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Home My WebLink About95-04912 \ III ~ aI :3 . oil 7 (, q) { :.1 ~ J n a- T -. ~ lAW OfflCt. MANCKE, WAGNER, HERSHEY Be TULLY ill" ~OAh4 rRON' 5U[( t JOHN D. MANCKE p, RICtU.RO wAGNER DAVia E. HERSHEY WILLIAM T. lULL V H....U..9f1UIlG. r. '1110 AREA CODE 711 23'.7051 September 25, 1995 Mr. Scott Emey State Farm Insurance Company 115 Umeklln Road New Cumberland, PA 17070 RE: Claim No: Date of Loss: Your Insured: Our Client: 3B-7111-025 03.1 B-95 John J. Wells Danielle Unter Dear Mr, Erney: Enclosed please find a copy of the Order and Petition for Approval of Minor Settlement set for October 16. 1995 at 4:00 pm In Courtroom 4 of the Cumberland County Courthouse for the above-captioned case, Very truly yours, ,Jf' iI! I n,~ John B. Mancke JBM/hrc Enclosure '~~6 .. f ~ ~ lAW OHICfS MANCKE, WAGNER, Hf::RSHEY 8: TULLY n:u NORTH "'Of'ol' 51A[[f JOHN B. MANCKE P. RICHARD WAGNER DA VID E. HERSHE If WILLIAM T. TULLY AREA CODE 717 2304.7051 HARRIS8URG. P. 17110 September 25, 1995 Mr. John F, HU2Var, III USF&G Insurance 2605 Interstate Drive Harrisburg, PA 17110 RE: 2600 UAL 278869 01 1 Danlelle Untner Date of Loss: 03.18.95 Dear Mr. HU2Var: Enclosed please find a copy of the Order and Petition for Approval of Minor Settlement set for October 16, 1995 at 4:00 pm in Courtroom 4 of the Cumberland County Courthouse for the above-captloned case. Very truly yours, .fl.' ,~~ I;v:, John B. Mancke JBM/hrc Enclosure ......, -, r'~~Y_' ~ ~ ~ ~~ -,- IV) ~ ........~ kR "=S "''"'l Q ~~ ~ ~ C1 ::~ ' - :5 ",t; ::\...a A 0"- ;:!j c;.)z(.,~ ~ ~ ,.... .1 ~ ci u ,~ ~ i,- %'('3:>0- ~ co 01-:&".1 ~ . . '. -$)~ :~.;.~ ,;'~. LI"I '".\l;Z _ ,;.:' ~l-..J ~~ ~. ...~ ,-- f\~ J Ji ...'" gl'.,) -- ~ Cj f:' . Ii> W ;.oJ 10 z -' ~ Cl ~ ;:: I~.si~ ~~~il o lI)!l Z a: il c( W" ;:eI: . . . . ;:. ~n:::~.: ,C,."'" ~ _IC' C~... Of' M ~ICII""\ "...-0 .. '... ACtION .' M~v . MANU'.. WAGNI Jl Iii H5IH', I'. t Ull' .. ~~;at..o.w ~ r..r ~.h IHl t>>.:J.:-~ ~'~Dft. lM..ttf1'WIK'--.'rOtJ .. i""tAf.. DANIELLE N. LINTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. LINTNER and MELODY LINTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA ~ NO. qs- 411 L ~~Jt~ : CIVIL ACTION - LAW Plaintiffs v. TIMOTHY L. WELLS Defendant ORDER . , AND NOW, thIS,;'l"(~day of Jc 1.1& IIi f~ (, ,1995, upon consideration of the wtthln , petition, a hearing Is scheduled for /u th day of (( I! (I- ILl. l ,1995, at 1.ll:o'c1ock /"",)/ In Courtroom L, Cumberland County Courthouse, Carlisle, PA. Plaintiff's attomey shall give notification to the insurance companies involved of said hearing. By the Court, J, DANIELLE N. LINTNER, Minor, by Michael E, Lintner and Melody Lintner, her parents and natural guardians, and MICHAEL E, LINTNER and MELODY LINTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA 9S - ';'11'/.1 0,..., ( h r_"i NO. CIVIL ACTION. LAW Plaintiffs v. TIMOTHY L WELLS Defendant /'_ ORDEB ... Ochhcr AND NOW, tlUll-..Ldayof ~]t;, I~~' 1995, the settlement totaling $175,000 is hereby approved and the parents and natural guardians are authorized to sign any and all releases to give approval of this settlement and it is further ordered that the distribution outlined in Exhibit A of the Petition is approved and that the sum of $135,702 be deposited in the name of Danlelle N. Lintner, minor, by her parents and natural guardians, Michael E. Lintner and Melody Lintner, and such amount shall be deposited In one or more savings accounts in the name of the minor In a bank, building and loan association, or savings and loan association, which deposits are insured by a federal govemment agency. It is further provided that the amount deposited in anyone such savings institution shall not exceed the amount to which the accounts are Insured and further ordered that no withdrawal can be made from any account until the minor, Danlelle Lintner, has attained her majority except as authorized by prior Order of the Court. It Is further ordered that proof 01 the deposit shall be promptly filed 01 record with the Prothonotary. By the Court, d-. , 11 f- . J. Ocr I II '" . ' '55 I 1 J ill J '~ ,~ ~ ~ .t, Q.,..., .q -.::::-.. . ':) ~ - '1 f R .~ DANIEu.E N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PlEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. : CIVIL ACTION - LAW Plaintiffs v. TIMOTHY L WEu.s Defendant PEImON FOR APPROVAL OF MINOR SETn,J;MENT AND NOW this $' day of "7.., A~y..k, 1995, comes plaintiffs by their attorneys, Mancke, Wagner, Hershey & Tully who respectfully represent: 1. Danlelle N, Untner Is a minor having been bOm on December 29, 1980 and who currently resides at 1463 Pine Road, Carlisle, Cumberland County, with her parents and natural guardians, Michael E. Untner and Melody Untner. 2, Danlelle N. Untner was a passenger and Involved In an accldent, which occurred on March 18, 1995, and at that time Danielle Untner was residing with her parents and natural guardians, Michael Untner and Melody Untner and stili resides with her parents. 3. pursuant to the Pennsylvania Rules of CMI procedure 2039, the plaintiffs herein desire to settle a personal InJUry case Involving serious and permanent Injuries sustained by Danlelle N. Untner on or abOUt March 18, 1995 while Danielle Untner was a passenger In a vehicle driven by TImothy L Wells, which vehicle was owned by TImothy Wells parents, John and Uncia Wells, which vehicle was being operated on SR 3021 (Bumt House Road), Dickinson Township, Cumberland County, Pennsytvanla, at which time TImothy Wells loSt control of his vehicle while traveling at an excessive rate of speed, which caused Danlelle Untner to be thrown from the Wells vehicle. 4. At the time of the accident, Danlelle Untner suffered serious Injuries which Include severa closed head Injury, left femur fracture, right tibial fracture, and acute onset of severe hydrocephalus. 5. Danlelle Untner was treated at Hershey Medical Center where she was hospitalized and underwent extensive medical treatment and numerous surgeries and continues to undergo home cara treatment on a regular basis, 6. All medical expenses for treatment have been paid by the applicable Insurance carrier and/or by other applicable Insurance with the exception of $298 which is due to the Carlisle Community Ambulance Service. 7. Plaintiffs have approved the payment 01 counsel fees as set forth in Exhibit A, which counsel fees have been reduced to 20% contingency fee from the 1/3 contingency fee agreement and power of attorney outlined In Exhibit 8, It is further averred that plaintiffs have been informed by the law firm of Mancke, Wagner, Hershey & Tully that all Mura attomeys fees in order to give full effect to this settlement and to ongoing legal services ralated to this settlement will be waived and there will be no further fees In regards to this settlement or any further legal actions required to give effect to this settlement, Including but not limited to any Mure required petltlcns or payment and/or Incompetency should the need arise. 8. Defendant's Insurance carrier, State Farm Insurance Company, pursuant to correspondence of June 29, 1995, has Indicated a willingness to pay policy limits in the amount of $100,000 to settle the personal injury claim and have provided such verification which Is DISTRIBUTION Total Distribution. . . . . , , . , . . . . . . . . . . . . . . , . . . , . . . . . . . , , , . . . . . $170,000.00 Daniells N. Untner, Minor, by her parents and natural guardians, Michael E. Untner and Melody Untner .......'................. $135,702.00 Carlisle Community Ambulance ,.,............,...,.........,..,. $298.00 Mancke, Wagner, Hershey & Tully (attomey fees) ........,.,... . . . . . $34,000.00 EXHIBIT .A. .....w O''''CIS MANCKE, WAGNER, HERSHEY & TULLY 22:313 NORTH ,RONT SUllO AREA CODE 717 2)".70'1 JOHN B. MANCKE P. RICHARD WAONER DAVID It. HERSHEY WIL1.IAM T. TULLY DAVID R. BAISCHI HARRISBURG. tlA. 17110 POWER or ATTORNBY AND CONTINGENT rEB AGREEMENT KNOW ALL MEN BY THESE PRESENTS, that I/We Q~~-J,I pIll 2-: '" 11",.,~ ' do hereby retain MANCKE, WAGN~, HERSHEY & TULLY of Harrisburg, pennsylvania, as my/our attorneys to negotiate for an adjustment or to institute for me/us in my/our name any legal actions or proceedings that in their judgment~ neces ary, in co nection with my/our claim for damages against ? or anyone else as a result of .~n ur:Les;w: dama s susta:Lned by me/us on the -l.S- day of IlLvrl.i'^, 199.52' I/We agree not to settle or adjust the above claim or any proceedings based thereon without the written consent of my/our said attorneys. NOW, THEREFORE, in consideration of the services so to be rendered by my/our said attorneys, I/we hereby consent, promise and agree te ~ pay to my/our said attorneys for their professional services "l" rendered THIRTY-THREE AND ONE-THIRD (33 1/3%) percent of whatever sum is recovered as a result of settlement wit:l,......L .....lL 1:'1.15 oj:\e,,"QSsary:lEpensElS il'l9urred il'l ~he. evu~t of any :r~CCl\'~~'Y. O~ FOR-'l'Y {4.0l). ~~iI1 i-be ~ IllUt :LS :.::..g~ e: :r.:~;; :La hdd pll1s 'neeeslilHY ;;q;l!<I;~e5 ihcl:trrcli in the e....el'lt of any IlWOlR l:u....'<l'ery, AND NOW, this c,~ day of I~~__, 199~ the above contingent Fee Agreement and Power of~ has been read, approved and understood by me/us and the receipt of a copy thereof acknowledged. The terms set forth are agreeable. ~~,Cl:~~~{sEAL) (SEAL) (SEAL) EXHIBIT .B" ... .' VERifiCATION I verify that the statements made In the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 54904, relating to unswom falsification to authorltles. Dated: If/I? ) It .;- ~~~1j7Z;LJ~ '-D .::t. ~ "- '.... ... ~ ~ - ~ t;;,... ...... . I,:r . ;~~t:ti ......'.' ",-' r1' :;:,' ~ ~ ,. '", ;e . '_l " ;-'. "" DO ..."'." $'*,Y 'MA' Il!!.-".' -- iiIl.."1:; ~T -- .. .... ri~ w :II!! Z:J ~ (!J I- ,. I~.ali ~~~II U U) H ~ 15" :e:I: . . ,.......',.....1S per 21 -1f&--~ ~r/t~'3Wi _ "JU'~ . . ..__..~~_._.__...... MANCKE, WAGNER. HERSHEY & TULLY DANIELLE N. LINTNER, Minor, by Michael E. Lintner and Melody Lintner, her parents and natural guardians, and MICHAEL E. LINTNER and MELODY LINTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 95-4912 CIVIL TERM : CIVIL ACTION - LAW Plaintiffs v. TIMOTHY L WELLS Defendant ORDER AND NOW, this :2~' day of 0"...... , 1995, It Is ordered and decreed that Michael E, Lintner and Melody Lintner are hereby authorized to pay: (1) the amount of $39,872.14 for the purchase of one van outlined In Exhibit .B" and (2) pay to Melinda Piper for the care of Dan'elle at the rate of $5,50 per hour, not to exceed 6 days per week, at 8 hours per day, for a period not to exceed one year, to be paid bl. weekly. AND FURTHER, PNC Bank is authorized to release the sums herein indicated based on the terms indicated. BY THE COURT: DATED: lid- J. - -. DANIELLE N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO, 95-4912 CIVIL TERM : CIVIL ACTION - LAW Plalntllls v. TIMOTHY L. WELLS Defendant PETITION FOR RB.EASE OF FUNDS OF MINOR SETTlEMENT 1. The Plalntills In the above-captloned case hereby petition the Court for payment from settlement, which was approved by Your Honorable Court on October 16, 1995 and a copy of said approval Is attached as Exhibit 'A'. 