The URL can be used to link to this page

Home My WebLink About95-02702 .j j! . --;:# r 2 a -;!. ~ J .' J / co 0, r-j <'OJ , I l() 0- KREITHEN, BARON & CARPEY BY, NICHOLAS D. MAXYMUIK I.D. NO. 62180 10'1'11 FLO(JH L! () 1 l'IWSTNIIT STllI':I':T 1'111 LADELI'II lA, I'A. 1'110'1 (211)) Idl.~ H~!Hh ATTORNEY FOR PLAINTIFFS BH I ANNA IIANNAWA Y, .. III i 11"1 , by <llld t III Ul/lIh hl'1 ",lIl~lIt d/Hi IIdt ul'al qUdldldll, KELLY HEl'I'EHT and KELLY HEI'I'IWT, in h"l "WII dqht COUHT OF COMMON I'LEAS CUMBEHLAND COUNTY v. No. 95"2702 VINCENT B. WIIITE dlld BETTY L. WIIITE, husband ann wite, t/d/b/a TilE WIHE WIIEEL BICYCLE SIIOI' v. KELLY HEl'PEHT AND NOW, thifl . / I o r ~ R D E R day of \ " \ ..\ <, 1.1,( , , 1996, upon conoideration of the Petition hn Leave to Settle or Compl"omise A Minor's Action, it is OIWEIlED that petitioner is authorized to enter into a settlement with Defendants, Vincent B. White and Betty L. White, h/w and d/b/a The Wil'" Wheel Bicycle Shop, ill the gross sum of Twelve Thousand Five lIundl'ed Dollars ($12,500). IT IS FURTHEH OIWEHED and llECHEELJ t hat the set tlelllrent pl"oceeds be distributed as [allows: KHEITIIEN, BAHON " CAIlI'EY For Coullsel Fee $ 3,891.78 ~ 373.34 " $ 74.00 $ 150.00 $ 132.05 $ 27.00 $ 67.10 $ 450.15 KREITllEN, BAIWN " CAIlI'EY For Costs OUTSTANDING MEDICAL BILLS: Dr. Gal ldghel' Neurological SUlgelY Seidle Memol'ial lIospital Hitzman Iladiology Polyclinic Med. Center ~cU ,,/ ;' J/u..,\ . cP. '. TO: Nlciluliltl Il. Milxymllik, ^tllllll"y Illl K,d 1 Y He!'p"I'l. I'd I ,'III dlld Ndl III,,] GUill'didll of Bl iclt\lld lLullldWdY, il miuur, Baid IIlIm lu Ill' pld",'d ill.1 l,'dl'ldlly inUU1'C!d fJiivinqu dt'I'O\1l\t ()) fl~dl~rdl ly insured Havin,=-~n t'I~I-~ it it'dt t~ tu be marked, "Nol I () I", wi l i1'lt'i!WIl until Bald mill!)l Il'ilclll'fl 1.11" age of 1 fl, O}' IIpUIl l lIP old"l 01 A COllrt of Competellt JUI'iBdiction. " (. " (. ~ 7.784.73 12,500.00 TOTAL BY TilE covin: ~ A V' V ,'\ ~ tJ r-... - -....: ..() - c " ( Z 'U ~ (""!. I' ."-'1' r.'i, . , , t '. ~ .' . . , , ;. ltl n ~.J , "\"1 -l I -'1 ,-t i~ r... ...... !( ,...,) . .. ! " ." I r ! i I t ! I I I I , I t I ; f I KREITHEN, BARON'" CARI'EY BY, NICIIOLAS D. MAXYMUIK LD. NO. 62180 10'1'11 FLOOH l;W 1 ('III.:~;TNIIT ~;THEET PIIII.AIJEI.PIIIA, 1'1\, 1'110" (21',) !,(,] n;~fl(, ATTORNEY FOR PLAINTIFFS BHIANNA IIANN1\WAY, 01 m! 1\1>1 by and 11110\1'.111 h,,, 1'011 "111 dlld nat\ll'''] q\li1ldidll. I(EI,J,Y IO<:PPEHT and KELLY HEPPI':H'I', i \I It''l oWII J'iglll {'Olllfl' OF COMI~()N PLEAS ('I 'MI\EI~ I ,ANIl COIINTY v, No. Y',,2'!02 VI NCENT B, Will TE and BETTY I.. WHITE, 1t\l8band and wi f "', t/d/b/a TilE WIHE WIlEEL BICYCLE SIIOP v, KELL,Y HEPPEHT AND NOW, tltin ORDER ") I ~ r- day of (- ( ..\ t, I ~C-~ , 1996, U[Xlll consideration of tile Pet i t iOIl 1'<>1' Leave to Settle or Compl'onlise 1\ Minor's Actiol1, iL in UIWEHEll tllat Pelitioner in authol'ized to entel' into a flett]empnt witlt Il,efendantfl, Vincent B. White and Betty IJ, White, h/w and d/b/a Tile Wire Whee] Bicycl" Shop, in the grOSf3 sum at Twe]ve TItOlwand Five Ilundred 1l0]lilllJ ($12,500), I TIS FUHTHEH OIHlEHEI1 .1Ild IJECHEEIl t hat the set t] "menl proceeds be distributed all fo]]ow,;: KHEITIIEN, BAIlON 10 CAI~PEY For CO\lnHe] FE''' <" "' J,IlYl,'!!! KllE I TIlEN, BAHoN 10 CAHPEY FOJ ('ouLu $ l'7),J4 OUT~;T1\NllJN(; MEllIC1\!. BlLL~;: IJI', Ga]laqlt"1 Npuloloqic.(t I ~ilJl qPIY Seidl" Memc" iill Ilolll'! t .1] H! t. Zllliln Hild i 01 o'lY Poly"lini,' Ml'd. ('pnll'l $ 74,00 $ 1 ',(). 00 $ 132.05 $ 27.00 $ [,7-'..lQ $ 11~) 0 . ] !:) Ql'lL....I1CTIilli. ('( JM I '1{I.Jl'IT l, Pli1intiffn, Bt'iillllltl 11,11 11 J."l Wd Y dIHJ Kfdly Heppe}"t. arf~ individuals lesidinq ,II. thl' "lll)v" addll'flO. 2. IJ"I,'nd,lIltfl. Vin.'('nl H, Whil.' alld Hl.'tty individualH doill~J hllHillflHH 11I1I)I'f till' "IJl)Vt' f iet it inuB prillC'ip.:-ll pLlt't> of lllH;iIl('tHJ oIl tl1l_' d,hnvp dddlf-'Hll. Will to.' alf.' name WiLh a 3. At i111 t iml,'o 1"I..v<lnl agent 13, l3ervants, wOI'kmen dnd/o! and course of t1wi I' pmployment . hO.""ln ,III dr:ll.'ndanto acted by f'mp]oy""n ill't i nC) within the scope 4. At all times relevant IWI'ein defendanl.H, Vincent Whit," and Betty Whi tl'. owned, occupi(.'d, leased. controlled and/ol' maintained the premifles located at 23 E. Main Street, Cumberland County, P(~nI18ylvdllia. ~. On 01 aboul. June 3, ]994, plaintilf, Brianna lJannaway, wau walking on the second floc)!' deck of apal'tment B at the above location when a hOl'izontal wooden lailing dislodged from the vertical SUppoI't causing hel' to sl ip, stumble, trip and/or fall on to the pavement Aome tell (10) f'~et below her to sustain injuI'ies and damages, the detai Is of which al'e Bet fOI:th hereinaftel'. 6. PI'ior to the date of the uaid accident defendants, Vincent and net ty Whi te, had dil'ect knowl edge of the above described cOlldition and/or it existed for such a length of time that they knew and/or should have kllOVI of itl3 exiBtence. 'I. The negl iq(,nce and call>j'~flf3IJef]B of defendantB, Vincent and Hetty White, jointly and sevel'ally conBisted of: condition, thel'eon; (al fail ing to maintain the [ll"emifJes in a non-defective which would IH'ol:p.cl alld Ilafeguard persons lawfully (b) permitting till: premineo to rpmain in a defective condition 80 as to conotitule a dangel', menace, nuisance and trap for pel"SOIW lawfully on said pIPmifJes; (el f ai 1 inq ! <l !lav,' infJpec! cd Baid pn~mises at IPiHJ<lnabll' inll'l'vill" in ol<h'l" to d,'tel'mille tlw conditioll of said 1>l'f~lI1i Ben; (d) f ai 1 in'1 to WaIn penlOlw lwing Baid prp.mises of the d(~ff~ctivp condition; (p.) circulTlstances; fa! I in'1 and to exercise due CHl.e under the (----, Lil ,-.., / "c,...... \..'.j .." '"'::.-. "", ,'----' - - I.J "'" '\ ~ ....... "-,, :>-\J '~ ~~- \,1.1 1..'" -t::--, ( '-, ~ " "'.\ l.i ~'- ":-~\ r:-- \-\ ,. t..l,:) <Jl 1',! ~ ~~o .....' ,~ , · .,~ r -U ~, Z 1~ ;>:J'l\..=lF o '\;lJ1 :-1 m: ,r ''',''2 i o {(\,Vl: ri R'~ 1 -I' ~-- ;r> ni \0 ;J Cl ; -< ~\ .... TO, Kelly Reppert., I'anmt and Nat.uI'id Gual"dian of Ill' i anna IlLlIlnaway, a mi 1101', to be pJ,lCL>d ill a feLj,.I'ally in!lun:;d savings account or federally insured Davingn certificate to be marked, "Not. to be wHhdl'awn until said minol reaclwD the age of 1B, 01' upon the Onlel of A Court of Competent ,Jurilldiction." S7,764.73 TOTAl, S12,500.00 whose principal pI ace of bUll i ncss il t al I reI evant times WilB 21) East Main Street, Mcchanicsbul'g, PA 1701)',. 7. On 6/3/94, tlw minol' fllwt.ai ned the following injuries hai!'line skull (ractlll'e, cetelll.al concuusion, and othel. injuries, when she tell fl"om through a 1008e pOl'ch I'ai 1 ing onto concrete sidewalk. 