 b (" . Notary Residing at 7 f7 7lIIhz/{;rtJl. !..j;/I{) '//'ibyff ;70<("'3 19 COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL CARMELO J. CLAUDIO, Notary Public Lemoyne Bora, Cumberland County My Commission Expires Feb. 27, 2010 3 .~ urcler , J. . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by Shana Smith, Transferor and Civil Action No. Symetra Assigned Benefits Service Company, Transferee ORDER OF COURT AND NOW, to wit, this _ day of , 2006, upon consideration of the Application for Court Approval of a Transfer of Structured Settlement Payment Rights and Joint Petition for Order granting said Application, it is hereby ORDERED that a hearing shall be held on said Application and JointPetition on the _ day of , 2006, at o'clock, _.m., Courtroom No. --' Cumberland County Courthouse, Carlisle, Pennsylvania. BY THE COURT: Civil Action No. ~ . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by Shana Smith, Transferor and Symetra Assigned Benefits Service Company, Transferee CERTIFICATE OF SERVICE I, Nicholas D. Krawec, Esquire, hereby certify that a true and correct copy of the foregoing Application for Court Approval of a Transfer of Structured Settlement Payment Rights was served on the following by certified U. S. Mail, return receipt requested, this "ItA day of fJprl/ , 2006, addressed as follows: Shana Smith 2205 Cedar Run Drive, Extended Apt. B Camp Hill, PA 17011 Symetra Life Insurance Company PO Box 34690 Seattle, WA98l24 Symetra Assigned Benefits Service Company PO Box 34734 Seattle, WA 98124 ~ / ,~ ./ ~ .' 0 -(,Q.. .--' p~~, ... -..- fl ~ i'.: F~ tr( ::.1" If( . - ut" ~ GJ \) ,\ II -' -- VI "f-J ~ (,J )1 ."- ~ (/J (.!. :D .f=- ~ , " "', i ( . 'J I\F~ ( ( :OliO IBy; .. \, I l! - - .-----~ ~c_,.,,~~1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In Re: Approval for Transfer of Structured Settlement Payment Rights by Shana Smith, Transferor and Civil Action No. D~. -!9?7 GZ,-l(T0~ Symetra Assigned Benefits Service Company, Transferee ORDER OF COURT AND NOW, to wit, this .rJ!'-day of ~ ' 2006, upon consideration of the Application for Court Approval of a Transfer of Structured Settlement Payment Rights and Joint Petition for Order granting said Application, it is hereby ORDERED that a hearing shall be held on said Application and JointPetition on the ~S~ay of fY\a ' 2006, at 1 D: 00 o'clock, Ji..m., Courtroom No. S , Cumberland County Courthouse, Carlisle, Pennsylvania. BY THE COURT: \\ '\. J. ,i., S .~::; . ." ... ." IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In re: Approval for Transfer Of Structured Settlement Payment Rights by Shana Smith, Transferor No: 2006-01997 and Symetra Assigned Benefits Service Company, Transferee AFFIDAVIT OF SERVICE OF NOTICE OF PROPOSED TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS FILED ON BEHALF OF Plaintiff(s) COUNSEL OF RECORD FOR THIS PARTY: NICHOLAS D. KRAWEC, ESQUIRE P A ill #38527 DEBORAH R. ERBSTEIN, ESQUIRE PA ill #86470 CHRISTOPHER M, BOBACK, ESQUIRE PA ID #91730 Bernstein Law Finn, P,C. Finn #718 Suite 2200 Gulf Tower Pittsburgh, PA 15219 412-456-8114 BERNSTEIN FILE NO. C0063031 Ib000300VOOl .