2. The sum of $135,702.00 has been deposited In PNC Bank pursuant to Court Order. 3. At time of said hearing, testimony was taken relative to the need for the purchase of a van because of the medical condition of Danlelle and further testimony was taken relative to the need for help In the care of Danlelle by Melinda Piper, who Is the sister of Melody Untner. 4, Request Is hereby made by the parents and natural guardians for the following: (a) Release of the amount of $39,872.14, and the approval of the Court of the release of those funds from the account indicated, for the purchase of the van outlined In Exhibit 'B', which is attached hereto and made a part hereof. (b) ReleaSe of the amount to pay Melinda Piper for care of Danleller at the rate of $5.50 per hour, not to exceed 6 days per week, at 8 hours per day, for a period not to exceed one year, to be paid b1-weekly. WHEREFORE, Plaintiffs request Your Honorable Court to enter an Order accordingly. Respectfully submitted, MANCKE, WAGNER, HERSHEY, & TULLY L- By John Attorney. 2233 N Front Street Harrisburg PA 17110 (717) 234-7051 Attorneys for Plaintiffs DATED: 10-26-95 ** CUSTOMER COPY ** Mobility Independent Transportation Systems. Inc. DATE: 10/18/95 R,O. 2, Box 316, Glen Rock, PA 17327 Melod Lintner PURCHASER'S NAME 1463 Pine Rd STREET ADDRESS PA STATE 17013 ZIP RETAIL ORDER FOR A MOTOR VEHICLE Scott Heatwole SALESMAN'S NAME Carlisle CITY 717-486-7918 Proposal for Conversion RES. PHONE PLEASE ENTER MY ORDER FOR THE FOLLOWING VEHICLE BUS. PHONE x NEW 0 USED 0 DEMO STYLE: Grand MODEL: Vovaaer o SOLD "AS IS-NOT EXPRESSLY WARRANTED OR GUARANTEED." YEAR: 1995 EXT: L1aht Driftwood JOB NUMBER: 1109 VIN: 1P4GH44R4SX623716 MAKE: Plvmouth INT: Grev VEHICHLE: V-6 engine - 3,3 Liter Atomatic transmission with overdrive Air Conditioning Power Steering Power Anti Lock Brakes Power Windows Power Mirrors Power Door Locks Power 1/4 Vents Cruise Control Remote Keyless Entry Tilt Steering Wheel AM - FM Stereo with Cassette Lift Gate Release Rear Window Defroster Rear Wiper and Washer Sunscreen Glass Full Tank Of Gas Inspection All Season Steel Belted Radials with Spare and Cover Full Instrumentation Dual Alrbags Warranty: Chrysler 36 Months 36,000 Miles Bumper to Bumper PURCHASER'S SIGNATURE AU WAARANTIES. IF N<<. BY A MAl<<EN::T\JlfR OR SlI'PI.ER OTIER TIM DEALER ARE TlEIRS, NOT DEALER'S AHl OIU SUCH MAl<<EN::l\ftR OR OTIER SUPPLIER SHAll BE lIABlE FOR PERFORMANCE ~ SUCH WARIWIrEs. lKESS DEALER FlJlNISIES \lUYER WITH A SEPARATE WRITTEN WARRANTY OR SERVICE CONTR.\CT I.WlE BY DEALER ON ITS OWN BEHALf. DOOR IEREBY DlSClAMI AU. WARRANTIES EXPRESS OR 1I.fIUED. INCl.lIlHl N<< IlI'lEO WAARANTIES OF t.ERCHANTABIUTY OR FITNESS FORA PARTICUM PlJU'OSE: IAl ON AU. GOODS & SERVICE SOlD BY DEALERAHll8l ON AU. USED VEHIClES WHICH AAE HEREBY SOlD 'M ~T EXPRESS!. Y WARRANTED OR GUAlWlTEEO,' IF THIS CONTR.\CT IS FOR A USED vatcLE, TIE N'ORIoIATION YOU SEE ON TIE lFIOER.Il TRADE COIUSSION) WINlOW FORM IS PART OF TItS CONTRN::T. INfORMl.TION ON TIE WINOOW FORM ClIIERRIDES N<< CONTRARY PROIIISIONS IN TIE CONTl'lACT OF SoAlE, The ton. oM __ 01... 0rd0I'...... "'11I" _1_" ..........11I""1..... _'01......-. .1 ""nOn ........~...... _...._ Of ""Iorod "". or .. be '_oiood. I honiby -IV 1lot!lO _I _......- ., mo ... ......... ollis mob voIido -' 01 """"" in oritng on .. 11oo 01... 19..men, I ho;e lUll.. molloJ prill"" on'" _ _ _ ond _ "" 011*1 01... onlor ...... 01'" _ prill"" _ "'Y...._ ,cortfy ....,.. 01.... oge, ond honiby octnooIedgo....... 01. oq>y"'" onlor, DATe 7.7':135.5899. ..800,lU.6U7. fAX 7.7,117,0.\18 EXHIBIT "n" / ** CUSTOMER COPY ** Mobility Independent Transportation Systems. Inc, DATE: 10/18/95 R.D. 2, Box 316, Glen Rock, PA 17327 Melod RETAIL ORDER FOR A MOTOR VEHICLE Lintner PURCHASER'S NAME 1463 Pine Rd STREET ADDRESS PA STATE 17013 ZIP Carlisle CITY 717-486-7918 Proposal for Conversion RES. PHONE PLEASE ENTER MY ORDER FOR THE FOLLOWING VEHICLE Scott Heatwole SALESMAN'S NAME BUS. PHONE x NEW 0 USED 0 DEMO STYLE: Grand MODEL: Vovaaer o SOLD "AS IS-NOT EXPRESSLY WARRANTED OR GUARANTEED." YEAR: 1995 MAKE: Plvmouth EXT: Liaht Driftwood INT: Grey JOB NUMBER: 1109 VIN: 1P4GH44R4SX623716 CONVERSION: IMS Rampvan Electrically Operated Ramp I Swing Open Feature Electrically Operated Door Air Kneel Suspension Manual Tie-Down and Seat Belt For Wheelchair (4 Positions) Single Exterior Rear Switch Controls Power Door Lock-Out Dash Controls 10' Lowered Floor 10' Lowered Door Emergency Door Release Emergency Ramp Release Removable Front Passenger Seat and Base IMS 3 yr. I 36,000 Mile - 7yr.l70.000 Mile Warranty $38,350.00 Sale Price 1,438,14 Tax + 84,00 Tags $39,872.14 Total AlL WARRANTIES, IF mi. BY A MAMJFACT\JIER OR SU'l'UER OMR TIWl OEAlER ARE TlEIRS. NOT 0EAlER'S NO otI..Y SUCH t.WUACT\JIER OR OTlER SUPPLIER SHAll BE LWlLE FOR PERfORMANCE \NlER SUCH WMRNmES. UlUSS 0EAlER FIJlNISIf:S BUYER WITH A SEPARATE WRITTEN WARRANTY OR SERVICE CONTRACT lAoIllE BY OEAlER ON ITS OWN 8EHAl1. OEAlER IERf8Y DISC\ANl All WARRNlTlES. EXPRESS OR 1IoI'lED. N:WlNl Nft M'lIED WARRANTIES OF t.ERC~A8IUTY OR FlTtESS FOR A PART1C1J.AR NlPOSE: (.tl ON ALl GOODS & SERVICE SOlD BY 0EAlER AI&) (8) ON ALl USE1l VEHICLES WHICH ARE HEREBY SOlD OM I$-NOT EXPRESSlY WARlWITED OR GUARANTEED: IF THIS CONTRACT IS FOR A USED VEHICLE. TIE NORMATiON YOU SEE ON TIE (FEDERAL TRADE COlMSSION) WII'IlOW FORM IS PART Of THS CONTRACT, INfORIJATION ON THE WIIIlOW FORMOIIERRIDES mi CONTRARY PRO\IISIONS IN TIE CONTRACT Of SAlE, The tool IN MOOnd pogo 01 Ilia Ordor ~ '" enln _...., .lIoc:lng.... II'"'- en not 0" __ II _tIrdng of my..1In 0lI.....~,g _ hot boen modo Of ",,"'ed ~Io, Ol ... bo '""'9izod. IIlortby oortfy ""no _I hot boen .._to ... b '" II'"'- of.... motor IIIIido IlOIplIl IlII'Ift in ...tog III '" .... of.... "!l,.."""'l I h.... rood '" Olltlor prinlod III '" _ pogo _end _to ~ II I*l ofilia '"* '" ~ ~ __ prinlod _ '"".......' I oortfy "" I om 01'" oge, rod ....eby ",k~ lICI\>t 01. cq>y 01.... O<dor, PURCHASER'S SIGNATURE DATE 717.135.5899. 1,800,2.U.6487' fAX 717.227,0-\18 " VERIFICAllON I verify that the statements made In the foregoing document are tnJe and correct. I understand that false statements herein are made subject to the penaftles of 18 Pa.C.S. 54904, relating to unsworn falsification to authorities. ~tll~~~ Dated: 10, ~5.q 5 " VERIFICATION I verify that the statements made In the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 54904, relating to unswom falsification to authorities. 'y ~Oc~p ~ ~,~ Dated: ID .15 L)5 I:R >-e - ~ ~z w..:;:,. o~o- '" _a""z In ..... -c "'%0> ("I') o...z.... '0." Ca: -,en UJQ..a:Z ....., =.....""z ~X'm'" f--ZQ,. ~ -=> ",C) ffi~l~ z::;) ~ ell- .. I ~ all I i ~ s i il z 15 a iI: . . . W' DO ....JIII.." f!iJlf...... T..AT fMl. "T",~ ,t " AMI) COA __ICl (.01''' Of' T 0'''0*., "'.In.."'" *C'hCltrf .' .,.... :&..._-"'... . _n.....~.. ".' .oot e::~~ 't: r~,.""', ... ..~ ...... ~.... . .. .- ~_....__._.M.'"._ MANCl(l W^nNf" tUHSHf'v& TULLY - -.. DANIELLE N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA . : NO. 95-4912 CIVIL TERM . . : CIVIL ACTION. LAW PlalntJffs v. TIMOTHY L. WELLS Defendant PROOF OF DEPOSIT Exhibit .A. - Opening deposit to Money Market, . . . . . . , ., $53,600.14 Exhlbft .B. - Certificate of Deposit No. 234297 . . , . , . . , , ., $14,000.00 Exhlbft "C. - Certificate of Deposit No. 234298 . . . . . . . . . ,. $14,000,00 Exhlbft .0. - Certificate of Deposit No. 234299 . , . . . . , . , .. $14,000.00 Exhibit .E" . Certificate of Deposit No. 234300 . , . , . , , , . '. $14,000.00 Exhlbit.P - Certificate of Deposit No, 234301 ,....",." $14,000.00 Exhibit "G. - Certificate of Deposit No, 234302 . . , . . . . , . .. $12,101.86 Total deposits .".,.,....,..... $135,702.00 Respectfully submitted, MANCKE, WAGNER, HERSHEY, & TULLY ok..} ~ ::=0.07212 2233 North Front Street Harrisburg PA 17110 (717) 234.7051 Attorneys for PIaIntIlfa DATED: 11.1-95 CERTIFICATE OF DEPOSIT Oct. 24. 1995 DATE PNClBANK NO, 176 CARLISLE 234297 PNe llaoL:. N.lliunal 1\\\111,,'1,111011 Smllht.:,,'nlral PA 320 12-23 HNTHS OFFICE TYPE PNC Bank, ~ofla~:')"~~WLEDGES THAT GONS UNDER CT ORDER 9-20-95 MICHAEL E AND MELODY LINTNER 198-66-7713 NAME ADDRESS l'lOJ t".1IUi KU CARLISbB fA 170139321 SSN P fJ I: I 'LJ n ,,,...... .l.,~', t"'1....... ....... HAS DEPOSITED WITH BANK II ~ 'i I( " , : I' i '; " ,; l'" , DOLLARS. payable to the depositor upon maturity as herer~c,lied and upon presentation and surrender of IhlS cerlllLcale. ThIS certili5tte will malure (time period) Irom the date tlereof o ON THEt 'ttiHltlITY DATE, THE CERTIFICATE WILL BE AUTOMATICALLY RENEWED lor an addl\lonal 1 YEM. (time periOd) term beyono Its or!glnallerm and there alter tor addItional periOdS of (lime peuod) each. unless lAj the depOSitor nOlllles the Bank no later than len (10) days alter the original or any subsequent matuflty date nol 10 renew the certificate al maluflly or (B) at least Ihirty (30) days prior 10 lhe original or any subsequent maturIty date. the Bdnk nas seN wrlUen nOllce to deposllor of Bank's election to terminate this deposit al maturity. If this cerllflcate IS not renewed at any matul1ly cale, no mterest Will accrue aher such matunty date o UPON MATURITY, THE DEPOSIT WILL BE PAID upon presenlat'on and surrender 01 ""s cerU',cale wlln Inlerest Irom the dale hereof. No interest will be earned after the slaled maturity. 4.750 Cld'I'l'AbIZB IlPl'BRE5T %: interest Will be The cer1illcale}t'f1 ~from the date hereof unlil the maturity date at a rate 01 palei . Interest to be paid by' depOSIt to: The Bank reserves the right on AUTOMATIC RENEWALS 10 change Ihe interest rate and ar.nual percef"llage lie!d 101 any subseQuent renewal pertodlS) S.., lhallne rale and annual percentage yield tor such renewal penod(s, WIll be sQuallo lhose lhl,? Sar... IS ct~erlng al SuCh lime lor lis certlflcales Of depOSit V,O") like amOunlS and maturities. ThiS certifIcate is not assignable or lransferabte ellcept en II'~ O(c..s cf :""\e ;SSulr,g o!llce (;II !r:~ Bank and IS subJec11C " ' applicable laws and regulalions 01 the Uniled States and Pennsvl\lama, and IS gO\lerned by Oanj.. n..I'_'5 The interest rate, annual percentage yield and maturity dale for this account .re stated on the Rate Disclosure provided 10 you. See e separst count Ag ement tor other important terms. ~ ~ C\~&-x Q, ~, Cf') '-..:~~;__) CU~ER SIGNATURE Gt2':.