8. Attached is a statement, under oath, of the minor's parents and/or guardian and/or guardian ad litem certifying the physical and/or mental condition ot the minor, as well as her approval of the proposed settlement and distribution, 9. The following settlement has been pl"oposedl The gross amount of 12,500.00. 10. CClJnsel is of the professional 0pinion that the proposed settlement is fair and reasonable and that it adequately compensates for the injuries sustained, and expenses incurred, and he does further approve the proposed distribution contained in the form of Order attached hereto. 11. Counsel was retained upon a contingent fee basis of one-third of the net proceeds, by your petitioner including costs, a copy of the retainer agreement is attached. 12. Counsel l"equests a fee in the sum of $3,891.78 which is 13 1/3\ of the net settlement payable to the minor. 13. The Department of Public Welfare, or any other entity, does not have a claim or lien against the plaintJffu. 14. Counsel has not and will not n'!ceive collatel"al payments as counsel fees tal" representation involving the same matter from third parties. AI'FI DAVI'I' COMMONWEALTH OF PENNSYLVANIA COUNTY OF PHILADELPHIA RICHARD M. GOLOMB, ESQUIRE being duly sworn according to law, deposes and says that he is counsel fOl' Bl"ianna Hannaway, a minor, and that he has negotiated the proposed settlement with Jeffel"y Alan Mills. Esquin~ and he respectfully requests Court Appl-oval for the Bet tIement because he considers the set t lement figure fair and reasonable and adequate compensation for the injuries sustained by minor plaintiff under all the circumstances. IItr\ltl(cl~S RICHARD M. GOLOMB, ESQUIRE SWORN TO AND SUBSCRIBED BEFOR/i ME THIS ;3 DAY OF.~;D r , 1996 ~:'('<:h'I:! .' ,/ (I.(ru ~ GFAI IlIIMA CIIIIIII/~' .. ,,,. l'u~lI. _"Phll.~.lpl", ' "., .",,"l~ .........loIIE.jo" ~"\ III ltlll ,'i 'I ,\ " '01 I ,. , i I I I I i ,I , , I La:. 1\1."1I~ 1.1'\1.1"1' POWI'll or lI'I','ontlr.v .' DIITe: to.lt, '\'"1 I I "I . ,I/We, the undereiqned, do Appoint the lAW firm ot Kreithcn, Daron, Villari ~ ColDmb to institute And lIIAintaJ:n en eetion alJAinst any pereon or firm or corporation who mllY bel respons.lble for my/our claim for damllIJu sustained. on ~ t1 .1\"1 or to 0 t tect an amicable aettlement, I : ' I' . . I/We agree, that out oC whatevor num is eocured by my/our \tt~rneys or by me/us trom tho Abovo responeible partiee, eith,r by IJny or :,eettlement or verdict, I:he attorney e.ha1.l re':ain '?1. '.1 percent or the qross, recovery And in addition thereto, the expenses or, .suit, pretriAl dincovery, invoetigAtion, medicAl ellpert eVllluation(li) and reporte, end the teee IInd ellpeneee oC witnesses, and other allpenses paid in hllndlinq the eile, it IIny, ShAll than be reimbursed to the SAid attorneye. I :'., ! "11 medical bills incurred as a ,Accident/incident, whether expended by couneel or not, shall be charlJeable to my/our ehllre rreviously paid by insurance~ ! I .Counsel reseive the right to withdrllw it, atter investilJation, . they believe that there is no merit in pursuing my/our clAim. P 1f\....fV' reeult or the on behalt ot me/us exclusively, it not ! !1Il0ULD NO HONEY DE RECOVERED DY !JUIT OR SCT'I'LEHENT, SAID ATTORIIEYS SIf"LL If^VE 110 CLAIM ACAINST ME/US rOR SERVICES RENDERED, EXCEPT ^S ^CRCED UPON IN /lDVANCE. I . . Counsel is not required to take appeals Arbitration or trial under this agreement. , either tram. 'I I/We hereby authorize the said attorneys to pay bllls tor' mediCAl And hospital treatment by payment directly to physiciAns or hospitals concerned tram the proceeds of Any medical insurance benef.lts received by them, I hereby acknowledge thAt Krelthen, Daron, Vlllllri , Colomb has undertaken'thie representation on II contingent tee erren\Jeme'nt liS Itllted IIbova. AI A result, this tirm is shllrin'1 in both the risk And recovery regllrlllees ot the number ot houk"ll inveeted And has a vested interest in the1 r work product end the f 11e And proceeds at thls'case. I/We authorize said ettorneys to notity the IIppropriate insurllnce cllrrier ot their clAim tor Cee And that the lnsurence cerriershall include them AS pAyee on Any drett, I/We turther understAnd thAt part ot the tee lIB set torth Above will be pAid to reterrAl counsel I/We hereby AcknowlolllJe receipt oC ^ dupliCAte copy ot this contingent ree ~qreement, , I (!lr.IIL) (!lr.IIL) (!lr.AL) (!lP.H) I , " , , " C' . ) ) , '_' I .. " 'r' " '] 1': .J :.1 I Ii. T i(:-1 r :;J ..') :;'.) IH .' , 1 t:::.. -', whose principal place of business at all relevanl t.imeli WdS 2'0 East Main So'eet, ~1echanicsburg, PA 1'/00'0, 7, On 6/3/901, tl1>: min')!" sustained the following injuries hait'line skull ft"acture, cet"ebral concussion, and othet' injuries, when she fell from tht'ough a 10088 potTh t'ailing onto concrete sidewalk. 8. Attached is a statement, under oath, of the minor's parents and/or guardian and/or guardian ad litem certifying the physical and/or mental condition of the minor, as well as her approval of the proposed settlement and distribution. 9. The following selt lement has been proposed: The gross amount of 12,500.00. 10. CC'lnsel is of the professional "pinion that the proposed settlement is fair and reasonable and that it adequately compensates for the injuries sustained, and expenses incurred, and he does further approve the proposed distribution contained in the ferm of order attached hereto, 11. Counsel was t'etained upon a cont ingent fee basis of one-third of the net proceeds, by your petitioner including costs, a copy of the retainer agreement is attached, 12. counsel request8 a tee in the sum of $3,891. 78 which is 13 1/3\ of the net settlement payable to the minor, 13, Th", Department at Public Welfare, 01' any other entity, does not have a claim at lien a<JainB!. the plaintiffs. 14, Counsel has not and will not receive collatel'a1 payments an counsel feeo tOI n.,pleiH:lltdl inn invulvin\) t Ill~ same matter from third partieo, 1(,., Tht~ I$'l s~tt lflmt~nt Ihtj/ahlp tu lilt' rnitHJl (atter df.:d,uc't.iul1 (:If cOGln dud att()l.rlt~i'8 f~:eB) is $",78-1,'13, WHE:REFOHE, ret it ion"l' requests that she be permitted t.u enLer' into the setllf'ment I'ecited above and that the COInt enLer' an Older of Distribution as follows: KRE1TlIEN, BARON, VILLARI & GOLOMB For counsel Fee $ 3,891.78 KREITliEN, BARON, VILLARI & GOLOMB for" Cost s $ 373.34 OUTSTANDING MEDICAL BILLS: Dr, Gallagher Neurological surgery Seidle Memorial Hospital Ritzman Radiology Polyclinic Med, Center $ 74,00 $150.00 $132,05 $ 27,00 $ 67,10 $450.15 TO: Kelly Reppert, Parent and Natural Guardian of Brianna Hannaway, a minor, to be placed in a federally insured savings account or federally insured savings certificate to be marked, "Not to be withdrawn until said minor reaches the age of 18, or upon the Order of A Cour~ of Competent Jurisdiction." 