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In re: Approval for Transfer Of Structured Settlement Payment Rights by Shana Smith, Transferor No: 2006-01997 and Symetra Assigned Benefits Service Company, Transferee AFFIDAVIT OF SERVICE OF NOTICE OF PROPOSED TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS Before me, the undersigned authority, personally appeared Nicholas D, Krawec, Esquire, who, being du1y sworn according to law, deposes and says that he caused to be mailed a copy of the Notice of Proposed Transfer of Structured Settlement Payment Rights in the above-captioned matter by certified mail on May 3, 2006 to Shana Smith as evidenced by certified mail receipt no. 7005 182000030004 1755 and that the Notice of Proposed Transfer of Structured Settlement Payment Rights was received by Shana Smith on May 8, 2006. Said certified mail receipts are attached hereto and made a part hereof. Further Affiant sayeth naught. ~~ Sworn to and subscribed before me this .t/!!} day of May, 2 06. Notary_s... UncIa eo,te. NcUry PubIIo Ofty of Plttlburgh. Allegheny County My Commllllon ecpn. o.t:iet 29, 2007 Member. PeI...,....A8.oOfdon 01 Now... IbOOO300VOOl ... lbOOO300VOOl , ~ LO LO ?"- M U.S Postal Service CERTIFIED MAIL. RECEIPT (Domestic Mail Only; No Insurance Coverage ProvIded) ::r CJ CJ CJ USE Postage $ ITl CJ Cerlllled Fee CJ Retum ReceIpt Fee CJ (EndonIement Required) d ReslrlcI8d Delivery Fee n.J (EncIor8ement Required) ~ ....:f . U1 CJ CJ I"- .. ., #. (") "'-.) c: = 0 = .... <" ~ ., i~t~ :x :i! h ):0- -< nl:r:J -0 hi Q") :'JO r::,) 1 }!C1 :0.- ~ "tl 3: f_~ .;Q -~,~c ) CO :'-rn ,::) .. ~ w :U O'l --< 1. ~'j..;d ~OJ {k,6.. h ~ (i~~ fj;f &. ~I';.;/J /11 /7r)11 2. ArtIcle Nurl1ber . (>>an* IttIm ..mc.18beI) PS Form 3811. February 2004 .~lll.'III"'" 1:I~.j~"""'_Il. .r 11 ilfll .'t1IIIli tlCloOA 4. ANI.... ~ fIlidNlWJ 0.... 7005 1820 0003"0004 1755 00rnMtlcA8tum ReceIpt 1~..u-1Wl ~ '. i ~".. ... .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In re: Approval for Transfer Of Structured Settlement Payment Rights by Shana Smith, Transferor No: 2006-01997 and Symetra Assigned Benefits Service Company, Transferee AFFIDAVIT OF SERVICE OF NOTICE OF PROPOSED TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS FILED ON BEHALF OF Plaintiff( s) COUNSEL OF RECORD FOR THIS PARTY: NICHOLAS D. KRAWEC, ESQUIRE PA ID #38527 DEBORAH R. ERBSTEIN, ESQUIRE PA ill #86470 CHRISTOPHER M, BOBACK, ESQUIRE PA ID #91730 Bernstein Law Finn, p,c. Firm #718 Suite 2200 Gulf Tower Pittsburgh, P A 15219 412-456-8114 BERNSTEIN FILE NO. C0063031 Ib000300VOOl ~-' ... IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION In re: Approval for Transfer Of Structured Settlement Payment Rights by Shana Smith, Transferor No: 2006-01997 and Symetra Assigned Benefits Service Company, Transferee AFFIDAVIT OF SERVICE OF NOTICE OF PROPOSED TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS Before me, the undersigned authority, personally appeared Nicholas D. Krawec, Esquire, who, being duly sworn according to law, deposes and says that he caused to be mailed a copy of the Notice of Proposed Transfer of Structured Settlement Payment Rights in the above-captioned matter by certified mail on May 3, 2006 to Symetra Life Insurance Company and Symetra Assigned Benefits Service Company as evidenced by certified mail receipt no. 7005 18200003 0004 1748 and certified mail receipt no. 7005 1820 0003 0004 1731 and that the Notice of Proposed Transfer of Structured Settlement Payment Rights was received by Symetra Life Insurance Company and Symetra Assigned Benefits Service Company on May 8, 2006. Said certified mail receipts are attached hereto and made a part hereof. Further Affiant sayeth naught. ~~ Sworn to and subscribed before me this l)"\tayof May, 2006. Notary Seal . Linda Boyle, Notary Publfo City of P~sburgh, Allegheny County I O~18iOn Expi,... October 29, 2007 Member. ...,.,..... AI.