~015 Exhibit "B" CERTIFICATE OF DEPOSIT. Oct. 24. 1995 PNClBANK NO. 176 CARLISLE OFFICE 234298 ~ - PNC nJn~. Natillnal '\~M~i.1l1l1R SOUIlKl:IlIlOlI IlA DATE TYPE 318 271-364 DYS PNC ~ank. NaK~'ic~t1t~~~ '\lfltbrLEDGES THAT GONS UNDER CT ORDER 9-20-95 1463 PINE RD CARUl~LS PA l/U1J~J~1 SSN MICHAEL S AND MELODY LINTNER 198-66-7713 NAME ADDRESS I'fJ " r ' , ...... " ..... I .' ...... "'" · HAS DEPOSITED WITH BANK . . t..',;,' I' t.: ~ I !' . .....,.... DOLLARS. payable to the depositor upon maturity as herei~lr tii~~ 'an 'upon presentatiOn and' surrender 0 thiS cer1ihcale. This certificate will mature (time period) trom the dale hereol o X ON THE 2~tTHRW DATE. THE CERTIFICATE WILL BE AUTOMATICALLY RENEWED lor an additional (time peflod) term beyond Its original term and thereafter lor additional periods 01 271 DAYS (hme period) each. unless IAllhe deposIto' nohhes the Bank no lalarthan ten (10) days after the original or any subsequent maturity dale not to renew the certificate al maturity or (8) at least thirty (3D) days prior to the original Of any subsequent maturlly dale. the Bank has sent written nohce to depOSitor of Bank's election to terminale this deposil al maturity. IIlhis certificate is not renewed at any maturity date. no interest Will accrue atter such maturlly date. o UPON MATURITY. THE DEPOSIT WILL BE PAID upon presentahon and su"ende' of Ihis cenillcate wilh inlerest from the dale hereo/. No interest wlil be earned atter the statod ",Slunl,. 5.460 CAPITALIZE INTEREST %: interest will be The certiticate X~ ~..it'Ja,r'i1Jrom the date hereof until the maturity dale al a rate of pa,d .lU"mm/\'SI to be paid by' depoSIt 10: The Bank reserves the fight on AUTOMATIC RENEWALS to change the Interesl rate and annua.; pL!rCen1age yield tor any subsequent renewal period(s) S0 Inallhe rate and annual percentage Yield lor such renewal pCflOd(51 Will be equal 10 thOSe tne ear-,M, :5 ol!ef1ng al such lime lor lis cerMicates 01 depOSit ....,1"'\ ;,io.C amounts and malunlies. This certificate is not aSSignable or translerable e.c(.pt en 1t.,~ :x,:;.::, ,11he ,ssuing aflll:e of the Bank and is subJecl to a:t at:pi;cab!e laws and regulatIons of lhe Umted Slates and Pt'nnsylvama. al"d IS gr:'.~IPt:'C by 5"r'";.. S .:e5 The inte I rate. annual percentage yield and nlaturity date for this account .re stated on the Rate Disclosure provided to you. See t separate co nl Agr ent for other Importanl 10'015. \1..s:;i, I <:.. '- ~ ;~~~'I.....~~~ ;,....)"'~('~~l.L..."-_._) Cu$'l'OMEA SIGNATURE tiI2~-40'S Exhibit "e" CERTIFICATE OF DEPOSIT Oct. 24. 1995 PNClBANK NO 234299 I'NC llank. Naliunal A.\\Il\:1J1l11n Slluthcenlr.J1 PA DATE 176 CARLISLE OFFICE -- TYPE 318 271-364 DYS PNC Blnk. N~~D~ffl"ltilOf:i_I. A~LEDGES THAT GDNS UNDER CT ORDER 9-20-95 1463 PINE RD CARLISLE PA 170139321 MICHAEL E AND MELODY LINTNER 198-66-7713 SSN NAME ADDRESS P fJ ,: Yf i ,f ,'"'\''"'\..... .\,~', ,..., ,-. . HAS DEPOSITED WITH BANK ,t' .J..~' '_.' '_: " .; I.' I '\ ~! :: I ,.';',' <: DOLLARS, payable to the deposilor upon matullty as hereln~'7"{ s~"lIWd and upon presenlalion and su"ender ollhoS cerlilicale, ThIS certllicale will malure (lome period) tram Ihe dale he,eol o X ON THE MT'tlA'is DATE. THE CERTIFICATE WILL BE AUTOMATICALLY RENEWED lor an .dditional (time perIod) lelm oe~'ond .IS orlgln81 term anO :hereaUer lor additional penods 01 271 DAYS (lII;,e perood) eacn, unl." (AI the depos,'or nOI,I,esthf Bank no laler lhan len (10) days alter Ih. original or any subsequenl maluroty date not 10 ,eMW tOO cefl,licale al maturoty or (B) at le.st Ihllly (30) days proor 10 Ihe original or any subsequenl maturoly date. lhe Bank haS senl w"lIen nolo,e 10 deposllO' 01 Bank's elechOn to termlnalelhis deposit at malurity, IIlhis ce'tllicate ,s not renewed at any maturoty cale, no In'ere" wIll accrue alter such malullty date UPON MATURITY, THE DEPOSIT WILL BE PAID upon presentaloon and surrende' at Ih,S ce",Iocate w,th interest Irom Ihe date hereof. No interest will be earned after the stated matunty. o The certificate will bm inlerest Irom the date hereof unlllthe maturify date at a rate 01 5.460 %; interest woII be pa,d AT ~Jilst to be paid by I depos't 10: CAPITALIZE INTEREST The Bank rese,ves the righl on AUTOMATIC RENEWALS to change lhe ,nlere" rale and annuli o.'centage y'elo tor any subsequent renewal periodls) ,': tnattne ra'e and annual percentage y,eid lor such renewal peroodlS) WIll be equal 10 tnose tne 8a", ,s o"e"ng at sucn \,....elor ,IS cerlol,cales 01 depos,1 Vi,:" "k. amounts and malurot,es This cerlilocale 's nol assignable or translerable e,cepl on 1M coe., 0' Ir,eSsu,ng o'Ioce of the Bank and is subject 10 ' apphcable lawS and legulal'ons ollhe Un,led Slales and Pennsylvania, and 's !;oveneo L) 8,"" s 'u' s The interest rale, annual percenlage yield and maturity date lor Ihis accounl are staled on the Rale Disclosure provided 10 you, See Ihe arala Ac nt Agreeme or olher 'mporlanl ,~~s:~~ Q. ~~ CX:,~c..&..-. ') CUSTOMER SIGNATURE 6'24~O'S ,.' Exhibit "D" .........." 1....."1 ~ u. ...._. ........., Oct. 24, 1~95 ---- Pl'1\.....1IJ)A\.l~ J&. IlXC BJIll... Sillillll.11 '\\\I""!.llIllll Sllulh......lllr;11 p:\ NO 234300 DATE 318 271-364 DYS 176 CARLISLE OFFICE TYPE PNC Bank, Na~i!a'il'''IlIIW1IE~:-cmil6'REDGES THAT GDNS UNDER CT ORDER 9-20-95 1463 PIHK RD . ~AnL~DL6 ~A 110l~9~~1 MICHAEL E AND MELODY LINTNER 198-66-7713 NAME ADDRESS SSN PfJe Lfrjt""~,\..~"n' t....:,.~ HAS DEPOSITED WITH BANK I ". 't '. . . . . '.Ii:. " ,\. DOLLARS payable to the depositor upon maturity as hereln~'f fPfnlVt! Bnd upon presenlatlon Bnd surrender of this certificate ThiS cel1lhc8tf)cWill mature tt.me penod) tram the date he real o ON THE IJ.'HU~~s DATE, THE CERTIFICATE WILL BE AUTOMATICALLY RENEWED lor an. add,loonal . . \lIme period) term bevonO liS ortg.nalterm and Ihereallel 101 additional periods 01 ~ 11 UAU:i (time period) eacn. unless (A) the depOSitor notlhes the Bank no later than ten (10) days alter the original or any subsequent maturlly date nol 10 renew the certificate al matullly or (B) at least thirty (30) days prior to the original or any subsequent matullly dale. the Bank has sent wllllen nollce 10 deposllor 01 Bank's election to terminale this deposit at maturity. II this cerMicale is not renewed al any malullty dale. no IOterest will accrue after such maturity date. UPON MATURITY, THE DEPOSIT WILL BE PAID upon presenlation a"d surrender 01 thiS cenllicate with interest tram the date hereof. No interest will be ealned after the stated malunly. o The certilicate wi~~etiQ/.llWHfr' the date hereol untillhe malullty dale al a rate 01 paId '_..'1~ier.sllo ba paid by I depos't 10: The Bank rese:rves the right on AUTOMATIC RENEWALS to change the mlerest rate and anr'ual percentage Yield lor any subseQuent re"ewal period(sl ~u Ihal the rale' and annual percentage yield lor such renewal period(s) wIll be eQual 10 those tr.e Bank IS olfering al SuCh !lme lor liS certificates of depoSIt ....;1. Illo.e amounts and maturilies. This certificate is not assignable or lrJnslt~lab!e e>.ccpt on Ihl' 000;'5 01 the IssuIng of lice 0' the Bank and is 5ubJeCllo ;,' applicable laws and regulallons ollhe United States and Pennsylvania. and IS governed bl Bsn7-S n.les The mterest rate. annual percentage yield anJ maturity date lor this account are stated on the Rate Disclosure provided to you 5e, he separ Account ment tor other impOrlf'll.1 terms. I _ \-'~b & ~. Cl.< -'--.....1 II cu ER SIGNATURE 5.460 CAPITALHa; IIlTt;IU\ST %; interest will be 612440\5 , Exhibit "E" '~ CERTIFICATE OF DEPOSIT oct~4, 1995 "- 318 271-364 DYS PNClRANK NO 234301 176 CARLISLE DATE PNC RJn". N.llillnal A\'I~I..lllln S41Ulh,tnlr..1 PA TYPE OFFICE PNC Bank, N.'ill\1'l_'Yt~IM8~WlEOGES THAT . GONS UNDER CT ORDER 9-20-95 NAME UbJ PJ.1l1S IW ADDRESS C~I5L1 PA 110139321 ? fJ I: 'lI' i ('\ ," ,", .i,~'.,n ,J(....... HAS DEPOSITED WITH BANK !l.~." If .~, ~~ ,.'.. ..' ~" ". ~ _' '. .; :. d DOLLARS. payable 10. the depositor upon maturlly 8S herein&!,.t~Y!! and upon presentation and surrender ol1hlS certlf.cale. ThiS certlhC811twill mature (lime period) trom the date hereot. o ON THE ~nUBi'ls DATE, THE CERTIFICATE WILL BE AUTOMATICALLY RENEWED lor an addllional (lime pen0(2) torm beyond lis ofl9,nal term and therea',er 10' additional peraods 01 ~ I i Ulutt (lime period) each, unless IAllhe depOSitor nOli lIes the Bank no late, than ten (10) days aher the original or any subsequent maturlly date not \0 renew lhe certlllcate al maturity or (B) II least lhirty (30) days prior 10 the original or any subsequent maluflty dale. the Bank I1dS sent ",vntlen notice 10 depositor cl Bank's election to terminate this deposit at maturity. II this ceflllieale IS nalrenewed at any malu' .tv cale. no Inlerest WIll accrue atler such malUrlty dale. UPON MATURITY. THE DEPOSIT WILL BE PAID upon presenlatlon and surrender ot 11'\15 certlhcale With Interestlrom the dale hereof. No interest will be earned after the sltlled maturity. MICHAEL E AND MELODY LINTNER 198-66-7713 SSN o 5.460 o.u; inleresl will be The certificate Wil~\b\.MW" the date hereof until the maturity date at a rate of pa,d . Inleresllo be paid by , depas,t to: The Bank reserves the righl on AUTOMATIC RENEWALS to change the Inlerest ra~e and ann:.-al ~l"cer'tJge }'Ield for 8r,y slit:)5eQuent renewal per1od(S) ~(. thatllle rale and annual percentage yield far such renewal pCflOd(S) ",\'111 tie CQual10 Ihc~eo :r,t' 3:,r, '~:;~!l)r,r:y al suC" l,r~e 'or ,IS CeUlllcales 01 deposll 'N." l,I,e amountS and mal unties. This certificate is nol assignable or 1r(tn~!vfabl~ C~C(';..'1 cn ~.-~ ~, ~". :t't: ,..o;u:r.; i".l',:'] -:11r'C Bank. and IS subject to ., applicable laws and regulations 01 the United States and PennsylYJ,r'a. :I"c1 ~s go...'~rr,ec C, ea~... '>:\.. :5 The inlerest ,ale, annual pereenlage yield end maturity date for this account are stated on the Rate Dlsclosu,e prOVided to you. See the cparate Ac nt Agre nl tor other Importanl terms .Q I a.... O\'\:~C<,:. <S-~ ~: ;,...,\ . _I....: }-.2:J '-~"- '&:~,--) CU UER SIGNATURE ~A~11AUl~b 1~1~~~1 612"~O'S Exhibit "F" DATE CERTIFICATE OF DEPOSIT Oct. 24. 