57.784.73 $12,500.00 TOTAL KREITHEN, BARON, VILLARI & GOLOMB ~f'{Y)&.6:{~~$ BY: RICHAROM-:- GOCOMIJ-,--~:SQUIRE Attorney for Pet Hioner" I/EHIFICATIOtl I. KELLY HEPl'ERT. "m the Petit.ioner h this action and hereby verify that the statements made in the fOl'egoing Petition to Settle lIr Compl"omise MinOl"' s Act ion are t l"Ue and Con"eet to the best of my knowledge, infonnation and bellef. I understand that the statement in said Petition are made subject to the penalLies of 18 Pa. C,8, Section 4?04 rel~ting to unsworn falsification to authorities. I , Date: AUOUJT ),1 \ ICjCU,,- I .J ! - . I ~ . ,^. i II. I - ~~(.D-"p... d' KELL'Y'~Rtf v . , , . I I.~ 111,111'.1.1'11.11'1' cmu:\L2L.l\tX.Qlll!L1. OhTl! I 10'\\, '\'1 I " I/WIl, ~he 'underaiqned, do appoint p,!\,,(Y'I the lev Hrm of Kreithlln, naron, villAri ~ Golomb to institute anll ""Ilntaln an IIction agllinst any person or Hrm or corporation who mflV be r08ponoible tor my/our cia im tor damlllles sustained on 6 ~' .1\'-1 or to 0 reoct an amicable Plttlement. ' I I I/We agrell, that out of whatever !lum is secured by my/our \ttf'rneys or by me/us from the above responsible parties, eith~r by vllY ot ',settlement or verdict, I:he attorl\oy e.hall re':ain ?.1. /;1 percent ot tho gross, recovery IInd In IIddltlon thereto, the OMpenSeB at, suit, pretrllll diocovery, invootil)lItion, medical expert evaluatlon(lI) and reports, IInd the tees and oxpensee at witneuee, Ilnd other exponees paid In handllnl) tho tilo, it IIny, shall then bo reimbursed to the said ettorneye, , , ' ":"1'1 medicd bills Incurred es e ,lIccldent/lncldent, whether expended by counllel or not, shall be charl)oehle to my/our shere previously paid by Inourance, II , ,Counsel reserve the ril)ht to wlthdrav if, etter investil)lItion, ' they believe that there Is no merit in pursuing my/our claim. result at the on behalf at me/ulI exclusively, if not 1 !lIlOULD 110 HOllEY DE RECOVERED nv !lUIT OR !lE'M'LEHEIlT, S"'ID "'TTORUEVS SII...LL U"'VE UO CU.IH ^C...UIST HE/US rOR SERVICES nENDEnED, EXCEPT "'S hCREtO urou III hOV...IICE. counsel is not required to take appeals arbitration or trial under thie Ill)reement. , either tram I I/We hereby authorize the said Ilttorneys to pay bil.ls for' medicsl and hoapital treatment by payment directly to physicians or hospitals concerned f'rom the proceeds of eny medical insurance benetits received by thom, 1 hereby acknowledl)e that Kreithen, Daron, Villari' Colomb has undertaken' this representation on II contingent tee arrangeme'nt es stilted above. ...S a result, this tirm is shar1nlJ in both the dISk lint! recovery relJ"rtlleslS of' the number of hours Invuted end has II vested interest In thBi r work product and the f 110 and procaads or this'cllse, I/We Authorizo SAid Attorneys to notify the appropriate insurance carrier ot their cleim for tee and that the Insurance carrier shall include them as pllyee on any draf't, I/We turther understand that part of the fee lIB Bet f'orth above \/ill be paid to reterrel counsel - I/We heroby ackno\/lell<jo ,'ecolpt of II tlllpl1cel:e copy of this continl)ent ree "'l)reemont, , , \. KI~~- ~:~#c ~~ p::r.hL) (neAL) .'1 'I ',\ .' ',j ',,1 (Or.hL) (OeA'_) I " KREITHEN, BARON, VILLARI ~ GOLOMB BYI RICHARD M, GOLOMB I.D. NO, 42845 10TH PLOOR 1201 CHESTNUT STREET PHILADELPHIA. PA. 19107 (215) 563 -8286 ATTORNEY FOR PLAINTIFFS BRIANNA HANNAWAY, a minor, by and through her parent and natural guardian, KELLY REPPERT and KELLY REPPERT, in her own right COURT OF COMMON PLEAS CUMBERLAND COUNTY v. No. 95-2702 VINCENT B. WHITE and BETTY L. WHITE, husband and wife, t/d/b/a THE WIRE WHEEL BICYCLE SHOP v. KELLY REPPERT PETITION POR LEAVE TO COMPROMISE MINOR'S ACTION TO THE HONORABLE, THE JUDGES OF THE SAID COURT, The petition of Brianna Hannaway, a minor by her parent and natural guardian, Kelly Reppert, and her attorneys, KREITHEN, BARON, VILLARI & GOLOMB respectfully represents: 1. Petitioner is Kelly Reppert, p...rent and natural guardian of Brianna Hannaway, a minor. 2. The minor was born on 2/15/92 and her social security number is 211-72-1669. 3. The minor resides with Kelly Reppert at the following address, 510 Simpson Street, Mechanicsburg, PA 17055. 5. The minor's mother is Kelly Reppert, who resides at the following address: 510 Simpson St reet, Mechanicsburg, PA 17055, 6, The defendants are Vincent B. White and Betty L. White, husband and wife, t/d/b/a The Wire Wheel Bicycle Shop, whose principal place of business at all relevant tinwD was 25 East Main Street, Mechanicsburg, PA 17055. 7. On 6/3/94, the minot sustained the following injuries haidine skull fractur"e, cerelJl'al concussion, and other injuries, when she fell El-om tht'Ough a loose porch railing onto concrete sidewalk. 8. Attached is a statement, under oath, of the minor's parents and/or guardian and/or guardian ad litem certifying the physical and/or mental condition of the minor, as well as her approval of the proposed settlement and distribution. 9. The following settlement has been proposed: The gross amount of 12,500.00. 10. Counsel is of the professional ,.,pinion that the proposed settlement is fair and reasonable and that it adequately compensates for the injuries sustained, and expenses incurred, and he does further approve the proposed distribution contained in the ferm of Order attached hereto. 11. Counsel was retained upon a contingent fee basis of one-third of the net proceeds, by your petitioner including costs, a copy of the retainer agreement is attached. 12. Counsel requests a fee in the sum of $3,891.78 which is 13 1/3% of the net settlement ~ayable to the minor, 13, 1'h", Department of Public Welfar-e, or any other entity, does not have a claim or lien against the plaintiffs. 14, counsel has not and will not receive collateral pilyments as counsel fees for repn!sentiltion involving the Bame matter from third parties, ]t '1'1\1--' 11('t fif'ltl,Jll'Pllt 1'(1)-'.-\1,1." tl_f tlltl minot' (after d~du('lil.lfl (f C,-lf~tA i:tIld ilttl)nl'""/S ft-...r;) li-1 ~.J,'IA.l,7.!. \\Ht.REFuF.