~ 01....... fI-, .. 1:0 ::r ~ M " . ::r CJ CJ CJ m CJ CertlIiecIFee CJ CJ Return R~ Fee (EndOlll8rl1ent Recjulred) ~ (J!.~_ d~Fee 1:0 -............,ent fleqiilAld) M U') CJ CJ ~ ER: COMPLETE THIS SECTION . . . . . Complete items 1, 2, and 3. Also complete iteJ:l1 4 if Restricted Delivery is desired. . Print your name and address on the reverse so that we can return the card to you, . Attach this card to the back of the mailpiece, or on the front if space permits. 1. ArtIcle Addressed to: S,JtivU -:J (joy ~? 1/ ~tJ ~ [.11- 91'/;.( ~ B Received ~(Prfn eOA::t'R'f 0, Is delivery add from Item 11 D Yes If YES, enter delivery address below: D No I'" 3~lce Type CettIfIed Mall D Express Mall Registered D Return Receipt fOr Merchandise D Insured Mall D 0.0.0, 4. RestrIcted DelIv9ry? (EldnJ Fee) . D Yes 2. Artlcle Number (Tnmsfer from- servk;elabel) PS Fonn 3811, February 2004 7005 1820 0003 0004 1748 Domestic Return Receipt _ 102595-02-M-1540 ~ .... ...=I rn r'- ...=I U S. Postal Service" ECEIPT C"ERTIFIED MAIL R. Coverage Provided) estic Mall Only; No Insurance " t rn CertlIled Fee C C Return Recelpt Fee C (Endorsement Required) C Restricted Delivery Fee ru (~rsement ReqUired) otJ ...=I LIl C C r'- USE ::r C C C Postage $ See Reverse for Instruc 10 U, June 2002 · Complete Items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desIred. · 'Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the lTlailpiece, or on the front if space permits. 1. ArtlcleAddressedte: AI' . ..../ 0Y~ ~~ m 3l/1.JY ~ tUA 9/'/d/ oY~ " ONe' 2. Article Number , rfransrer from S8I'\Ifce label) PS Fonn 3811, February 2004 ~ 3. Service Type ~ Mall C Expn,ss.MaII 6 R~I~ C Return ,Receipt for MerchandiSE! C JIlSIWd Mall C C.O.D. 4. Restricted Delivery? (EJctJa Fee) C Yes 7005 1820 0003 0004 1731 DomestIc Return Receipt 102595-<l2-M-1540 o G ~;:...s ""Dee rrl it: '-7 "!' [;,5; r:$ <: ~;"E:: Pc..:: ~ Jf' " f'-..) c:::;I c:::;I <:r' :x > -< ~ ~ if,:n hi =.89 OCI .._~...;::. :r: -h C)-~ 0""("') brn -:..t ~ -J -u 3 c.a <=> o ~ 1,' " IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA CIVIL DMSION In Re: Approval for Transfer of Structured Settlement Payment Rights by No.: 0& - J q q ~ Shana Smith, Transferor ORDER APPROVING STRUCTURED SETILEMENT TRANSFER and Symetra Assigned Benefits Service Company, Transferee Upon an application for Court Approval of a Transfer of Structured Settlement Payment Rights ("Application") duly brought by Symetra Assigned Benefits Service Company as Transferee ("SABSCO"), and the Court having considered documents in support herein and written submissions, if any, filed by said interested parties named below: Transferor/Payee (and dependents): clo Shana Smith 2205 Cedar Run Drive Extended Apartment B CamphiU, Pennsylvania 17011 Structured Settlement Obligor: Symetra Assigned Benefits Service Company PO Box 34734 Seattle, WA 98124 ndk01l712VOOl '.... . , Annuity Issuer: Symetra Life Insurance Company PO Box 34690 Seattle, VVi\ 98124 The Court, upon said i\pplication, hereby makes the following findings: 1. That the transfer sought to be approved complies with the requirements of the Pennsylvania Structured Settlement Protection i\ct, P i\ St. 40 ~ 400 I, et seq. (hereafter "the i\ct"), 26 D.S.C. ~ 5891, and does not contravene any applicable statute or order of any court or other government or responsible administrative authority; 2. That said transfer is in the best interest ofShana Smith, Transferor/Payee, taking into account the