1995 PNClBANK NO 234302 176 CARLISLE 312 32-91 DAYS I'NC nJll~. NaliuOil1 """,I\:I.1"(ln StlUlh,clIual PA TYPE OFFICE PNC Bank, NaUtlII'htm!Uft' LfA~~'illtf~DGES THAT GONS UNDER CT ORDER 9-20-95 1.11;' PlIllS RD C~ISLI PA 17013'3%1 MICHAEL E AND HELODY LINTNER 198-66-7713 NAME ADDRESS SSN HAS DEPOSITED WITH BANK payable ',0 the depositor upon maturity as hl"lna,,!' This certlhcate fill malure o ON THE M;tTUBfhlksDATE, THE .I/~',' P t:: ".~-... su"and'er" Ii'll certificate IlIme PIttGeS) 'rom the date hereof CERTIFICATE WILL BE AUTOMATICALLY RENEWED lor an addllional (time peflod) term beyond Its o'IQlnall.rm and th,realle, tor additional periods J MUfUno 01 (lime petledl each, unless IA) the depOSitor nOhlles the Bank no later than len (10) days after the original or any subsequent maturlly date nol 10 renew the cerllllcale at matutlty or (8) al least thirty (30) days prior to the original or any subsequenl maturity date. the Bank has senl wullen nollce 10 depo$llor of Bank's election to lerminate this deposit at malurlty.lIthis certificate IS nol renewed al any maturity date. no Interes1 Will accrue after such malurl1y date. UPON MATURITY. THE DEPOSIT WILL BE PAID upon preaenlallon and surrender 01 IhlS cen,"cale wllh inlere.. Irom the date hereof. No interest will be earned afler the slaled maturily. _ DOLLARS, o The cenificale will Wr~'f6J(iW Ihe date hereof untillhe maturity dale at a rale 01 pa,d . IntereSllo be paid by I depoSit 10: The Bank reserves the right on AUTOMATIC RENEWALS to change the Interesl rate and annual percenta;e ~'leld for any subseQuen1 renewal period!s) so lnal the rate and aonyal percentage yield lor such renewal perlOd(sl Will be equatlo Ihose the Bank .s oller jng at such lime lor Its cerliflcales at depoSit WIlh !:ke amounls and maturities, This cerllficate is 1'001 assigna~le or translerable e_c('pl on the cco..s 01 lh"~ fssu:ng ofliC~ ollhe Bank and IS subJecl to all applicable laws and regulations of the Uniled Slates and PennsylvanIa. and IS gO\lcrned by BanI<. 5 les The inlerest rate. annUli percentlge yield and maturity date lor this account are stated on the Rate Disclosure provided to you. See t separate aunt A ent for other Importan1 terml. :>""0<':',..,,(', ~ --%~- CU '-'EA SIGNATURE 6'~~-JOIS 5.150 %: intelest will be ~ftrlJ~l~~ lftr~~Dl l~~,<;.._L~__ ) ,." EXhibit "(;" en ~ CO) .. [ CO) g~ :r:: 0... "I .:r ,~ I ~ 0... 'lJ s:.: La.I {(J en ::E 1.<. 0.0 .::::> 0 en Q . . .. 00 H""fIY C'tllfl"., TMAt tNt WitH'" ,ti .. 'ffiMJI .~ CO'" M(:T co.... 0" '"f O.IC)!.....l AJO ... 'kit IIC-lu.. OV M/\~\lCYf \..\.'_'\liNf H Ht H~it~l " ~ J t 't '''' A~...' Sl, . Ii.~ I!! Z,;:) ~ 01- .. I~~ii ~ ~ ~ II o l/) I Za: ~W ~:r ", ~~'f"~.;f,~~,:t- ~f :::1;;:'f'..,If" 'J:' u..... I'.....~ :'~'f.:1i-= ~l ':tt-... ,. -~ DANIELLE N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E, UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERlAND COUNTY, PENNSYLVANIA : NO, 95-4912 CIVIL TERM : CIVIL ACTION. LAW Plaintiffs v, TIMOTHY L WELLS Defendant ORDER AND NOW, this ....r... day of ~'''e.. '- , 1996, It Is ordered and decreed that Michael E, Untner and Melody Untner are hereby authorized to pay: 1, Melinda Piper for the care of Danlelle at the rate of $5,50 per hour, not to exceed 6 days per week, at 8 hours per day, for a period not to exceed one year, to be paid bl-weekly, 2, The amount of $25,956.00 for the bedroom addition and the handicapped accessibility, 3. The amount of $4,640,00 for one Inclinette. AND FURTHER, PNC Bank Is authorized to release the sums herein Indicated based on the terms Indicated, BY THE COURT: DATED: ~<'rJd / / J, DANIELlE N. LINTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E, UNTNER and MELODY LINTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 95-4912 CIVIL TERM : CIVIL ACTION. LAW Plalntiffs v, TIMOTHY L WELLS Defendant PETITION FOR RElEASE OF FUNDS OF MINOR SETTU:MENT 1. The Plaintiffs In the above-captloned case hereby petition the Court for payment from settlement, which was approved by Your Honorable Court on October 16, 1995 and a copy of said approval is attached as exhibit 'A'. 2, The sum of $135,702.00 has been deposited in PNC Bank pursuant to Court Order, 3. At the time ofthe hearing and by Court Order dated October 27,1995, a copy of which is attached hereto and made a part hereof as exhibit 'B', Your Honorable Court approved expenditure of amount for the purchase of a van and for payment of Melinda Pipar to care for Danlelle at the rate of $5.50 par hour, not to exceed six days per week at eight hours per day for a period not to exceed one year, to be paid bl-weekly, 4. Because of the medical condition of Danielle and the need for help in the care of Danielle by Melinda Piper, who is the sister of Melody Untner, it is hereby requested that the Court extend authorization to pay Melinda Piper for the care of Danlelle for an additional period, not to exceed one year, at the rate of $5.50 per hour, not to exceed six days per week, eight hours per day, to be paid bl-weekly. 5, Oanlelle's condition has not Improved to the extent that the care by Melinda Piper Is not needed. 6, Further, Oanlelle's bedroom Is not handicapped accessible and the bedroom needs to be extended to make It handicapped accessible and to Increase the size of the bedroom to facilitate movement In a wheelchair. 7, A proposal has been received for the bedroom addition and for the handicapped accessibility, a copy of which Is attached hereto and made a part hereof as Exhibit "C". 6. In addition, an Incllnator is necessary to operate from the basement to the first floor that would allow and facilitate the movement of Oanlelle from the basement to the first floor, 9, An estimate for the Inclinator Is attached hereto and made a part hereof as Exhibit "0". WHEREFORE, Petitioners pray Your Honorable Court to authorize payment as follows: (a) Payment to Melinda Piper for the care of Oanlelle at the rate of $5.50 per hour, not to exceed six days per week at eight hours per day, for a period not to exceed one year from the date of this Order, to be paid bi-weekly, (b) Payment of the amount of $25,956,00 pursuant to Exhibit "C" for the bedroom addition and the handicapped accessibility, and (c) Payment of $4,640.00 pursuant to exhibit "0" to permit the purchase of one Inclineme, Respectfully submitted, MANCKE, WAGNER, HERSHEY, & TULl.Y DATED:! :: !h- By John Attome 1.0. No, 07212 2233 North Front Street HarriSburg PA 17110 (717) 234.7051 Attorneys for Plaintiffs ....... " DANlEUE N. UNlNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNlNER and MELODY UNlNER, : IN TIiE COURT OF COMMON PLEAS : CUMBERLAND COUNlY, PENNSYLVANIA : NO. : CIVIL AC'nON . LAW Plaintiffs v. T1MOlliY L wa.LS Defendant , ORDER AND NOW, this L day of DL~~ ,1995, the settlernenttotallng $175,000 is hereby approved and the parents and natural guardians are authorized to sign any and all releases to give approval of this settlement and it is further ordered that the distribution outlined In Exhibit A of the Petition is approved and that the sum of $135,702 be deposited in the name of Danielle N. Untner, minor, by her parents and natural guardians, Michael E. Untner and Melody Untner, and such amount shall be deposited in one or more savings accounts in the name of the minor In a bank, building and loan association, or savings and loan association, which deposits are insured by a federal government agency. It Is further provided that the amount deposited in anyone such savings institution shall not exceed the amount to which the accounts are Insured and further ordered that no withdrawal can be made from any account until the minor, Danielle Untner. has attained her maJority except as authorized by prior Order of the Court. It Is further TRUE COpy FROM RECORD , TSS1::mnywhtrll~I.II1f;reunt\lsetmYhand ,~ the seal of Slid Coo at Carlisle If..., (j- ' - 1 ordered that proof of the deposit shall be promptly filed of record with the Prothonotary. By the Court, 5 ~J~4 Fr:"kks <; / J. EXHIBIT "A" DANIELLE N. UNTNER, Minor, by Michael E, Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNTNER and MELODY UNTNER, : IN IHE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 95-4912 CIVIL TERM CIVIL ACTION - LAW Plaintiffs v. TlMOIHY L WELLS l Defendant ORDER AND NOW, this n~y of ~v , 1995, it is ordered and decreed that Michael E. Untner and Melody Untner are hereby authorized to pay: (1) the amount of $39,872,14 for the purchase of one van outlined in Exhibit OBO and (2) pay to Melinda Piper for the care of Danielle at the rate of $5,50 per hour, not to exceed 6 days per week, at 8 hours per day, for a period not to exceed one year, to be paid bi- weekly. AND FURTHER, PNC Bank Is authorized to release the sums herein indicated based on the terms indicated, BY IHE COURT: /.5/ M...;... a.. . )k-a.-l J. DATED: T""'= r"'''''' C:I"'"I\~ R':CClRD ".. - h d , T--t'. .' . ,.. 1....l..,.~tmy an .:1 -" " ., ~;,d ~th~ sLal 0; :..J:d CO\.II: lit CJ:;i~;~, Pa. This .2'7 t/... day 01 W.., 199.s:: .............# ~~r~r~ofa:v~......... EXHIBIT "B" II/clil/elle. Sla/rLlFT. Model SC 'INCLlN-A70R. Sla/rLlFf. Model SL INCLINA'roR COMI'ANY 0... AMERICA 1'.0. Box 1557.2200 1'..lon Slre<I, lIarrisburg, I'A 17105 U.S.A, Thl<phone: (111) 234.8065 Fax: (717) 234.0941 " July uate 10, 1996 Melody Linter 14tiJ l'lne Koad Carlisle, l'A llUIJ One Incl inet te Please enter .IllY order for 10 601 1 PI' I 1 ' C 't Z:lU 1d 1 v., lZ., i.,n . in dl apacl YMe I oay Pe~\-rYer, 14 63 1'1 ne koad, Cad I:; ~w~cnl'A.o ~'u'f~lIe n ---------- 4,846.68 X^A^^~^^^^^~ on or about , and I agree to pay tye~BuS 00 ' for equipment only, or including the charge for installing, a deposit of S ' . to be paid upon the acceptance of Ihis order, and the balance when the installation has becn made. One Right Hand Inclinette, operating from 1)ipc basement to first floor. 4,640.00 , S Finish of IncUnelte or INCLlN-ATOR Car Beige (SlairLlFT car, rail, and motor hood finished in Brown only) (Model SC car and rail finished in Beige only) Locking swivel scat, back & arm rest, Special Altachments and scat belt. M' II . Motor to be located under basement stairs. Isce aneous Pennsylvania Sales & Use Tax is included in the above price. 