~. h!t 11 jll".'1 ',,'qllo:'Hts that sile be pelllliLted to enter inLo the settlement H,cited abOVf' dnd that the COU1't enter an Order of Distribution as follows: KRE I T1IEN, BAilON, V I LLAR I & GOLO~1l3 F01' Counse I Fee $ 3,891.78 KREITHEN, BARON, VILLARI I;. GOLOMB F01' Cost s $ 373.34 OUTSTANDING MEDICAL BILLS: Pr. Gallagher Neurological Surgery Seidle Memorial Hospital Ritzman Radiology Polyclinic Med, Center $ 74.00 $150.00 $132.05 $ 27.00 $ 67.10 $450.15 TO: Kelly Reppert, Parent and Natural Guardian of Brianna Hannaway, a minor, to be placed in a federally insured savings account or federally insured savings certiricate to be marked, "Not to be withdrawn until said minor reaches the age of 18, or upon the Order of A Cour~ of Competent Jurisdiction." T8TAL $7.784,73 $12,500.00 KREITHEN, BARON, VILLARI & GOLOMB BY: Qr~ '<'\&..{\.i~-n~ RlcffARtS--M:---(jOLOMB, ESQUIRE Attorney for Petitioner VERIFICATION I, KELLY REPPERT, am the petitioner i~ this action and hereby verify that the statements made in the foregoing Petition to Settle or Compromise Minor's Action are true and correct to the best of my knowledge, information and belief. I understand that the statement in said Petition are made subject to the penal Lies of 18 Pa. C.S. Section 4904 rel~ting to unsworn falsification to authorities. Date:~ll)r ~~I ) ICjCUc_ ,j .- "'''I..f- K~b}~~;~~~ --.-, " v . , I l.L .1,-llt.I;"!I."'!' J10wr.n 01' lI'I"'Onur.v . DIITP.: 10'\\. '\'-\' I " II, rLlY' I "I I j ,I1We, the undersigned, do appoint the law tirm ot Kre1thlln, Daron, Villari" Golomb to institute ami maintain an action against any person or tirm or corporation who may be responRible tor my/our claim tor damages Bustained. on h '1>' .,\"1' or to e t tect an amicable nettlement. I I' ' I/We agree that out ot whatever Dum is secured by my/our 1tt~rneys or by ~e/us trom the above responsible parties, eith~r by way or'lsettlement or verdict, \:he attorney e.hall re':llin ~1. ',:1 percent or the gross, recovery and in addition thereto, the eMpenses at, suit, pretrilll diDcovery, inventiCJation, medical ellpert evaluation(lI) and reports, and the tees and ellpenses at witneues, and other ellpenses paid in hand~inCJ the tile, it any, shall then be reimbursed to the sllid attorneys, , , ' , , ! :"1'1 medical bills incurred aD a ,/lccldent/lncident, whether ellpended by counsel or not, shall be charC]oable to my/our share previously paid by inDurance~ ' ! I ' ,Counsel reserve the right to withdraw it, atter investigation" they believe that there is no merit in pursuing my/our claim. result at tho on behalt ot me/us ellclull1vely, it not I SHOULD NO MONEV DE RECOVEnED 0'/ !lUIT OR SETTLEMENT, S.'.ID .'.TTORHE'/S SHALL HAVE NO CLAIM AGUNST ME/US rOR SERVICES RENDERED, EXCEPT AS AGREED UPON IN ADVANCE. , ' : counsel is not required to take arbitration or trial under this agreement. I appeals either '/ tram, 1/We hereby authoriu the said attorneys to pay bills tor' medical and hoapital treatment by payment directly to physicians or hospitals concerned trom the proceeds o( any medical insurance benetits received by them, I hereby acknowledl]e that Kreithen, Oaron, Villari , Colomb has undertaken' this representation on a continC]ent (ee arrangeme'nt ft5 stated above. As a result, this tirm is sharing in both the rJlIk and recovery rBlJllrdlolJs ot the number or houra invested and has II vested interest in their work product and the Hle and proceeds ot this'case. I/We authorize said attorneys to notity the appropriate insurance carrier at their claim tor tee and that the insurance carrier shall include them as payee on any dratt. I/We further understand that part ot the tee as !let torth above will be paid to reterrlll counsel I/We hereby acknowledCJe receipt of 1\ duplicate copy or thiD contingent ree Agreement, , I (~r.h~) < ~- (!lr.hL) A{".//c ~t/ ,'i 'I "\ " '01 , I lor.H) ( nr.,'.,,) ,t,'1 'I; ';,.\,\ !;( ',-.i, I,', i., ,-. " t - ~ . '1 i' " .! l!,t . "'! ! '!' " ", . , ',' ~ '1 ! I" " . lj!J'I ~ j l ' 'I;; \0 III \,l1r I I, I'IILIII j. 'I 11' ';,'L ,"11: i! i I; WIT!! ,:I ! r r,. '.'! I\. 1 ' : I \11 .j! " f, J"; !.. , , , u_ "Ju"'<-- Ii ~. ('. "-J~7~ .0, ,(Ild':-. ,~+'f. .. ~. '\ h: 1; 1 :i , . . . ,. ..L H -&': ,. d~. " ; )i, " I. i I. " , , . if BEP-0U IH. 13,"0 l'IWH,NIIIIlI.IIUIl 1I11IIl'NIIIII:I. UHII Ill, '/1 'nUlIlI.1 I IN 'l'IIB COUR'l' O~' Cor+ION P"~~SE OF CUMDERJ.AND COUNTY, PENNSYLVANIA CIVIL ACTION " LAW BRIANNA lIANNAWAY, a minor, by and through her parent and natural guardian, KELI,Y REPPERT and KELI,Y REPPER'!', in her own right : : No. 95-2702 Vii. : . . VINCENT B. WHITE and BETTY L. : WHITE, husband and wife, t/d/b/a/ 'rHE WIRE WHEEL BICYCLE SHOP . . Vii. KENNETH E. REPPERT, JR. PRABCIPE TO ISSDH WRIT TO THE PROTHONOTARY: Kindly issue a writ to join the additional defendant, KENNETH E. REPPERT, JR., at 611B General Drive. Aparlmont 36, Hechanicsburg, PA 17055. Respectfully Submitted, ~' OHENADEL & UMBENllAUER Date: gW9s By: f e Alan Mills Att ey for Defendants Att ey 1.0. #47136 212 rlh Queen street Lancoster, PA 17603 (717) 299-3726 PAI1E ~/~ IN TilE COURT 01' COMMON I'I,EAS OF ClJMBILHI,I\ND COUNTY, PENNSYLVI\NIA CIVIL ACTION - I,AW DHIANNA llI\NNIIWAY, a mlnol, by and t:Ill'oll<Jh hel' pal enl and natural gual'dian, KELI,Y HEPPERT and KELLY REPPEHT, in her own dght va, No. 95-2702 VINCENT B. WHITE and BETTY L. WIIITE, husband and wife, t/d/h/a TilE WIHE WHEEl, BICYCLE SllOP vs. KEI,LY REPPERT DEFENDANTS' ANSWER AND NEW MATTER I~PLAIHTlll'~QH1'lJilli'I AND NOW, the Defendants Vincenl B. White and llelty I" White, husband and wife, l/d/b/i'! The Wile ~Iheel Bicycle Ghar, by and through theil' aLtolneys, Nikolaus, llohelladel & lJml,enhauel', tile with the following IInswel and New Mall e, : I. Admitted. II i8 i1dmitted, oil bel iet, thaL BJianna llannaway, a minD!", and IHn palent and lIilt UI al qualdian, Kelly Reppell, are individualu livinll at (,] Ja! Ueneva dl'ive, Apartment 36, Mechani('ulJ\llq, l'"nnlJylvilnla, 2, Admitted, L Denied, l'illillJlilph J of lh.. l'lailltifts' Complaint is a cDncluuion 0' law to which no l'eupon8ive pleading io lequired. 4. IIdll1lt' ed in pillt and denil!d in parI. It iu admitted that on June 3, 1994 the Defendants vincent B. White and Betty L. White owned property located at 23 East Main Street, Mechanicsburg, cumberland county, Pennsylvania. It is further admitted that on that date the Defendants leased Apartment B at this location to Kelly A. (McGovern) Reppert and Kenneth E. Reppert, Jr. It is specifically denied that the Defendants occupied the premises as residents but did locate their business, The Wire Wheel Bicycle Shop, on the first floor, the address of which is 25 East Main Street, Mechanicsburg, Cumberland County, Pennsylvania. The averment that the Defendants controlled and/or maintained the apartment located at 23 East Main Street, Mechanicsburg, cumberland County, Pennsylvania is a conclusion of law to which no responsive pleading is required. In the event that a response is deemed necessary it is specifically denied that the Defendants Vincent B. White and Betty L. White controlled or maintained the second floor apartment known as Apartment B at 23 East Main Street, Mechanicsbul-g, Cumberland County, Pennsylvania. 