welfare and support ofShana Smith's dependents (if any); 3. That Shana Smith has been advised in writing by S.ABSCO, Transferee, to seek independent legal advice regarding the transfer and has received said advice or expressly and knowingly waived said advice in a separate written acknowledgment; 4. That Si\BSCO has provided the Disclosure Statement as required by the i\ct to Shana Smith; 5. That S.ABSCO has provided Shana Smith with a copy of the transferee's application, with attachments, a copy of the notice and proposed order; and 6. That S.ABSCO has provided written notice of said i\pplication to the J\nnuity Issuer, the Structured Settlement Obligor, and other interested parties as required by the i\ct, none of whom have submitted written objections to said transfer. Based on the foregoing fmdings, it is hereby ORDERED, i\DJUDGED, i\ND DECREED that the transfer of the structured settlement payment rights, as described ndkOI1712VOOI ..Jo' ~ in the "Purchase and Sale Agreement" filed with the Application herein, is hereby approved and no party to this proceeding shall hereafter refuse to honor this approved transfer. It is FURTIIER ORDERED that, pursuant to the Act, by making and delivering the Transferred Payments to SABSCO, as set forth herein, the Annuity Issuer and the Structured Settlement Obligor will be discharged from all liability for these Transferred Payments due the Transferor/Payee under the annuity. Annuity Issuer and Structured Settlement Obligor are hereby ordered to remit the following periodic payments, to wit: $25,000.00 lump sum payment due October 28,2006 and $57,66!.81 lump sum payment due October 28,2008 to: Symetra Assigned Benefits Service Company (its successors and/or assigns) P.O. Box 34734 Seattle, WA 98124 Tax ill # 91-1246870 SABSCO shall service the payment and remit $48,611.8lto Payee. The Transferred Payments, as described in the "Purchase and Sale Agreement" filed with the Application herein, shall be paid to SABSCO regardless of whether Shana Smith is alive or deceased when the Transferred Payments become due. This Order is entered without prejudice to the rights of Symetra Life Insurance Company and/or Symetra Assigned Benefits Service Company and the Court makes no finding regarding the enforceability of any non-assignment provisions contained in the original settlement agreement or related documents. This Order in no way modifies or negates the ownership or control of the underlying annuity contract by Symetra Life Insurance Company and/or Symetra Assigned Benefits Service Company. It is further ordered that the Structured Settlement Obligor and Annuity Issuer shall irrevocably change the beneficiary for the Transferred Payments to SABSCO ndk01l712VOOl \.... ~ , ' . ' and no other individual or entity other than SABSCO, its successors or assigns, shall have the authority to change the beneficiary for the Transferred Payments. Symetra Assigned Benefits Service Company and Symetra Life Insurance Company shall provide formal acknowledgement of the terms of this transfer within 10 days of the date of receipt of this Order. The formal acknowledgement letter shall be delivered to SABSCO at PO Box 34734, Seattle, Washington 98124. This Order concludes the proceedings herein. t" DATED this 15 day of ~o..'l ,2006. BY THE COURT: ~tW\ ruoGE . \ \ ndkOll712VOOI ... v, r': ',/,/":'1..1,08:\[ \1.=J.j . I 'J.-. ' '''-''''In'' ,1-...1.1'" L.' ' :: ':'1' ~ 1'..) 92 :Oll,l~ SZ AIJH 9DilZ ^tlV1C~,,::'U,)iJ JHl j() 3~:}1:: ;:;C)-{J]l!j