4,640.00 Thtal, S Deposit Paid, Installation complete is included in the price except Ihat purchaser is to provide electrical outlet, as directed. Balance, S In default of paying upon completion of installation. Selling Company shall have full right and power, at its option, to enler upon Ihe premises, or wherever said above mentioned material may be found, without process of law, and take and remove said property, the title of said merchandise to be and remain in said Selling Company until paid for In full, This order covers all agreements between the parties hereto relalive to Ihe lransactlon, and Selling Company shall not be bound by any representation or promises made by any salesman relative to this transaction, which Is not embodied herein, This order is taken subject to Ihe approval of, and contingencies beyond lhe control of, the Selling Company, Urn lied Warranl)' fUrnished wllh equipment or upon specla' request Accepted this INCLlNAlOR COMPANY OF AMERICA Day of .19_ Pu..haacr By Oy KIOIIBIT "0" VBRII'ICATIOH I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. section 4904, relating to unsworn falsification to authorities. \-O""'JC~ Q. ~~~ DATE: 8 J 0 Cfle .. r:, "", I u'" (""J c u' I~ . u (. ,"':'. " ll. I ." " ,,' L: '" @ a .. . .. - . ... \)0 ..."... (....,... f"'" '"' .,1_ ~. .. 11I'1\" ...."1 (~nllll ""t ,'Il'" ')' _..1 ,"'411;""..., ,..tc..,_""....... .- !\,'^Nt". \/v.'\.(jNtH .UH~iHt)o.~ 'lilll ... 't....... " . ~ Ii>- w ...J ~ 0 Z ...J ~ ~ Cl ~ . ... . ~ Ql j . c W .. ~ ci ~ . >- i It Ww " j :Io(:r .. en Ul/) ~ ii Za: ~ It ... C <(W ... z ~:r " ....-.....,...."" 10 ..", '." ..,,, '..~, r..._< .""." '.t..' -. ....,.., ......~ ,... w.o' .. ...,...,. &'........~ .. ..t..... 1 , '. DANIEu.E N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her paren1ll and natural guardians, and MICHAEL E, UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 95-4912 CIVIL TERM : CIVIL ACTION. LAW Plaintiffs v, TIMOTHY L WELLS Defendant ORDER . AND NOW, this ~ day of N.~ , 1996, It Is ordered and decreed that PNC Bank Is authorized to release the sum of $1,522.67 to the Department of Welfare as reimbursement for medical bills that have not been provided by other Insurance providers. BY THE COURT: DATED: jro/li J. ""r"... r'-H',~- ,. .", 11'_'." .. '. . -",:' '", ' '. ~ ..' ""...:1 L., ,. ,~ \ :.',r;'/ .. ":"(': ". . ~ DANIElLE N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 9~912 CIVIL TERM : CIVIL ACTION - LAW Plaintiffs v. TIMOTHY L WELLS Defendant t'l:1111ON FOR RElEASE OF FUNDS OF MINOR SET1l.EMENT 1. The Plaintiffs In the above-captioned case hereby petition the Court for payment from settlement, which was approved by Your Honorable Court on October 16, 1995 and a copy of said approval Is attached as exhibit "A", 2. The sum of $135,702.00 has been deposited In PNC Bank pursuant to Court Order. 3, Various medical bills have been paid by the Department of Welfare which has requested reimbursement of the medical bills which total $2,030.23, A summary of those bills which are not COY8red by other health care providers Is attached hereto and made a part hereof as exhibit "B", 4, The Department of Welfare has authorized the reduction of 25% for counsel fees which Is being waived by Mancke, Wagner, Hershey & Tully so that the amount due to the Department of Public Welfare as reimbursement Is $1,522.67. , WHEREFORE, your Petitioner prays Your Honorable Court to authorize PNC Bank to pay the Department of WeHara the sum of $1,522.67 as reimbursement for medical bills that have not been provided by other Insurance providers. Respectfully submitted, MANCKE, WAGNER, HERSHEY, & TULLY By John B, Attorney D. No. 07212 2233 North Front Street Harrisburg PA 17110 (717) 234-7051 DATED: II-IG-Q" ...n07 Attorney for Plaintiffs " . , VERIFICAllON I verify that the statements made In the foregoing document are true and correct. I understand that false statements herein are made subject to the penallies of 18 Pa,C.S. 94904, relating to unsworn falsification to authorities, ~d~ '& " Dated: /1 /;)/1~ DANIEUE N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E, UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO, CIVIL ACTION. LAW Plaintiffs v, TIMOTHY L WELLS DefBndant ORDER AND NOW, this L day of DL~~ ,1995, the settlement totaling $175,000 is hereby approved and the parents and natural guardians are authorized to sign any and all releases to give approval of this settlement and it is further ordered that the distribution outlined in Exhibit A of the Petition is approved and that the sum of $135,702 be deposited in the name of Danielle N. Untner, minor, by her parents and natural guardians, Michael E. Untner and Melody Untner, and such amount shall be deposited in one or more savings accounts in the name of the minor in a bank, building and loan association, or savings and loan association, whic~ deposits are insured by a federal govemment agency, It is further provided that the amount deposited in anyone such savings institution shall not exceed the amount to which the accounts are insured and further orderBd that no withdrawal can be made from any account until the minor, Danielle Untner, has attainBd her majority except as authorizBd by prior Order of the Court. It Is further ordered that proof of the deposit shall be promptly filed of record with the Prothonotary. TRUE COpy FROM RECORD In TCSll:il'lny \\'~I~if:'~1 i h~re U'1!O set my hand ~,ll1the Scal III Qid CCoU(tal C.lli"e 0.. Tn ~~,; ~. ,r~. :)(Jft. . -l:9~ PrOlhor.Olary By the Court, 5 P:::e./.4 A-::ib 5 Exhibit "1\" J. DATE: 10/08/96 COMMONWEALTH OF PENNSYLVANIA oEPARIMENT OF PUBLIC WELFARE .._~._---_.- ,.-...... -"'.'-'-'...--." ..-.+.-..---..--.--..----.... STATEMENT OF CLAIM '- ~~~~~~:5~~AN_I:L~__~~~__ MEDICAL USUAL ClIAlIGU AIWlT AI'HOVED 4,015.90 2,030.Z3 CASH PUIQI CXl\/OED DOLLAR MDl,IIIT 0.00 I TOTAllElllIIIISEIlEIlT, TO 0PIl 2,03Q,Z3 I Exhibit "B" '-. .-....-.-.-..-..-.- .---..- r~-- --._.--._...~._~---- DATE: 10/08/96 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE STATEMENT OF CLAIM l---j--' n_' n__'_ n___ ,- NAME LINTNER. OANIELLE 10 B70129557 - ._.~.._---_.- ~-_._-- ._._---_...._--~.__.---_.- HMC FAN & COMM MEO OEPT 500 UNIVERSITY DRIVE P D BOX 854 HERSHEY . PA 17033 DATE OF --I-- -;;MENT----r- ~1~1~~L--l----:;;USTEO--[-~~L----1 SERVICE DATE CRN CRN CHARGES --~--- ---- ~- --~- -- ---- -. -~ ~ - ---~- ------- AMOUMT APPROVEO -1 07/10/95 - 07/10/95 07/27/96 0202,30029/01 5200260092/01 6S,C~ 25.00 DIAGNOSIS I: 85140 - CEREBEL/BRAIN_STM_CONTUS PROCEDURE : 99213 - OY/OP VST FOR EVAL & MGMT OF ESTAB PAT. PROB-LOW TO MOO SEVERITY 15-MIN FAC-FA 11/21/95 - 11/21/95 07/27/96 6202230030/01 5345170813/01 6S.00 2S.00 DIAGNOSIS I: 85400 - BRAIN_INJURY_NEC PROCEDURE : 99213 - OY/OP VST FOR EVAL & MGMT OF ESTAB PAT, PROB-LOW TO MOO SEVERITY 1S-MIN FAC-FA 05/13/96 - OS/13/96 06/10/96 6143211042/01 0000000000/00 40.00 20.00 OIAGNOSIS I: 85400 - BRAIN_INJURY_NEC PROCEDURE : 99212 - OY/OP VST FOR EVAL & MGMT OF ESTAB PAT. PROB-SELF LTO OR MINOR 10-MIN FACE-FAC PIOVIDft SUI tOTAL HMC FAN & COMM MEO OEPT 01-0663531 170,00 70.00 .1..- ----- --.-- [- - - - DATE: lD/08/96 --------_._-----~-~. --~. COMMONWEALTH DF PENNSYLVANIA DEPARTMENT OF PUBLlt WELFARE .. .__~.___...___._.___._.___.___m.__ STATEMENT OF tLAIM 8- -- --- NAME LINTNER, DANIELLE ID B70129557 - ---- - --------- - --- - - -~ tlMt NEUROLOGICAL SURG DIV 5DO UNIVERSITY DRIVE POBOX 854 HERSHEY . PA 17033 ~:~~I~: I~~~: I__OR~_~~~~L_J~--_~~~~T;;-I_-~_~~~S_-~=I =D_ 06/21/95 - 06/21/95 07/27/96 62D2230031/01 51792~17;/01 69.00 25.00 DIAGNOSIS I: 85400 - BRAIN_INJURY_NEt PROCEDURE : 99213 - DV/DP YST FDR EVAL & MGMT OF ESTAB PAT. PROB'LOW TO MOO SEVERITY 15-MIN FAt'FA 04/01/96 . 04/01196 04/29/96 6102220188/01 0000000000/00 89.00 20.00 OIAGNOSIS I: 85400 - BRAIN_INJURY_NEt PROCEDURE : 99214 . DV/DP VST FOR EVAL & MGMT OF ESTAB PAT, PR08-MOO TO HIGH SEVERITY 25-MIN FAt-F 05/13/96 - 05/13/96 06/10/96 6143211041/01 0000000000/00 64.00 20.00 OIAGNOSIS I: 85400 - BRAIN_INJURY_NEt PROCEDURE : 99213 - OV/DP VST FOR EVAL & MGMT OF ESTAB PAT. PROB-LOW TO MOO SEVERITY 15-MIN FAt-FA PIlIVIOh SW TOTAL 65.00 tlMt NEUROLOGICAL SURG OIV 01-0665142 222.00 -. _._-~.~--- '....--.. DATE: 10/08/96 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE -'-'-:'-.---'------------1 _,_ _________________J STATEMENT OF CLAIM [~:~l~_~~~~;7DANIEL~E_~~~ - - ] HMC PEDIATRIC SURGICAL 01 5DD.UNIVERSITY DRIVE POBOX 854 HERSHEY . PA 17033 ::~~I~: P:::NT _1_ ~~,~A~-_-~[ ~~~E:_~[=~c~~_ -1 05/03/96 - 05/03/96 05/27/96 6131~3D99f/01 0000000090/00 36,09 DIAGNOSIS 1: 9974 - SURG_CCJ4PLIC-GI_TRACT DIAGNOSIS 2: 6829_ - CELLULITIS NOS PROCEDURE : 99211 - OV/OP VST FOR EVAL & MGMT OF ESTAB PAT. PRDB-MINIMAL 5-MIN AIWN;j APPR~j 16.50 , l'ROVlOU .. TOTAL HMe PEDIATRIC SURGICAL OJ 01-0665652 36.00 16.50 . LAT~~--'O~;% - _==-_~_~-_=_____ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE STATEMENT OF CLAIM ~-~~~l-LINT~~R' DANIEL;; ID 87D129557 ------ - -~-.--l PlIOVIOU SUBtOTAl. HMC RADIOLOGY DEPARTMENT 01 -0667147 75,DD 7.5D .. DATE: 10/08/96 COMMONWEALTH Of PENNSYLVANIA DEPARTMENT Of PUBLIC WELfARE STATEMENT OF CLAIM r~AM~1 LINTNER, DANIELLE 1...1~._8_7012955 7 KREAMER PHARMACY INC 19 SOUTN MARKET STREET ELIZABETHTOWN . PA 17022 -- -- .. DATE OF -I"--~~~~~ -. f. "-;'~I;AL -j-- SERVICE DATE CRN -- ------ -------- ~--- - - - - ...- .n]_........ .-.. ---.'.'---1.---.-'.-----.'....-- ADJUSTED USUAL AMOUNT CRN CHARGES APPROVED - ~.- ---.------.-. _..,-~- -------- -.. 06/07/95 - 06/07/95 lD/C9/95 ~236700507/D4 OOOOOOQOOO/OO DIAGNOSIS I: 8030 - CLOSE.SKULL.FRACTURE.NEC PROCEDURE : 84036 . ENTERAL fEEOING SUPPLY KIT;GRAYITY FED PER OAY n5,OO 33,75 06/07/95 - 06/07/95 11/13/95 5304120142/01 0000000000/00 DIAGNOSIS 1: 8030 - CLOSE.SKULLJRACTUllE.NEC DIAGNOSIS 2: 7883. INCONTINENCE OF UllINE PROCEDURE : Z4629 - INCONTINENCE PANTS.DISP EACH PR n.oo 0.55 06/07/95 - 06/07/95 DIAGNOSIS 1: 8030 PROCEDURE : Z0241 10/09/95 5236200507/02 - CLOSE.SKULL.FRACTURE.NEC - REHAB SHOWER COMMODE CHAIR 000??oo000/00 455.25 113.81 07117/95 - 07117/95 10/02/95 525n21n8/01 ??oo00??oo/00 78.75 15.75 DIAGNOSIS 1: 8OJO - CLOSE.SKULl.FRACTUllE.NEC PROCEDURE : 84150 - ENTERAL FDRMULAE;CATEGORY I;SEMI-SYNTHETINTACT PROT/PROTEIN ISOlATES 100 CL.1U 01/09/96 - 01/09/96 OIAGNOSIS 1: 8030 OIAGNOSIS 2: 7883. PROCEDURE : K0133 . 06/03/96 6143130034/01 - CLOSE.SKULL.FRACTURE.NEC INCONTINENCE Of URINE INTERMITTENT URINARY CATH.DISPOSABLE; o00ooo0000/00 73.50 73.50 STRAIGHT TIP 01/16/96 . 01/16/96 04/29196 6096141799/01 DOODOOOODO/OO 41.04 29,40 DIAGNOSIS 1: 0030 - CLOSE.SKULL.FRACTURE.NEC OIAGNOSIS 2: 7883. - INCONTINENCE Of URINE PROCEDURE : 84150 - ENTERAL FORMULAE;CATEGORY I;SEMI-SYNTHETINTACT PROT/PROTEIN ISOlATES lDO CL.1U 02/05/96 - 02/05196 05/13/96 6121110430/01 ?o?ooooooo/00 27.36 5,47 DIAGNOSIS 1: 8030 - CLOSE.SKULL.FRACTURE.NEC OIAGNOSIS 2: 7883. - INCONTINENCE Of URINE PROCEDURE : 84150 - ENTERAL fORMUlAE,CATEGORY I;SEMI-SYNTHETINTACT PROTIPROTEIN ISOlATES 100 CL.1U PlICMOR .. TOTAL KREAMER PHARllACY INC 19-0ll68548 J w_~ I 2n,23 r-" .