5. Denied. After reasonable investigation the Defendants Vincent B. White and Betty L. White are without sufficient knowledge or information to form a belief as to the truth of the averments contained in Paragraph 5 of the Plaintiffs' Complaint. Strict proof is demanded, if relevant, at trial. 6, Denied. Paragraph 6 of the Plaintiffs' Complaint is R 2 conclusion of law to which no responsive pleading required. To the extent that a response is deemed necessary the Defendants Vincent B. White and Betty L. White specifically deny any knowledge of the "condition" referenced in Paragraph 6 of the Plaintiffs' Complaint. 7. Paragraph 7 of the Plaintiffs' Complaint is a conclusion of law to which no responsive pleading is required. In the event that a response is deemed necessary the Defendants Vincent B. White and Betty L. White specifically deny they were negligent or careless in any of the particulars alleged in Paragraph 7(a) through 7(f) of the Plaintiffs' Complaint. To the contrary, the Defendants Vincent B. White and Betty L. White believe and therefore aver that they acted at all times relevant to the Plaintiffs' Complaint in a reasonable and prudent manner with the due regard for the safety of others. B. Denied. Paragraph B of the Plaintiffs' Complaint is a conclusion of law to which no responsive pleading is required. WHEREFORE, the Defendants Vincent B. White and Betty L. White t/d/b/a The Wire Wheel Bicycle Shop respectfully request this Honorable Court dismiss the Plaintiffs' Complaint and enter judgement in favor of the Defendants and against the Plaintiffs. NEW MATTER 9. The Plaintiffs' Complaint fails to state a claim or cause of action against the Defendants upon relief can be 3 Ulallt ml, 10. Tile 1'111111111111' ""1111'1;11111 fallll In utale facts demonlll 1III Ill\! 11\1' '-Xlllll"I"" ,>I II 1.1"'lI'll of 11IlY Il~gal duty of the lJefelldant/J 10 till' I'Llillt illll, II, Till' JlIllIl il'II "I d'"I1,I'II'". II tiny. HUllLailled by Hrisnna lIannilway may II"VI' 1"'I'''I'I''xllll,ltl'ly ('.IIIIH.d Dr ,'unlrlbuled La, by the calel"UII"l"llJ .tIId II. 'II i,,"II"" ,,, i<..lly Hl'ppelt, hel parent and Ililtulal 'JllIlIdl.,Il. ,tII<1 11,,1 IIY .wl "I "mlllulon of Vincent B. White or \lelty I.. WillI", AIIY,IIIIl'111I1 wllll'h i<!!lly HepperL might be ellt Itl....l III I'W"V"I '1'1'1111111 I h.' p"tendalltu must be reduced by tllolle damlllJl!Il .111 I IllIll ,11>1 ,. I" i<,,11 Y Hepl",.t, 12, TIll! ,'illlll" 01 ,wI i"ll of IIw I'lallltiff j(1)lly Heppert is ban'e,l III wlllll!! "I ill 1""1 I,y I h" I'ellllllylvallia ('umparat ive Negl iljlllH'" HI allll I', 42 1'.I,(',S,A. S'Il02 ...t, !leg. WIIJo:IIEFuHE. IIIl' p"t"lIdillllu 1"IlIl!H'tlully n~queBI' LhiB 1I0llolabl., ('()\1I1 1'1111'1 )11<1'111"'111 ill lavll) 01 the DefendanLs and agalnlll II", I'lililll I If Il, IfIM .HATTI1\ l'URJ\.IAlfLT.Q,..b.~R&J'.~252Id) Vinc.nt D, Whit. and B.tty L. Whit. t/d/b/a Th. Wire Wh..l Bicycl. Shop v.. K.lly R.pp.rt I J, Th.' lit" "lId'lIlt" 1I1'1l'by 111I'1l1 1'''1 ilt f) by ll'ferellCe l'illiHlIapllll I 1111"".,11 11 III lll.dl AIlIlW"1 alltl New MaLter to the PIal III III u' 1'lIl11pl il i III 14, If Utl'llInil Iltlllll'~WilY. il tnllWI. ,lid IHlstaill injuries liS 4 alleged, which is specifically denied, her injuries were caused solely by the negligent, careless and reckless conduct of Kelly Reppert in the following particulars: a. failing to adequately supervise Brianna lIannaway on June 3, 1994 at the time of the incident complained of in the Plaintiff's Complaint; b. having been specifically advised that the open stairway and the balcony at the rear of the second floor apartment may be dangerous for children, handicapped 01- other persons, failed to restrict Brianna lIannaway's access to the open stairway and balcony; c. failing to plan for Brianna lIannaway's safety on or around the open stairway and balcony at the rear of the second floor apartment; d. failure to utilize child safety devices to protect Brianna Hannaway from any potential risk posed by the open stairway and balcony at the rear of the second floor apartment; and, e. permitting Brianna lIannaway to play or wander unattended and unsupervised on June 3, 1994 on the second floor wooden deck of Apartment B. 15. In the event that B1-ianna lIannaway, a minor, obtains any judgement against the Defendants Vincent B. White and Betty L. White for injuries alleged to have been sustained as a result 5 CERTIFICATE OF SERVICE 1 heleby celli t y I hal hilVl' I hi /J dilY Ilf!l"ved a L r'ue and cOl'lecL ropy ollhe IOleqolll(j dew \I III I' 11 I \11'''11 Ih., (ollowing person(a) and in the lollowinq 111 a 1lIH! I , which ,WI vice uatls[ied the requirelllents o[ the l'ellllllylvilllia H\lleH ,,( ('ivil I'I'ocedun~. Iie.n'ice bY Fh 6L ClalllLl1illl..l1ilill.QJlli!I!Las Follows I Richard M. Golmnb, Esquire Kl-eithen, Baron, Villali '" Golomb 10th Floor, 1201 Chestnut Street Philadelphia, 1'1\ InO'7 N I KOl,1\U:O, 1I0HlcNA lEI. '" UMBENH1\UER -..... By I , ---. Jeffre~ 1\lan Mills 1\ttoriy fOl Defendants 212 Noeth Queen Street I.anca tlH", P1\ 17603 (717) 299.3726 I.D. #4'7136 Dater 6 199r, . 3. The Addilional Defendant Kenneth E. Heppel't, ,Jr. ia an adult individual believed to be lflsidinll at GlIB Geneva lWive, ApI. ,j(" Meehan I cBburg, Pennsyl vanl a 1'10',., . 4, The Delenllant[l Vincent B. White ilnd Belly 1.. White, hUBband and wite, l/d/h/d The wi Jf~ Wheel Bicycle Shop leased on Septf!mbel' 8, 1993 lhe Becond (loDr apartment known as IIpal't1nent Il to the propel'ly lo('aled at 23B Eaat Main stn~l~t, Mechanicsbul'g, Pennsylvania 17D',!, to Kenneth E. Heppert, .11'. and Kelly A. McGovenl (a/k/a Kelly Heppeal. 5. The Defendants bel ieve and thelefore aVel' that Kelly A. MeGovenl at 80me point after Septembel' 8, 1993 married Kenneth E. Heppel't, Jr. and is now known as Kelly Heppert. 6. The Defendants believe and therefore aver that Kenneth E. ({eppert, Jr. and Kelly A. Mc(Joveln resided together with the minor child Brimma Ilannaway In the apartment lf~ased by the Defendants to Kenneth E. Heppen, ,11'. and Kelly lI. McGovern located at 2313 Easl Main flUeel, MechanicBbulg, Pennsylvania 1705', on .June J, 1994, 'I. The Plaintiff, Bdanna lIannaway, a minor, by and through hel' palent and natllla] 'lllaldian, Kf,j]y H"ppert and Kelly Heppel-t, In hel own llqhl, haa Illed a Complaint against Vincent II, White and Betty I" While, Inmbilnd awl wife, t/d/b/a The Wire Wheel Bh.,ycle Bhop, a copy 01 which III all ached heret.o aa Exhibit 2 "A" and incorporated hel-ein by reference. B. As alleged in the Complaint. on June 3, 1994 Brianna Hannaway fell ten feet from the second floor deck of Apartment B at the residence leased by her parents located at 23 East Main Street, cumberland County, Pennsylvania. 9. The Defendant denies any negligence or liability to the Plaintiff and alleges that any injuries sustained by the Plaintiff, such injuries being expressly denied, were caused by the negligence of the Additional Defendant Kenneth E. Reppert, Jr. 10. Prior to June 3, 1994 the Additional Defendant Kenneth E. Reppert, Jr. had direct knowledge of the condition of the open stairway and balcony at the rear of the second floor apartment leased to him and Kelly A. McGovern. 11. At the time of the fall referred to in the Plaintiff's Complaint, the Additional Defendant was negligent, careless and reckless. which negligence, carelessness and recklessness included the following: a. failing to adequately supervise Brianna Hannaway on June 3, 1994 at the time of the incident complained of in the Plaintiff's Complaint; b. having been specifically advised of the condition of the open stairway and the balcony at the rear of the second floor apartment failed to restrict Brianna 3 Hannaway's access to the open stah.way and balcony; c. failing to plan for Bdanna Hallnilway's safety on or around the open stairway and balcony at the rear of the second floor apartment; d. failure to utilize child safety devices to protect Brianna Hannaway from any potential risk posed by the open stairway and balcony at the rear of the second floor apartment; and, e. permitting Brianna Hannaway to play or wander unattended and unsupervised on June 3, 1994 on the second floor wooden deck of Apartment B. 12. In the event that the Plaintiff recovers any judgement againat the Defendant herein as a result of injuries alleged to have been sustained by the Plaintiff in the accident referred to in the Plaintiff's Complaint, such liability to the Plaintiff being expressly denied, then vincent B. White and Betty L. White, husband and wife, t/d/b/a The Wire Wheel Bicycle Shop asserts that Additional Defendant Kenneth E. Reppert, Jr. is solely liable, jointly and severally liable or liable over to Vincent B. White and Betty L. White, husband and wife, t/d/b/a The Wire Wheel Bicycle Shop on the cause of action asserted by the Plaintiff. WHEREFORE, Vincent B. White and Betty L, White, husband and wife, t/d/b/a The Wire Wheel Bicycle Shop, demands judgement 4 VERIPICATION I, Betty L. White, have read the foregoing and hereby affirm that it is true and correct to the best of my personal knowledge, information and belief. I acknowledge that, had I knowingly made false EJtatements in the foregoing Complaint Joining Kenneth E. Reppert, Jr. as an Additional Defendant, I would be subject to the penalties of a misdemeanor of the third class pursuant to 18 Pa. C.B.A. 4909 regarding unsworn falsification to authorities. ) ...1V11(,.-~ )/~ ~ Setty L{ W ite \~IIEln;F( lIn:, 1'1 d 1111 j t t 11, <I 1'111 d 11<1 J U<lqllll'1I1 111 1 Ill' II f ilV"1 111 accmdallcn wHit till' civil ",'I loll. KRBITIlEN, BAIWN, VII,LAHI '" GOLOMB IlY I V Ii' \\I)\,;, (l~ ",,,b RTciiARn-M-.---<]C51X)MIY-... -..-. ._~_.-~~-- At tnlll"ya tOI l'laint.ifta " =- '" ",,- '-" -= '," " t..: ,. , :r .. . " " '. t:- . "- . .., l' " r \;, ., -.-, ~,. .1; 0: 'M ~ ~lECHAtll CSBUI/11 H'l I i~1~,j p.1.) I l.;12,' 1 ~/ 1'~1t;)2 PI~1 . ilIl/I bbNI.::II-'7.::-IH'9 PHI1717IF)5-~'n~ WKI (~~~1000-~~0~ lL"'....f~... HHt~I~;..~;f""",.L~r\lr-4(if'h:1 ,... ,~I,I..'!. bkl I L'~IlIIS I<Ef=, ['bPT,thWICP-R I "" NIlrHH YORK STREEl 1:1' IH. g FLAGS, k3,R&.RI2, tIUMBE.R "1/10li'0 I 0(1 I 1Z,~11ll0011/1~12 ~1\ll~'1/l011l11/l3 DI~TE t...'1t/lt../g7 ~11l14/97 1..'11/14/9/ ~lEt~I' NO WITHDkAWALS ALLOWED ON THIS ALCUUNT'.' RELEA~E DATE OF THIS ACCOUNT IS 02/15/10 TH~ [EkTI~ILA1E. ....'UL ~~R COURT ORDER... rH I '3 INCLUDES ';;F'( DESC DT Ol"[:tl f:\ALAtICE ':WAIL RATE nD DIV LST HCT FL,HjS "11i'l, RSA 01!!!'P ;:"~l. !Z\1lI 0 . \:ll/1~0 .0(1 011497 41Zl 15YR IJI1497 775'3. 13 IZl 6.36"'0 .1Zl0 IJI14'H \~:2, 41i1 TOTAL 'sHA"RES"' t"CEDGED I 7784.73 . . ~ -_._--- ~ ---- . -----_._-- CRCH - 164494-40 HANNAWAY/BRIANNA R BRI I DRrEI011l4/~7 CErn DESCI '3 YEf4R CloRl1f-ICATlo TRX REPORTING SSNI 211721669 fAX RE.~~RlING CD I S CERT DloSl: AIlBk I ~,,'R CERT NU~l()t:::I~ I J 1 OWI.,E R NAI~E I ALCI II o URIG A~1T1 775'H3 T'(PE T RAN S FER T R R GET S 1 SOU R C E S ALCOUNT/bFX SURNAME. TY~~ ALCOUNT/b~X SURNAME rH-~-: I lR-4. I R.-(' t Tk-B. ~'HTUHj TV DIHu ""~Lt';;I)"" ISbUL OAT~I ~1!14/91 CI"O':)S r-'I.EDtjE EdJFF 1.. 1 1._~It':'l r-'u~nL T Y AM T . . ,~~1 UI.'l':N DI'lIE. ~11/14"!" (,. :;(,~,~) I ~~ 1'11-1. TR-3. TR-:;I 11(--7. o I V I DEND 11A 1 E I III V DISI,' C(lOl, U,ObS PLDG Hce, , 1 .-.,.GE 1 AMOUI-IT I ;; TA rE~lENT UC<OEi<. .01..'1 ~HH IJI SP CUDr, I [~rn I,'LDG HMT I !"rD ll/D COutHI 1,.~t.IHL TV I,HTL I t-<OLLU'iUl DAT~. RONR 7759.73 ~1 . 000111 ,2H,)/ll\ll\/ll,\1! , II' [lI'nULI'l'S, I ",1,1 1"1:111 nil ['1;1.. 1I,Id '-.UJ ~'r.I:l'I-. I llr.H p'h,-.rIUiI . l'\l.l t.11 \,l ~'r11 U ILl t vln ~IITHI",I'[', CL f..: t tJ (I) 'U' I 111,1':. p.""lll"H 1 1..'11:1,.:'-..,. . 10:'(1 . ~1'; ILl lEt'I13 [1i1'r'S. 1111I.HOt. j) r,'" ", , I,ll!' f-OI'H~ 111 :, I' I,LI~ " . ~,7\.Y;'1 =,0~41l1 ~)~~ I ~)\, IlilVi . ~~~ 77':.,-L 7 :: 7 /~,.::~. 7' ~', 'Ii" I.i, L_L",~,1 . llOCUMENf CODlB-~E m W. Un. MtllnhlJt.hlll !iUn f1uh ^l WUIlI UlIlllU" AIlII AlltlltlfllUlllllije lJW~4 Lhflllllfl III (""'tllt!lhlll 01,'11 (l~llllhllll pmlllCholl IJNt.lIl1lll!IUIIHV ChnllUll MEMBERSHIP/SIGNATURE CARD 1111 II ,I 11':1 I \rll , ^ " '"" ".,,,,,j ! oJl ,. I" DO NOT WnlTE ADOVE TIllS LINE II Mombershlp Inlormnllon - "_" a__ .._ .._ All n.~" PlI"" 'II lit' _ ,,_,r annau}a~ ..".... """IIJ,(.Nodh'~Dd( 511<d _, _____.ALf,cJ1Gfl\ CSb~fQ 1"'I~II.,I4'''I' J IJJ'I~'17J .1!.tlJq "rtb'(~llfl /6 ,qq). IU'lll~'II'l'lI'~tI.t.h"~ A,':'ltl'1Il111l1 blll'l /:.'1' pAnullD:.tJ ~'."}~.:"'~,-- "1"lhll" 7i';)'"'1Q6~t>'J% 1l1lu....I'hlll~ I "'t,klY"A,......" JOIl'l' C>-'~r' '~II'''' l"1I1Ilhul\tl'.1J !.!,'~I III 01'" "I lIull1 1ItIIlIJlN~" Jnm,O.,.,,,,I.,unl' (llfll"'U~I.h"1 !i'aH IN ".I*"ll1l1lh If/Illl'''''''' -----t- ,- n,n ,- 1.4,,,,1,,".111 '..1<Iul M'""IfI','h~III"'r1"h'rl r"""lfll . .. fi';;;;;'I'-ii;"II';,i,S;;;,,;iO(-~i"~I- ____~._..