--.-'-.-..-.-.------.. ..-.....- ~._.---..- ----.---.,-..,.-,. --.. ...... DATE: 10/08/96 COMMONWEALTH OF PENNSYLVANIA OEPARTHENT OF PUHLIC WELFARE Ln. u___. ______"___.__ .._un STATEHENT OF CLAIH NAME 10 ~~::::;7~ANI~~.~~-~_~J OEPT COHH & HHS CARLISLE CARLISLE NOSPITAL 246 PARKER ST PO BOK 310 CARLISLE . PA 17013 ORIGINA~] AOJUS~ CRN CAN ~_._.._---- ----- 11/29/95 .. 11/29/95 05/13/96 6116886703/02 0000000000/00 DIAGNOSIS: 80320 .. CL_SKL_FX_NEC/HENING_NEH PROCEOURE: W0939 .. HOKE HEALTN AGENCT VISIT TO PATIENT'S DATE OF SERVICf PATHENT OATE USUAL CHARGES 540,00 HOKEI29TN OAT & BETONOIBT HOKE HLTH AI 12/28/95 .. 12/28/95 05/13/96 6116886703/03 0000000000/00 480.00 OIAGIIOSIS: 80320 .. CL_SKLJX_NEC/HENING_HEH PROCEDURE: W0939 . HOKE HEALTH AGENCT VISIT TO PATIENT'S HOKEI29TH OAT & BETONOIBY HOKE HLTH AI 01/30/96 .. 01/30/96 05/13/96 6116886704/01 0000000000/00 480.00 DIAGNOSIS: 80320 . CL_SKL_FX_NEC/HENING_HEH PROCEDURE: W0939 . HOKE HEALTH AGENCT VISIT TO PATIENT'S HOKEl29TH OAT & BETOIIOIBT HOKE HLTH AI 02129/96 .. 02/29/96 05/13/96 6116886704/02 ?0ooooo000/00 540.00 DIAGNOSIS: 80320 . CL_SKL_FX_NECIHENING_HEH PROCEDURE: W0939 . HOKE HEALTH AGENCT VISIT TO PATIENT'S HOKEI29TH OAT & BETOIIOIBT HOKE HLTH AI 03/28/96 .. 03/28/96 05/13/96 6116886704/03 0000??oo00/00 480.00 DIAGNOSIS: 80320 .. CL_SKL_FX_NEC/HENING_HEH PROCEDURE: W0939 .. HOKE HEALTH AGENCT VISIT TO PATIENT'S HOKEI29TH OAT & BETONDIBT HOKE HLTH AI l'ICMllP SUI TOTAl. OEPT COHH & HHS CARLISLE 23-0961373 2.520.00 --I AP: J 333.00 296.00 296.00 333.00 296.00 1.554.00 - f --... -..---..-...... _..-~.._. .-.--..-------. l- -- -- - DATE: 10/08/96 --------------.-- COHMDNWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE STATEMENT OF CLAIM ..._-~--_.._._.__._-_._------_.... [ ~:E l~~i:~~;7~AN~E~~E_~~~~-__J ALEXANDER SPRING REHAB IN 27 BRllDKIIOlXl AVENUE CARLISLE . PA 17013 ;-;-GINAL---l_ AOJU~TEO -r USUA~-l CRN CRN CHARGES ------- .------ 08/19/96 - 08/19/96 09/16/96 6249180521/01 0000000000/00 110.00 DIAGNOSIS: 90082 - INJ_MLT_HEAO/NECK_VESSEL PROCEDURE: 92506 - MEDICAL EVALUATION SPEECH,LANGUAGE AND/ OR HEARING PROBLEMS DATE OF SERVICE PAYMENT DATE , PiIlVIOER SU8 MAL ALEXANDER SPRING REHAB IN 50-1555314 110.00 AMOUNT APPROVED -1 I 45.00 45.00 I~ . ( " ') ) \ "_, I' I; "", Ii>- W ..J loa Z 5 m:: Cl I- ... <( - ~~~i~ ~ ~~ U U Ul ft it Z II :; ~ <(W"X ~:r " MAR ..,/ m l 7 J99/1'J ~"'l'..'r'lt.:="',~ ~ ~"IiIl" .... D&!C-M!III ~...-= J:..i. ~ ..~ .. _, 00 "."f.~ C'lI"t'" h."t 'Nt "'tHo.... IS " llllOf "NO C~ "I{.t (:011I" 0'- '"t ('lAtQt""l '-Il.n ... ,... AI. '... .. , MAN<'~ I 11'. AGNf H HfflSHf Y 110 1 UU Y .. fff#iMf.,. ''-' DANIEu.E N, UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians. and MICHAEL E. UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. 95-4912 CIVIL TERM CIVIL ACTION - LAW Plaintiffs v. TIMOTHY L WELLS Defendant AND NOW, this L day of that PNC Bank Is authorized to: ORDER 4",,,'/ f ,1997, It Is hereby ordered and decreed 1. Release the sum of $916.00 as reimbursement for the costs of Insurance on the handicapped van to Michael E. and Melody Untner. 2. Pay the sum of $544,00 to the IRS and $120,00 the PA Department of Revenue for payment of the taxes due for the calendar year of 1996, which taxes total $664,00, 3, Payment for the substitution, when necessary, of Mary Coopar ($5,50 per hour) or Unda Cooper ($5,50 per hour) or a nurse's aide of Cumberland Crossings, Carlisle Hospital ($14,00 per hour), not to exceed six days per week, eight hours per day, for a period not to exceed September 9, 1997, to be paid bi-weekly with the understanding that Melinda Piper remains authorized pursuant to the previous court order, DATED: BY THE COOl I}/c _ J. -, <:e" f'\C~'~~ 1-11~~I"':~). rl\.,.lC ......:. ... .~ " r. ",' ....., ,'\-, f"'I'( '...,.:: "... -, .'.. 1...~., 9HP2-! b.iill:50 r, . > \...i.....:_~__\ .~.' ~ ,_ .~/....;.. ;\,' Fc.i'JN::'YL\lf\:\~'\ DANIEUE N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNlY, PENNSYLVANIA : NO, 95-4912 CIVIL TERM : CIVIL ACTION. LAW Plaintiffs v. TIMOTHY L WELLS Defendant t't: ",ION FOR A:I r:ASE OF FUNDS OF MINOR SETTl.EMENT 1. The Plaintiffs In the above-captloned case hereby petition the Court for payment from minor settlement, which was approved by Your Honorable Court on October 16, 1995 and a copy 01 said approval Is attached as Exhlbh "A", 2. On October 27, 1995, Your Honorable Court entered an Order, a copy of which Is attached hereto as Exhlbh "B", allowing for the payment for the care of Danielle for Melinda Piper at the rate of $5,50 par hour, not to exceed six days par week at eight hours par day, for a period not to exceed one year and to be paid b1-weekly. 3. On September 9, 1996, Your Honorable Court entered an Order, a copy of which Is attached hereto as Exhibh "C", pennittlng the extension of the payment for the care of Danielle at the rate of $5,50 per hour for Melinda Piper. 4. On November 20, 1996. Your Honorable Court entered an Order authorizing the reIea8e of funds to the Department of WeIfara, a copy of which Is attached as Exhibh "0". 5. Your Petitioner Indicates to Your Honorable Court that there are times when Melinda Piper Is not available to care for Danlelle and desires the flexibility of substituting Mary Cooper, grandmother, who was a nurse assistant for eight years, and/or Unda Cooper who Is an aunt and a nurse's aide for nine years, and/or nurse's aides of Cumberland Crossings, Carlisle Hospital, to substitute when Melinda Piper Is unavailable. The rate of Mary Cooper and Undll Cooper would be $5.50, however, the nurse's aides of Cumberland Crossings would be at the rate of $14.00 per hour and would only be used if none of the others, Including Melinda Piper, were unavailable. 6. In addition, Your Petitioner Indicates that an amount for taxes Is due for Danlelle Untner In the sum of $664.00, which proposed tax retums are attached hereto es exhibits "E-1" to "E-3" and "F.1" to "F-2", 7, In addition, Your Petitioner has been required to pay the sum of $916.00 for the cost of Insurance on the handicapped van and Is requesting reimbursement of $916.00 which was expended for the handicapped van and which would not have been necessary except for Danlelle's condition, A copy of the premium bill Is attached hereto es exhibit "0-1" to "0.2". WHEREFORE, your Petitioner prays Your Honorable Court to enter an Order authorizing: A. Pennisslon to substitute, when needed, Mary Cooper, Uncia Cooper, or a nurse's aide from Cumberland CrossIng at the Carlisle Hospital, and authorizes the payment for Mary Cooper and Unda Cooper at the rate 01 $5.50 per hour and the rate of $14.00 per hour for a nurse's aide from Cumberland Crossing under the circumstances where Melinda Piper, Mary Cooper or Uncia Cooper are unavallsble. The hours are not to exceed six days per week, eight hours per day, not to exceed the period ending September 9,1997 and to be paid b1-weekly. 8, PermIaslon to relmburae Petitioner for the payment 01 $916.00 oIlnaurance for the handIeapped van. . C. Permission for payment to Petitioner of $664,00 for the payment of Danlelle's taxes for the past calendar year. Respectfully submitted, MANCKE, WAGNER, HERSHEY, & TULLY DATED: ~..p5-41 .,... By \CL John B. \4ancke, Esquire Attorney I,D. No, 07212 2233 North Front Street Harrisburg PA 17110 (717) 234-7051 Attorney for PlaIntiffs DANIEUE N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E, UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PlEAS : CUMBERLAND COUNlY, PENNSYlVANIA NO, CIVIL ACTION - LA.W Plaintiffs v. TIMOTHY L WELLS Defendant ORDER AND NOW, this L day of DL~~ ,1995, the settlement totaling $175,000 Is hereby approved and the parents and natural guardians are authorized to sign any and all releases to give approval of this settlement and it is further ordered that the distribution outlined in exhibit A of the Petition is approved and that the sum of $135,702 be deposited in the name of Danielle N, Untner, minor, by her parents and natural guardians, Michael E. Untner and Melody Untner, and such amount shall be deposited in one or more savings accounts in the name of the minor In a bank, building and loan association, or savings and loan association, which deposItS are insured by a federal government agency. It is further provided that the amount deposited In anyone such savings institution shall not exceed the amount to which the accounts are insured and further ordered that no withdrawal can be made from any account until the minor, Danlelle Untner, has attained her majority except as authorized by prior Order of the Court, It Is further ordered that proof of the deposit shall be promptly filed of record with the Prothonotary. TRUE COpy FROf\., RECORD . In Tcstlm!)ny ~:J~n:'~f, i h':fll u'llil set my hand , ,"1d the seal 01 ~Jd CliUr at C'rl,'cle 0.. T ';s.... .. .. , r", C 19 By the Court, .5 I JC::~t. A-:iks s 1/ J. Exhibit "A" , .'..'- .'. . .~RISBURO. PA 17110 i.' ATTORNEY .' ..... ATTORNEY :'..k_n . ,-i<~. ,. '..'._.4,'_"" DANIEu.E N, UNTNER, Minor. by Michael E. Untner and Melody Untner. her parents and natural guardians. and MICHAEL E. UNTNER and MELODY UNTNER. IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. 95-4912 CIVIL TERM CIVIL ACTION. U.W Plaintiffs v. TIMOTHY L WELLS Defendant AND NOW. this ~~ay of ORDER tr2c::t.~,-, ,1995. it is ordered and decreed that Michael E. Untner and Melody Untner are hereby authorized to pay: (1) the amount of $39.872,14 for the purchase of one van outlined in Exhibit "B" and (2) pay to Melinda Piper for the care of Danielle at the rate of $5.50 per hour. not to exceed 6 days per week, at 8 hours per day. lor a period not to exceed one year, to be paid bi- weekly, AND FURTHER, PNC Bank is authorized to release the sums herein indicated based on the terms indicated, BY THE COURT: IV ~'\.~.~ (i. ).\.:.4..v' J. DATED: . ~ Exhibit "8" .) '1 t~ '. (.C ( t ~~h.J,l. 6. ' cr 2':1" . :/...., r-"J- h o:il.;. ,Ci i <}.)' HARRISBURG. PA 171 10 , ... TTOR~.EY -.:.., DANIEUE N. UNTNER, Minor, by MichaElI E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNTNER and MELODY UNTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO, 954912 CIVIL TERM CIVIL ACTION. LAW Plaintiffs v, TIMOTHY L WELlS Defendant ORDER AND NOW, this !J!!Lday of ~d;.......!... '-' ,1996, it Is ordered and decreed that Michael E. Untner and Melody Untner are hereby authorized to pay: 1, Melinda Piper for the care of Danielle at the rate of $5.50 per hour, not to exceed 6 days per week, at 8 hours per day, for a period not to exceed one year, to be paid bi-weekly, 2. The amount of $25,956.00 for the bedroom addition and the handicapped accessibility, 3, The amount of $4,640.00 for one Incllnette. AND FURTHER, PNC Bank is authorized to release the sums herein Indicated based on the terms indicated. BY THE COURT: -L/ . J,~I fL.,I....__ 6.,~ J. DATED: - 'I' ~ .~,.. .'\,' ;.:~,l:'\.' ;~~.~~D j ~ ,; l -', ~ - ,-' i 1-, ,'l~.itJ ,. . \" . ~ : ,- , ':: ~: C I' ' j"',l. 1'1' q.ti.. t ; } CJ." c, IJ ( " Exhibit nC'n '~dL~ ;h:J C( ~d.., 1? 9b ),) , ( -",/" '- I'ro:hc<'ot:ry . :r:r1J NOf'ITH '"OHT .",IIT HARRISBURO. pAt, 17110 ...nORNEY DANIELLE N, LINTNER, Minor, by Michael E, Lintner and Melody Lintner, her parents and natural guardians, and MICHAEL E. LINTNER and MELODY LINTNER, IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. 95-4912 CIVIL TERM CIVIL ACTION - LAW Plaintiffs v, TIMOTHY L WELLS Defendant ORDER ~ AND NOW, this :JD day of .J:J. cn1t-".J,..v , 1996, it is ordered and decreed that PNC Bank Is authorized to release the sum of $1,522.67 to the Department of Welfare as reimbursement for medical bills that have not been provided by other insurance providers, BY THE COURT: I~/ "ktVh; a.. ~ J. DATED: TR!l1: COpy FROM RECORD In T .:" > "., .. f. . r of I L . ..... >. t . r:<r.> l!"t1 ~t my hand aru Ih. '>J: of s~;d Court at Carlisle Pa . 4 . . Th.s:lt dJY of J(C1r: ...., 19Y~.. .,............"~~t~ r, ,'\.~~ ....... ._n.\-\... ,..0__ t/_ ..0\(..__ ,lJfi Prothonotary l'xhibit "n" HO..... a3~1I 1""J"T'b'r Pltl'~l~" yO", e.:i 0 boa u. tl~ ,~ Cotr !OW'lO' res' Ofl". "yOl,lll.1".. ';)'.7" 100.tll. SoH Pig. 1!l ~JLI.5(F Presidential Election Campaign Fund (See page 15,) Do you want S3 to go to this fund? . . . . , . . . If a 'oint r rn, does our spouse want S3 to 0 to this fund? 1 Single 2 0 Married filing joint return (even if only one had income) 3 0 Married filing separate return. Enter spouse's social security number above and full name here. ~ 4 0 Head of household (with qualifying person). (See page 16,) If the qualifying person is a child but not your dependent, enter this child's name here. ~ 5 0 Qualifying widow(er) with dependent child (year spouse died ~ 19 ). (See page 16.) 6a 0 Your..lf. If your parent (or someone else) can claim you as a dependent on his or her tax retum, do not } check box 6a. b 0 Spouae C Dependents, If more than SIX deDenden~s. see page 17. (21 Dependenn, so=:al (3) De;)endenl's (4) N::l. of se:iJflty number. If born In relationshIp months lved .. your Dec. '9*. see pa~ 18. to )'OU !'lome 10 1996 rO'rll 1049A label L . o E L H E . E IRS U" Only-Do no1 wlIf. Of ,lapl. In lhl' space, OMS No, lS045.0085 ~ ~ [jjjjjjjTI Depa.,."c", Ci' tile Tlel'l!.ury-lnlernal Rht'nve !)(>fVtCe U.S. Individual Income Tax Return 1996 (H) ,See [.Iaoe '5 I Use the IRS I.bel. eD~ pnnl In ALL CAPfT AL LEnERS. Oth.rwl~, 'f.."t".......'t I",' 1.11'1'''-' L/" fy. r,- :()I~/'-< I 'v' t1't:""l'"''''IJ''' '''''JU'' f,.., f\...... 11'1.1 L.Ur...... "'" ., Yes No 1 F.fSI namf 1.asl r:a.'T\f I I I d Total number of exemptions claimed. . . . . . . . . , . . , , 7 Wages, salaries, tips, etc. This should be shown in box 1 of your W-2 form(s). Allach Form(s) W-2. 8a Taxable interest income. If over S4oo, attach Schedule 1. b Tax.exe:n t interest. DO NOT include on hne 6a, 8b S 9 D,,,,dends, If over S400. attach Schedule 1. lOa -- ~ -- ~ ~ -- ~ -- ~ ~ ~ -- ~ -- ~ -- ~ -- -- ~ Total IRA distributions. 11 a Total penSions and annUities. 10aSITIJJll] 11aS[I[Jllll 10b Taxable amount (see page 20). 11 b Taxable amount (see page 20), 12 13a Unemployment compensation, Social security [[[[[]]] benefits, 13a S Add hnes 7 through 13b (far ri hI column), Your IRA deductIOn (see pa e 22). 13b Taxable amount (see page 22), 14 15a Th,S IS your total income, 15a$ 15b$ I I 16 b Spouse's IRA deduction (see page 22), c Add lines 15a and 15b. These are your total adjustments, Subtract hne 15c from line 14, Th,s IS your adjusted gross income. If under $28.495 (under S9,500 " a chIld did not lIVe with you), see the ,nstructlons for line 29c on page 29, ~ Attach Copy B of 1'1.2 and 109g.R here, c., ~o "3,,. I'.xhi.bit "E-'" For Privacy Act and Paperwork Reduction Act Notice, see page 9, ate: Cheching .Yes' will not change your lax or reduce ur refund. No. ot boa.. check.d on lines e. and 6b No. of your chlldr.n on Un. Ie who: . tind wtth you D IT] . did not II.... wtlh you due to dlvorc. or ..paration IT] t!\~~ pa5l~ 18) Oe-pendentl on Ie not IT] entered above Add numbon entered in IT] . . .. boa.. abo.. :a:~ ~ g S[[[[[]]] 10bS[[[[[]]] 11bS[[[[[]]] 12 S[[[[[]]] 13bS[[[[[]]] 14$~ 15cS ITIIIIJ 16 Sm.,!, I, rn _':<f"jl! , . 1 \191 Form 1040A page , 1996 Form 1040A page 2 17 $ DI:f2]Jl[E] 19 Enter the amount from line 16. Check { 0 You were 65 or older 0 Blind } Enter number of If: 0 Spouse was 65 or older 0 Blind boxes checked ~ b If you are married filing separately and your spouse itemizes deductions, see page 26 and check here . . . . . . . . . . . . . . . . . ~ 18b 0 Enter the standard deduction for your filing status. But see page 26 if you checked any box on line 18a or b OR someone can claim you as a dependent. e Single-4.000 e Married filing jointly or Qualifying widow(er)-6,700 e Head of household-5,900 e Married filing separately-3,350 Subtract line 19 from line 17. If line 19 is more than line 17, enter O. Multiply $2,550 by the total number of exemptions claimed on line 6d. Subtract line 21 from line 20. If line 21 is more than line 20, enter O. This is your taxable Income, II you want the IRS to figure your tax. see page 26, ~ 22 17 18a 18aD 20 21 22 19 $ 20 $ 21 $ $~ 23$~ 23 Find the tax on the amount on line 22 (see pa e 26 . 24a Credit for child and de en dent care ex enses. Attach Schedule 2. b Credit for the elderl or the disabled. Attach Schedule 3. c Add lines 24a and 24b. These are your total credits. Subtract line 24c from line 23. If line 24c is more than line 23, enter O. Advance earned income credit payments from Form(s) W-2. Household employment taxes. Attach Schedule H. Add lines 25, 26, and 27. This IS our total tax. 29a Total Federal income tax withheld from Forms W-2 and 1099. 24a$ 24b$ I I 24c$ 25 $ 26 $ 27 $ ~ 28 $ 25 26 27 28 29a$ 29b$ 29c$ I I b 1996 estimated tax pa ments and amount apphed from 1995 return. e Eamed income credit Attach Schedule EIC iI ou have a Qualifyin chlid. Nontaxable eamed income: amount ~ $ and t e ~ d Add lines 2ga. 29b, and 29c \00 not InClude nor.lo:::a:,le earned income). These are your total payments. ~ 29d$ If lone 29d IS more than line 28, subtract line 28 from line 29d. This is the amount you overpaid. 30 $ Amount of line 30 you want refunded to you. If you want It sent directly to your bank 31a $ account, see page 35 and fill in 31 b, c, and d. b Routing number 30 31a d Account number ITIJJJJJI] Ii: I Inri I U-I I I I 0 o Savings c Type: 0 Checking 32 Amount of line 30 you want applied to your 1997 estimated tax. 32 $o:=r1+rn 33 If line 28 is more than line 29d, subtract line 29d from line 28. This is the amount you owe, For details on how to a, includino what to write on our pa ment. see pa e 36. Estimated tax 34 $ $[[TIEEO] = = = = = = = = = = = = = = = = = 34 Sign here Uncief pe".a't,e1 ol oe'lI,1"\'. I de::tare that I havt f.aml~O In,s If turn at\d 3e::)"!'lp.a",y,ng scht-duteS and statements, and 10 the best of my knOW1f:Jgt ....a o.lI,t, t~ Iff trut. conK1. and 'cculale!)' t'st a! a.....o,J..~s and \ources of IncOtnt I r~ dUl'Ing 1he tar yla! Dt':::ar,lIO!"I 0' pr.glr., (other than lhe tllJtP'Y"fl IS b.seO on alllnlOll'nalfOl'l Of wrueh tl'te pf~atff "'.S AI')' _nowledgt ~ \,~.V~:'9:~'~, _ _ \ '. 0 '=~ ~r Ys~j'~ ~ -1 ~ pouU' !!o ~g".lur._ I' !o<nl return. QTH mu\l S'9" 'all" Soouw S OCCUOrIll()n Keep a copy of lt1lS return lor your records Paid preparer's use only ale ~ POepale- s .... Stgnature , Ch8C1o,1f ~tl!t-t"l~Y"dO [" F"l.m', name [0' ~'O,,'S ,I S6rl.e'Tlrin',..' ;1"'1 d:l,J'tS~ ~ ---- = = = 1916 Form 1040A pege 2 exhibit "E-2" Schedule 1 (Form 1040AI G"[;.lfpr.,," .,.... i." 1, .''. Interest and Dividend Income tor Form 1040A Filers 1996 (':'.'(1 . ,;, , . ,~r 'tour ~oclal 'iecunty number ", N,)rT'''''SI<;M()Wr'' jl' F.;...., ljl[1A F"-,t 1"(1 n"I". ..I';! U.f1lC~ /Ie L'rlrr-,,-.- Part I Interest Income (See pages 19 and 50.) Note: /I you receIved a Form 1099-INT. Form 1099-010. or substItute statement from a brokerage firm, enter the firm's name and the total mterest shcw" or ~"at form. 1 List name of payer. If any Interest IS from a seiler-financed mortgage and the buyer used the property as " personal residence, see page 50 and list thiS Interest firSt. Also, show that buyer's social secullty number and address. eJ'>J( r') r+ f\.., IC 1 $ $ 5 5 5 5 5 51 s' $ 5 2 $ 3 e 4 5 2 Ace :;' -;; :;-;...;-,~s ;;r ';re 1. 3 E.<c!ud;:cie 'rterest en senES ~= U S sa'.'ngs bends Issued after 1989 frem Form 8815. line 14. 'y'cu must Jttacn Fc.rm:S ~ S tc ~c.rm 1 C.1GA. 4 Subtrae: line 3 from line 2. Enter the result here and on Form 1040A, line 8a. Part II Amount ICj II I ! I H .;J.i c.i I Dividend Income ISee cages 20 1cd 50.1 Note: If you recelvea a Form 1099-01\1 or substItute stateme"t inm a brokerage fIfm. enter the'Ifm's "ar-:e a-:d U'e ~cta/ dl,;!cerds shewn on t!"3t f,=r"r. 5 L:st na<'1e of payer - == -- ~ = - 5 5 5 S S $ S S S $ $ $ $ $ == -- == ~ ~ -- ~ -- ~ -- == -- -- == 6 AdC ~r,t:> ;jr~0Uf't<.. 1.'- ".,,':; t:. ."r .,.... t, 6 $ 1996 Schedule 1 IF \.Hill 1040Aj ".~h::' ,~!~'~ ,,~ - '~n' . ~ :.....;\ r'o? ') For Paperwork Reduction Act Nohce. Sf?e FOfm H \OA Instruchons. . .. '__,S~....-.m"''f''~~,)I'<,.. )... .a.." Ddlibit "[;-3" o p.,"'f"4,""''''~'''.'I;JfJ'''' A,""our,t 'U ~, '>{ th.' ~E · PEN~!,!~!~~.!~""IW~,~~~'!m!M,!~!URN ~. ... YOU MUST FILE BY MIDNIGHT, TUESDAY APRIL 15. 1997'" Q.PA.40EZ 109.961 Common-Neatlh 01 Pennsylvania 1 996 PAOepanmenl01 Revenue R('~Il!"" ai, ,tit' tl'epllrltf'cl ,l'ItOfma!,on on your lat)el InCl platf I' In ,nt a'ta belo"," Make Ir'lr ntceSU'r COHt'Clfon!. on yOU' latH!1 and the,_ me SSNlNAMEiADDRESS Chino. bol belo.". EJ r- ,;).,,~,,~'.r~,I.j..rntltf ~DOu"'" ~:J(" ~',"", ',.-~..' ~..' 4 'r.",.. \tri,.'t.. TYPE F1L~,*'" Ontr Onel S ld"""" J 0 M 0 .."..r.... F 0 St(\Irlllt, """'edfMg~ '101'.11'''''..". 1:-01 f t.ClUH I'\t ta.Pfff'''M'U\t-: 'lilt' Il'It DI"" D..1t~ I q)( lo(, 'l '11 3 .n! '.JWt ,f~~"o~If'/I"O''V"'~,..,,:r/)l(l(t,'I(1~Jt./).jI'" /)~"'e ~~..., II"Mll' 1~\''''JV"\fIJ>1J'' ".. ,,:.,_,._..~r"I',,~.....&1,I.1'H';""..- on....~~.' ~ Lid T I~ t= R w ~ SI're! !tJ'"W' dJ~ It...,.. 0i<<11C ~PI"'t ofl'OI'3S, !:III....",...... w m\ r' O'ji) ~ <.1 l, 3 " IV': .... ~ R<<I~: ~f 'tIP.