__.___ .__ ___ _' ...... u. -~'_.~ I j'~~I~_~~~~~'_I~~:lt_'I_M~il:~' . ....~.-I ~~;il.i.,~~:l:;_~~"tltU""u -.~-- III --------_._--~-~-_..__._.__.__._._~ Type of Account -------~-_._._---------_. --.. >4 S~vlngs' 1 I Chrlstmns Club , XSlnglc I I Joinl I 1 Single I 1 Joinl I I Checking [ I Investment Sevlnos I I Singlo I I Joint I I Slnglo 1 I Jolnl 1 I Olher 1 I Single I I Jolnl '.lJlffl"~1 ffl\lUIt.d r." .nr jfVnlll/b .rc'fltml .._---_.~-_.. --_._-~._--~--_.._..__._.._--_._._--- ~ r'l: ,,r.r '). ./:':\ IlillV I lIRA" II Single I lIRA Certlllcste" 1.1 Single IICell.24" )(Share Certlllcele" - )(Slngle I I Joint I I Check Card/MAC II Olher ____ --, ,---------~- I I SlnOle I ] Joint ....dlilll)flIl/~..r~JI1lnfOq\J"..rt . Type of Ownership (Select one) IJ Solo Proprietorship 1.1 Par'nershlp I ) Corporation I I Organizational I JOlher__ )(rrusI Accounl II Estale Account I J Individual Accounl I I Jolnl Account II Minor Accounl I J Cuslodlnn Accounl II r Overdraft Protection (Number In order 01 profarenco-1, 2, 3) - - , --I IChlCk Digit Number "" "... on "'.1 _____ 6.v~'g. 1(0) t=1V.'I~;;.;t 6.~~~;i'05) 1- l'e~'ollB~ 6,,-,,:~!,.!-.l\B" ( ~) -' . W.O Certification of Taxpayer Identification Number (80clel Security Number) Cer1illcaUon.-Undo, ponalllel 01 pOIlury. I cmlllv Ihnl' 1, The numher shown on Ihis lorm Is mv cOfleclla.pavUf ldonlilicallon numbDf (Of I am walling for . numhor to be Issuud 10 "'0). and 2, I om no16ubjecl to bnckup withholding bOCAUSO: (A) I 8m oMompllrom backup withholdIng, or (b) I have nol been "oUlled bV Ih811110rn81 Revenue Service thai I am subJect to back'-lp withholding ftl 0 'esult 01 a'nllure 10 report Blllntef.11 or dividends. or Ie) \he IRS has noUlled me Ihlll 1m no loogor subloct to backup wllhholdlng Cerlllicatlon Instrucllons.-You musl cross oulllom 2 nhovo II you have heen nolilied bV Ihe IRS Ih81 you 8'8 cUffenllv suhJecllo backup wllhholdlng ~,cause 01 u derroportlng Inlomst o~ (hvldonds on your 1811 ,olurn I I I II am nol8 U 5 Cllllen Of Relldenl (Complnle w.e Form) ~.. ,...,.,~-I-'h(lClnQ1),I!I1nn~~o." " LO!l!J ~ ,- . Beneflclery for Life 8evlngslnsurence (If other then Joint Owner)-Applles only to nccountl open prior to Mey 1,1"11 Name of Ilonoliclnry(s) .. .~~~..~_'!..~.":!!'!-~~~ Address olllcnollclary II I hmohv mnke npplicittinnlor mnrtlhm&hill in tho Mornhms II' rodmnl Creel II Union, anlla\JlIlo III conlnll" In lie lIyl8wI and Arflendmont' thereof, 1.0fM1I of which hnvo heon made nvnllallle to Ill", PllIt 10 511hsl:fltJO lor nlloRsl ono (1) 6hrllo Momhels 111 II hlHehV fllJlhnrllfH110 lonJgnttt anv ullh. ',"I. huos fitJhr.crdlflr1 howlo III tho flnVIlIl'1l1 of luntls lH 11m lrilIl!H1C:llflO ot nnv hUSIlIO~llll' I"iS flr:cull/l1 nnd allluh nr:r.nllnll I Rl'knowledUI reo.lpl of thl Memhor~hip Meounl Agrcof1lolll whidl <<:nnlnIll5 oil f(lII'ViUll c:nnlrnchml nhhgl1l1ons 1m thil 8((:011111 Am' olll"h aecnul\ll I pI In Bcknowledgl receipt of Iho Hogulallol\ 1>18tlll~\lIO I'nlllphlot ff.&t,~,.~,Q.Q Ii!;;.,,,,(!; , I4fl N I.l flu) Rj ~ 1'",~g:.g,~~I0rlo.nna.llo.nno.uJ~ 'Lip I ql'-I I AI~\I~,(iZ,Y.I---~-- ,Inint Ownm f;l(Jnnhllll Duto 1'II1l11'1II11111V Mfl11lhOl'1 101111111 NlUII81"."'.tt..,...ltrl ,101111 OWll01 f;lunnllllll 1)l\lu " I us. Ollir Mlmhe,. 1" hder.1 CfllUl Union 1111'; ,1ppliCBlinn 8PIlrovod tlV 1110 I Jl\oAIII; I I r 1I11t1IItVII CHllIlllillno, IlIl I Manllllllulllp Olhlll' ::::.." .."...,". ""..", ..,.;.,,~ . J : ,'''il.1 .., \<L~ ~ ''-l'' \\'-,I\I'\''' \J y~ f\ R ~ ~lll S ) 'J.n I (I Members. l'EI)J!11AI. CIlI!DIT UNION CDA CERTIFICATE APPLICATION AND DISCLOSURE DO NOT WRITE ABOVE LINE I MATURITY DATE:, 0.-') -- IiT- I u ACCOUNH ..J t... '-l '1 ct y Pl.... Print ~. /: r' 1 '\ SOCIAL "\ I 1 2. I 1 C. MEMBERS NAME: \.'1\'1/1(\",\ '( ',ItlI.I)O,,_SE,CURITY' <,,,,I. ~_11UI ADDRESS: \\;. ,,).,(\i.. :'r"CITY:-1('rc.v.(l"~L-STATE: fc.. ZIP CODE: Ilu,[ , HDME PHONE NUMBER: ') rl 1\ -, I (" WORK NUMBER: , JOINT OWNER(S) NAME: vw. h.reby .pply lor. M.mber. II' Cerllllclte In Ihe .mounl .nd I.rm lilted below. CERTIfiCATE TERM .. DAY CERTIfiCATE 21 WEEK CERTIFICATE 11 MONTH CERTIFICATE 11 MONTH CERTIFICATE 10 MONTlt CERTIfiCATE 13 YEAR CERTIfiCATE METHOD Of OIVIOENO DllPOlmON 'LtAIE ACr.OUNT CHOOIE NUMIER ONE IAMOUNT OFFICE USE ONLY ANNUAL PERCENTAGE YIELD DIVIDEND RA1E SUfFIX' CODE 3MO 26W 1YR 11M 30M 6YR Irlnch: Tr It bm Hf EmpIDY" )1 lAME ACCOUNT . DEPOSIT lACk TO CERTIFICATE . DEPOSIT TO SAVINO I ACCOUNT . DEPOSIT TO CHECklNO ACCOUNT . DEPOSIT TO INVUTMENT SAVINGS ACCOUNT . MAil ME A CNECk MEMBERS SIGNATURE: (!,~.lA ~ DATE: ~ I ~ I y.C("( lLt~ r 0 J -b' LI r (I k<.- - /. Thllll ID urtlly Ihll Ihl Ibove namld r.1"On(III'1 Ihl owners 01 I Ce~ili"ll lceounlll Members lS1 federll Cledil Union, ThiS ce~iliclle mlY be ,edeemed II mllurllY.. Thl dlvldlnd rill Ind Annuli Pe,unllgl Y .Id Ire shown Ibov.. Thl AnnUl' Percent.g. Yield Ind dlvid.nd "I. mum. thaI the div,d.nd I. Idded 10 the principII 01 lhl ce~,f1cal., Thl. Icc~unll. subl.ctlo III linn. Ind condition. stll.d In Ihl C.~illclle Accounl DiSclosure, as lhey may be Im.nd,d 110m lime to Iim., Ind Incolpo,al.lhl sam. by refer.nce Inlo thl. Ig,um.nl. Dlvtd.nd.", bu.d on Ihl credit unlon'l nOllngll1 Ih. end 01 I dividend period Ind cannol b. guaranteed, A lubJ1antill Plnally II Imposed It urtlnulllundl 1'1 wllhdrawn b,'ore malu,lly d.I., Thl penally may IlSult In Invasion of pllncipal when fundS Ire wllhdrewn prlo, to Ih. mllurlly dltl ollhl urllflcatl. Thl ,anllly lor urltll..l.. pu,chlnd before J.nuary I, lIiS will be: II the matullly ollh. cen,liclll II onl Y.lr 0' 1m, lhl pln.11y 'I I fOrllltUII 01 an amount .qull to 90 dlys' dlvld.ndl bued on the dlvtd.nd ret. b.lng paid on lh. cerlilical. whether earn.d 0' nol. If the malU'il)' 01 the cI~IIIt111 II more Ihan onl yur,lhllorl.llulI II Iqull 10 180 dlys dlvtd.ndl bmd on Ih. dlvld.nd 'Ite being paid on th. tI~,licll. wh.lher earned 0' not Th"o~lltu'els calculltld Illhlllmpl. Inll...1 1111 btlng psld on Ihl u~InUII IIglldlm 0 how long Ihllunds h.v. remlined in Ihe Iccount Thl plnally 10' n~IlI"lu purchuld III" DllImb" II. III. will h: If Ih. CI~tntllll. onl year 0' IlSIhlhl pln.11y I. I 10rlelluII of In Imount equal 10 90 dlYs dlvld.nds. based on th. dividend fil. being p.id on lh. cerllflcall whlthl'"rnld 0' nOl, Thl plnllly lor U~lfltll" wll m.lurlll.1 01 01011 thin on. yea, will'Qulllh. dllfer.ncebetween the n.w dividend "Ie 10' Ih. remaininp r.erlod 01 11011 and thl "lltlng u~tntlll dlVldlnd rell dlvldld by 365 mulflplled by Ihl 1m valul o'lhl ce~lflclle .nd mulllph'd by Ih. number of days remammg on Ihe "" ing CI~lflcat.. Thl minimum penlll)' will bllhl g'"ler of Ihlllo,mul. (II Ihown b.lowl 0' $2500, Plnllly. (N.w Ra.a . fllsllno Ralal X Car1l1lcala Faca Vllul X Day. Remaining 365 , ,Th~1 C'edll union will give you .t least 20 dlYS nOllce p,lo, 10 maturily, The Whlicale wlllaulon"tltally b. renew,d 10' Inollier lerm al the ,lose 01 bUllnm on Ih.lnltlal malu,11y ~ _\ orllmllhl\'Urlly dill of lilY renewallerm unlmllll redeem.d within ..v.n (7) calendar days lh. rale 01 'arnmis 10' any renewal term .hall b. allhl ret. lhl credil union II , ..' . ",). . ,ume on new CI~lnc:al" oflhallerm, . \.fo...... ....... I . the 01 the c:ertlnull ownl,.lhl cllMule will Le 5urrenue,ed w!thout inculrll1g the U!I~ wIHI!Jr.1wal perla!!, '0' . ," .~, \i "" I.: J:',. j:~'~, ". . I i:-....c;'. HHI,r"4~,A'1 i (\1\ I AI-H'll~ r~ I<IEF t 0t. I,.. 'j, L<kl 1 OWIIIS DbPTlthWICP-R MECHANIC'3Bl'H13 ':'A 171&.'='::; BDa ll~',' 1 ~/ 1';)9,,':: PI~1 . \!II/I bbNt'::11-72-1f-f.9 I"Ht (717179~;-0n", WKI (0~01001l1-~1lI00 11,-' NORTH YORK STREEl CI' 11T I IJ FLAGSI kJ,R&.R12. r,IUMBE.R ,~il\\'''i1010(11 ilI~'1lI00 101/12 1l11l11l101ll11l11l13 DATE 01/14/97 1lI11l4/97 1lI1/14/9' ~IEt~I' NO WllHDkAWRLS ALLOWED ON THIS RLCUUN1..' RELER~E DATE OF THIS RCCOUNT IS 02/15/10 TH~ [Ekrl~llA1E '...,UL ~lR COURT ORDER..' IH 1:5 I tlClUDES :::F( DESC DT Ol'-Etl f:\HlAtICE ,:....All RATE no on' lST I'lCT FLHljS 'filii RSA 011497 ~'!:t, 00 0 . ~11l10\!l .00 ~'11497 ! 40 15YR IJI1497 775'~. /3 0 6. 3(,~lIJ .00 0114'H c:2,41t1 TOTAL 6HARES r:;-CEOGED I ---:;784.72, CRCH 1(,4494-40 HANNAWAY/BRIANNA A BRI I DArEI01/14/97 CERT DESet 13 YEAR C~Rl 1~ICATb TAX REPORTING 8SNl 2117216(,9 TAX RE.PUR1ING CD I S CERT DbSL; ABBkl U!lYR r4LCI II CERT NUMB~RI 0 URIG AMTI .11 OWNER NAt~E t 775973 fR-11 TR-3t TR-5t fI(--7 I D I'J I DEND RA IE , (J I V D I &1-' COOl, I .: I<tJ:~s PLOG Aer: I I 1 iH~GET AMOUNT I STAIH1ENT URDEI~I T RAN S FER TAR GET S ISO U R C E S TYPE ALCOUNT/SFX SURNAME. TY~~ RLCOUNT/b~X SURNAME rt~-~ I TR-41 (R-f'l 6. ;,,6,,10 I '" . ~"l1.'1 Tk-B I "lilTUHITr l?IFI;;L_.'i"~-L~L1~~_ Ib~Uf: DATf:1 1l11/14/91 CI'O'~S r'I.ED1,E SUFFI' I ~1'" I,'\-, r~nL T Y AM T I . ,,~~\ 111,'f:N OIl I f: I ,1\ I I.. i'1 7 ~H'lT 0 I S~, CUD" I C~R-l 1,'LDb R~1T, ~'ID ~liD eDUtn, 1-'~NnL T'" "IH~ I I,QLLu'JI~R OAT.. I RONR 7759.73 ,1 .11I11I1110 IJ0lillIJ/tllill ,") OlliIIJUn,s, I. ':'1,1 I"E I~ I OD f)1;L, l un ,.llJ V.-<t,l'I" !:ur~H ~HI-HII:H 1 . \~1.1 7/':,"1. 7~ Ii J V 1'1. III 1\.11 ., T[' \.11 Ilfl <1,1 f) : (Ud IJI'i Iul, IJ!.II; P".-ltlt-HI \.It.. 1.,,'+, . ~"'''I . l,)l..l lEH1'.;.; (\14', S I llllHHCILO LIt") 1'1 LIPI ~(:I-YII" 'cl' 1,/.1' I' I ], 7l'" 1511I940 I ""'II,)\)/iIllil . o ill '"/ :'5"::.. ? .'~ "I' .t" CDA M,~wb~m- CERTIFICATE APPLICATION AND DISCLOSURE DO NOT WAITE ABOVE LINE I IIW. h.reby .pply lor. M.mber. 111 C.r1lllc'I.ln Ih. MATURITV DATE:. ,,,,? . IfF- I (J lmounl Ind l.rm 1I.11d below. I J \ r ACCOUNT ._~\jU_~L_ PI....Prlnl '(lC\ r" I ( '\ SOCIAL " I. -12 -/1,// MEMBERS NAME: ( r I "/1 '. ',', _Ll:L'.J.J~ SECURITV. _.J~____",,-__,_ 1 ADDRESS: \ \ ," 1-,);,,( 1,-. I,,' CI+V: ((, p CAlI,,') ~_,6TATE:_L:._ ZIP CODE, Ll',_~_r_~_ HOME PHONE NUMBER: '~ Cj -. 1\ il /" _____ WORK NUMBER',_____,_ JOINT OWNER(S) NAME:" __,,__,_'._______ 13 CERTIfiCATE URM III OAY CERTIfiCATE II WEEK CERTIfiCATE 11 MONTH CERTIfiCATE 1. MONTH CERTifiCATE II MONTH CERTlflCAU YUlI CERTIfiCATE METHOO Of OIVIOEND DllPOlmON PLEAIE ACCOUNT CNDOIE NUMIER ONE OFFICE USE ONLY----- ANNUAL PERCENtAGE VIIID DIVIDEND RAIl IUfflX I I AMOUNT CODE 3MD raw 1YR 11M 3DM !VR -'tf()--- Emplolll tj I"nch: Tr Ir b(lt ,. (f lAME ACCOUNT . DEPOIIT lACK TO CERTIfiCATE . OEPOIIT TO IAVINOI ACCOUNT . OEPOIIT TO CHECKINO ACCOUNT . OEPOIIT TO INVUTMENT IAVINOI ACCOUNT . MAil ME A CHECK MEMBERS SIGNATURE: (!.~ lAJ _ PATE: _~ I ~ I Y ,Cf "1 ,(LU,..{t,1 r ~ J +1 LI. r tl 4 - I' This 1.10certllylh.llh. .bow n.m.~ Plllon(III"lh. ownell 011 Certilltll. mounl.1 Member. hi r,d".1 Credll Un,on 11". teflll".I. m'l b. IOdllnlld.1 m.lu'II~, Th. dlvld.nd /.1. .nd annuli Ptrcenlsg. YJ.ld.II Ihown .bo... Th. Annu.1 P""nl.gl Villd Ind diVldlnd "II ilium, Ihll Ihe diVidenD illdd.d 10 Ihe pllntlp.1 01 Ih. tertllitll', Thlllccounllllubl.cl 10.11 lerml.nd condltlonl.I.lld In Ihe Certificale lttounl OtltlolU", IIlh'l mIl b. .m.ndld "O/ll\lnll 10 1,"11, '"d IIItolpo"l. lhl 11m. blllllllnt. InlO thl,.grllm.n!. Olvld.ndl." blSed on thl credit union'. ..mlngl .t Ih. end 01. dividend plriod Ind t.nnol b. gu,,,"'eed A lubl1lnUII ptntlly Illmpolld "certlntlll lundllll withdrawn blloll m.lurily dll', Thl p.n.1I1 /11'1 '"ull in InVIIlon 01 prllltlPl1 when IU"~III' wllhdllwn prlol 10 Ihl IIIIlunly d.l. ollh. certlOtll.. nil p.n.lly lor Clrtlll"llI pU"hlld '1111I JlnUIIY 1, '181 will ,.: IIlhl /II.lur"1 011111 te~IIItllll. one Vltr 01 1m, Ihl plnollV I. . lon.lluII 01 II1l1110unl.qull 10 80 d.)'I' dl\1dlndl bmd on Ih. dMd.nd 1111 bllng Plld on III. tlrlifltel,l wllelhll "mId or nol IIlhl ml'uII'1. ollhl tlrtlfltll." mOll Ih.n on. year,!h. 10ntllulIl. .qull 10 110 dl)'l dlvidlnd, bllld on Ihl dividend "" being plld on Ih. torlllltll. Wllllhlll,"n'd 01 nol Th.lonllluII II tI,ltulal.d .llhlllmpl. Int.rul rII. being plld on thl cerllfitll. ltal/dlm 0 how long Ih. lundl hm IIm,'nld in Ih. moont Th. p,"111y 101 ClrtlllCll1I ,."hlll' .It., bmm'" 1'0 '"' will "1 If IhI certlntll"1 on.yw or I... Ihl OInllly IlIlonlllulI ol.n .mounllou.llo 90 dill diVidendi, bmd on Ih. dIVidend "" bllng p.ld on Ih. tlrt,lItlll whllh"lIln.d 01 no!. Th. P.na/ly lot ClIrtlOtlln wllh m.lurlll.. 01 mOlllh.n onlllll will eoulllhl dlllll.ntl belween Ihl ne. diVidend ,,1"01.111' "",lln'"G plllOd olliml .nd lh""lllng certlncatl dfvldlnU III. dMd.d bl365 mulllplled bl Ihllm Vllul ollh. tllliflt.l. .nd mulllpllld bllhl nO/llb" 01 d'I' "mllll'"G on Ihl ..rll,ng torlifit.11 Th. minimum penllly will b.lh. gllll.1 01 Ihlllormul.(u .hown b.low) or 12500, Plnelty . (NIW Rltl . [listinG Ratl) X t.r1ll1call Face Vllul X DIYI nlmalnlng 366 \. ,'" =Tbltrtdll union will OM you.t leut 20 d.ys notice pllof to maturity. The tellllieal' Will aulomalica!lr bllene'Ned lor another lelm al Ill. (.IOU vI bUlineu on thl initial mllurlty .\ " '~1 or ~~IY dill 01 any rentwallerm unlellllll redeemed wilhin seven (1) talenda, days Thl lal. 01 earnmgs lor anr lenl''''allerrn "hall b. lithe ,.l'th, credll union il .'1' 'f. "", L .,... U... on new ttrtlOcallS ollh.llllm. ...."......1'.11.1 tf , of \hi ClrUficate owner, Ihe ce'11fiule will be 5umndered Wllhuul i!llIJlrlflU IIle fally WI!hllranill pl'n,ll!, \d ' .....\'1 '. o "Jo"';.,,