~r IW, N"" W. It $lNr,,,.,,,as Bol ......,t.. C ~ ~ . u4r{L:<.:lLf 1'1 AD'S.,. ".~HOOt~ . D/j J'''j SCHOOL 015 T CQOE :J./o5o Ct. iUWINl'llt'/OCllCHll"IIf.otdSl SIll! Zcc.:ldt Pi+ 1 u 1-'3 oP'OOH fOR'" Itl71OOIU.!T o :~"'. t'II",' ,.o~ ",.n nol....~~ a .~;~ 1'a. 6(J()O,I!' C.~RL I;' Lf" o SSNlNAME/ADORESS CHANGE l' ANY o'ttlt ,tlov' ,"11Y"'JI'~ Ii c%.ttffl~IItO"" WOY' \915 PA, t," ''''~Tr Cllte_II'llt 80. "r~' ""'tH :...,~;t'~ a'~c ~'O;o>:)f!"lt ......, '''Ie:! lot Codf 0' "'" C~\ IO....'l'It OtlouT 0' "'...."'t.'''l ffIIt'f rOw ~"'c:l o. '2)1 9f Ioj,a'llf :'c Coot PLEASE DO NOT ENTER CENTS ROUND TO WHOLE DOLLARS lC Net PA Taxable CompensaMn Subtract hne 1b !rom hne 13 la S . lb S . Ie S . 2 S '1 ~ C; I . 3 S . 4 S <./ d Cj I . 5 S I ~C, 6 S . 7 S , Ba TillS "lU'" mull be hIed an or belor. April 15 '997 1a Gross Compensation trom W-2 form(s) and other stalements ';'~,,:t ','. 2 '(J'~, 1: '.,,., ::a~' c'"',,,.. olo..;OEZ 1 b Unretmbursed Emplnvee Busmess Expenses Irom PA Schedule UE 2 PA Taxable Interest (Complele and attach PA Schedule A If over 51,0001 3 PA Taxable DIvIdendS (Complele and attach PA Schedule B II over 51,000) 4 TOTAL PA TAXABLE INCOME Add I,nes 1 c 2 and 3 5 PA TAX LIABILITY MJI!loly line': by 2.8..0 (0.0281 6 TOlal PA Tal Withheld tram W.2 lormlS) and other slatements 7 Tota! Estlmaled Paymenls and Credlls See instructIOns 8a Household Members tram PA Schedule SP. Pan II. hne 4 8b Your Eliglbihty Income tram PA Schedule SP, Pan It I. hne 2 8b S 8e Your Totallneome Irom PA Schedule SP. ParI III line 1 8e S , . , . \ .;Jo, 1 .I 3d Tall ForgIveness Credit from PA Schedule SP. Pan III. hne 7 Bd S 9 TOTAL CREDITS AND PAYMENTS. Add hnes 6 7 ana Bd 9 S 'n ~~ 5 IS mo.e than hne 9 See InSlruchons tor How 10 ~~~-use ,ou-, PA.;.---- EO s Make check pa,a_b~,,-~~~!'r: _O!_REY!!I.~____ ___ , 1 OVERPAYMENT. LIne 9 IS more Ihan hne 5 n S , 12a AmCi,J"" I i:lf ~. ",au ~an' as a Refund Check mailed to you P1t... do nol ull IIbouI rour ~nd until. ...111 Ift.r IlUftI 120 Amount ollme 11 you want Crediled 10 your 1997 P.A. Esl1mated Tax Account 12a S . 1~b S , 12c Am('lunl of hne 11 you want 10 Oonll. 10 the WIld Resource ConSer'latlon Fund 12c S . 12d Amounl 01 hne " you want 10 Donll. to the U S OIVmptC CorT'lI11tltpe PA DIvIsion 12d " ltlf.lOl!\l.O! L1IlES 12a..tn. UcANO U.t MUST lQUAl.UId II. 111I tflUllll'TUIII UIIII.........~,II_ll....-'rt....llt\ll_....tullIIIlH..1MIft ..........~....... ..............""""...._,... .... e:en'Id...... 'l'OUISotrullu.e "_ . _.J .'.... ':-:.,'" ,',,"'1."" (r,\'... .''':,:.....~'j.,;,'.''J X \.~_.c._~--\'_ _ ~"-- \ \ I \:.~ ~-rr..-Jt.,r <:...,,,,,,., f:;.W..~I.,... ;,1',.,.." '<"""vl , .~ ^ ",'" ....,'",,'. .,.,. .... ". " '-,' ""'-'j' .POUBII C"I ('" A,. MA'W Al'&'" AI t lC:"lOUltfJ ""'0 fOAYS '.'-. Hfll VIA" '1'011 ..,I! ell\> h ebte It> 11'I,... ~nehon 0Ie"9'p." of .,011' o....,...,Ift....ll0 l"to 0"0"" 00"0" ""'"lNI" 'flvi1 FUND rJ PA SCHEDULE UE.2 ALLOWABLE EMPLOYEE BUSINESS EXPENSES 1~96 ".. "el." ul-= 1C''oo.\I6; PA DEPARtMENT Of REVENUE Name 01 la.payel Claiming E.pensns SOCI,II S(>cullly Numhl!1 I EmploY~1 ~ Telephone Number , I Employers Name 1 [mployl'! !> Addles!> -- ------- ----------.----- DO NOT USE CENTS ROUND TO WHOLE DOllARS Describe the dulll~;S ollhO Job In whiCh you Incurred Ihesl' e.pen!>ps PART A. UNION DUES. lISl Union namIH') and arnounllsl paid Enler lolal Allarh .1odlhonal Shpel!. .1 needed AS PART B WORK CLOTHES AND UNIFORMS. AeQuu(ld as a condlhon 01 employment AND nOI slulablf> 101 (>"'f"vd.I~' uSe B S PART C SMALL TOOLS AND SUPPLIES. ReQuued as a conditIon 01 employment AND nol pWI/J(Jed by Ulf' ('mployel C S PART D PRDFESSIDNAL LICENSE FEES. MALPRACTICE INSURANCE AND FIDEL'TY BOND PREMIUMS D S 'I ReqUired as .. condlllon 01 YOUI employment ~ TRAVEL AND MILEAGE. Use yOUf FOIm 2106 It ~1'lmjng;~~-~I~-;p;~-~el.-~-;mplele-;-PiS~'h;d~1-~-ui.,------~ -TS-r------ ------~- -- TOTAL EMPLOYEE BUSINESS EXPENSES Add Part!. A H\lOUgf1 E. (nll'r hell' and on hne 1b 01 y~~~I'.;.~~~;-;' t'1tij-~~------t- Separate PA schedules UE must be tiled II you have mOfe Ihan one occupahon andior yoU! spouse also InCUfS employee busmess expenses PART E Line 1b DO NOT use CENTS - ROUND TO WHOLE DOllARS ".c. 4~r.:, SP 10<0-%, PA SCHEDULE SP SPECIAL TAX FORGIVENESS CREDIT 1996 PA DEPARTMENT OF RfVENUE !J,lm(' as shown on your PA 1.1. relurn SOC.ill Secullly Number I I ____ __________ Before ~u cO~~~~~_~.I~~~_~.~_dyle PART I. Certification of eligibility: vall MUST comple1!:' thc' SP WORKSHEET Seclton A r :i as S. Smgle or M, M.rrled Filing Separately ..J I certlly that I personally plO"lded .11 leas! one.t"-,all 01 m~' Ol'.r, TOI.}i SuPPUrl ;Jnd I am Hl9'ble lor 1M lorg....ef1('~<;, " i",n,; as Menter youI spouse s name SOCial Secullly Numoer ,)nd I~ ~,pOljSf' !dlng a PA ScheeJul(' Sp? .J YES :.J NO 2 ..I I am being claimed as a aependenT on the PA tal relurn 01 I You may nol clllm any dependenll. t certlly That I am a dependent 01 a person who IS eligltle 101 la_ lorglvt>ness Name and SOCial Seculll~ Number Section B: Filing II J. Mlrried Filing JOintly and Cllimlng Tn Forgiven... Jointly 3 .J I Ind my spouse certIfy that we ail' .Ich ehglble lor lax lorglvenes!. ane! elect to 'Ill' a loml P,A Scn(>CJule SP Also use IhlS slatus II vou hiE' lomlly but onlv one spouse QualifIes IOf la. torglveness and the other <;poust' ,<; a !1",pf:>nd{'nl ~Ilt.. no ,"corr,(, Secllon C: Filing II F. Final PA Return for I decealed Individual 1 Ct'1If)' Itlat 1 t.alif read tht> Irs!rU(.t'0'~~ I"r tht" fltmg status 4 :J The decedenf 15 an ellg'ble claimant or an e1'9'b1e dependenllol ta. lorglveness purposes PART II. Number of Household Members for Ta. Forgiveness Purposes: Enlel the Intormallon 'or youlself your spouse and each depenOen! child Lis' III dependen1 children go 10 Plrl III. Household Members for TI. Forgiveness 1. Your Name " you alt" no! marl1ed and t1ave no dependen1S Age -- ssti-----mtlllncome. from your SP Worksheet. hne 21 I I :, ;..1 "" -----....-- --------.---- -+-- ---1 ..I I am clalmmg my spouse 2 Spou.. Nlme: -+------_._~- --------~" 4 jS , . Age --r--~~-..,..-----~"" Totlllnc:ome,_II Ilny j ~~~_I!' c!a,m,!",: ~~" ~e~~~ c~ i I S i) 'am .J My Spouse IS. .J n - n E' ----- . "w_______LJ,.m ..I M.Spou'e~_=- ----- -1--- . t~n---+-+-:: j-- :: :::~:::: ~ I -I L___ __~=~_.~_~~I_.I,~~~~~~--_-nM' Spou,e" ..I Number 01 Houlehold Members YOu you' spouse 111 fl""'9 IOlnlly 0' II ~'(}ut dependenIJ and only the dependef'\l Children tIe,ng cla'Il1l'J s !I"l'5 PI.. SChedule SP E~ltel herf and on line 131 01 your PA.40 01 line 8a 01 ~OU' PA,'OE1. Spouse IS tiling :.eparalely 3. Dependent(II Name(I): ~-~----- , - . _~__L~~_'.!..~nlhlp PART III. Calculating Your Ta. Forgiveness Credit: 1 TOTAL INCOME from IIne;:'l 01 '~e SP WOlksh..l II malflf!d enl~r the JOINT dm,lunl even.1 tlhng ~epar.Uf't.,. I~ 'i.ngif' use YOUR amount E!"ter TQTAllNCOME (In Irne 1Jc of PA-'O or Ill'll" fk 01 PA.'OEl , S j 2 YOUR ELIGIBILITY INCOME II HlnQ Smgle Of Marlled Ffhng Sepaldl("!" use !rlt> amounl loom 'l'lt" t: 01 YOUJ:l (,(Ilumll r.' SP WOlkstleel 1I1lhng a Jo.n! Re!ulI'I ;\'OU and yil\.l' SPOUSE' a'{' "il<..F1 f'hQlb1f'I \J~,'!he amount hom hnt> '7 olllll' J('lI~.T Cu\umfl 01 'lout SP WorksI"1t't'! [r'itt'. helto ,.....0 on lil1(> 13t1 o! i(...1 PA4(1 (>' lmt'- fltl oj W'oul PA-40Fl ~ J 4 PA TAX LIABILITY hom I.ne 10 01 fOul PA 40 {)f hilt:' !> (II ~'our PA 4Df I lESS RESIDENT CREDIT Iro", I'''P '4 Oi yO\ll PA40 1n,s tlE-d'l r:!!)(" ,\(.1 ~l1f".. lu' 1'. 40f l , ~ . i !l NET TAli: LIABILITY Subl'...:.! hH' 4 I'orr linE' :i ..~;j tolller "ef(' 6 PEACENTAGt OF TAX FORGIVENESS Irorr, n,(' I:hQ,t1.hl~ 1....('''...~1 "" I'". I'.l'! dlltllhf> ')","1,," ! H ",'.f'. '''1 ",ll'" r.;.,,_ ""OT. Pd" ,. t "!\.' Int. 1'f>'<""'\,I'JI-' "'''f'' " P,. I" "'" 1"I"",,"'t.nT ,.' ''''I:- f, TAX fORGIVENESS CREDIT from PI. Schedule SP ~.l,'''':''1 i"., ' ','''' ;' ,.." ,"",,, t'I"f" :1"" ,,, :, D :'''f' 1 3<.1 u' yC'u. PA 40 ()' !,...." thl ,.,! ,-'..' 1',11, 4'Jl.o' PA SCHEDULE A I B :,: ;'.:;":,:,\, Jf ""ENU' PA SCHEDULE A TAXABLE INTEREST and PA SCHEDULE B DIVIDENDS 1996 'l.w'I"':: ,I'; ,;hOWrl on your PA I.ll( rf\lllftl I SO!":I,ll SeC\III!', NWTlbl,'f LINTNER, DANIELLE N 198-66-7"113 PA SCHEDULE A - TAXABLE INTEREST PA SCHEDULE B - TAXABLE DIVIDENDS II yOUl PA (..llablo mlorost I"COmo IS 0'101 S 1 ,000. comploto Un!! schuduln Suo lho In51rucllons In your PA tax booklol lor what Inlorosl15 laxablu or olompl II additIOnal spacD IS noodod. anaeh soparato shoots II your PA taxablo dlvldond IncOmo 15 ovm S' ,000. completo It,.!; 5chndul" See Iho H1s1luctlons In your PA tax booklet lor whal dlvldonds must be mportod as taxable If addltlonalspaco IS ncedod, anach soparate 5hUl!I'i DO NOT UBe CENTS- ROUND TO WHOLE DOUARS DO NOT USE CENTS - ROUND TO WHOLE DOLlARS No1meotthePa er PNC BANK Amount 4,29" Name of the Pa er Amount Total PA T.xablelnlerestlncome S $ $ S $ S S S S $ S $ S S S 4,29' Total PA T.xable Dividend Income S $ $ $ $ $ $ $ $ S $ $ $ S S ;:>Jl, - : ,:'i-~ll) "Jl.: ~ ::>A;l.~[...T:1= ~E'JEN.;E PA SCHEDULE D SALE. EXCHANGE OR DISPOSITION OF PROPERTY 1996 ....arre(s) as shown onyour PA tax return SocIal SecUrity Number Enler all sales. exchanges or other diSpositIons 01 real or personal tangible and intangible property Amounts from federal Schedule 0 may not be correct lor PA purposes. Read alltnstruCllons DO NOT USE CENTS Nonresidents should fcaCl carefully the InstructIOns concerning Inlanglt:lc property ROUND TO WHOlE DOLLARS SPOUSES SHOULD FILE SEPARATE PA SCHEDULE(S) D UNLESS SELLING JOINTLY OWNED PROPERTY lal (b) lei Id) (el I') Oe::;crloethe property sold Month/Day,Year Month..Oav Year Gross Sales Price Coslor AdjuSled GAIN or [lOSS] IE_ample 100 shares 01 KABC" the croperty 'Nas The propertv 'Nas lor the propcrTV BasIs 01 the (el) mnus Ie} ,.';r'","';:r' sloel( or houseal123 'jOiO ;::wC~lasedor less expenses 01 ENTER [lOSSE'3]IN M.,,' 51 Anywhere, PA999991 aequored sale property sO'd [BRACKETSI $ $ $ S $ $ S S $ S s s s S $ S S S S S $ $ $ S S S S S $ $ 2 S J $ 2 'Wt G.M Of [Loss from abOve sales ~___~~_l'om PA Schedule(s) 0-1 InslaHmenl SaleS 4 ~ J)l able Return at CapltaJ Olstnbutlons Enler lotal dlstnbullOn Minus adjusted baSI') c., __ ~PIClJ'niJ'[losslfTamPA&heduleO-71 SaieoI6-1-71 Ptopuftv ~'I'~,('~.~~~:I~,()m PA Schedule PA-'9 Solie 01 a POfSonal Reg'deOC!!_~.~Jlossl. ent':.~~_______ _ _ ~~:~~,-~~.?f (Lossl hom PA Schedule ~K~' ~f NR~-' .___,___~_. .~'______.~___' ______. ___.___ ToUI Net Golln Of llolsl. Add h,'e"i 2lhfouQn! E nlf'! thp "'f~' rp';ljll tl(.'fe .l"d and on line r) 01 VOtl' P.IJ.-. If!ttlrn . ';j "1,'~(j~:~~'_~~:~_~?!lf q:~_~..9..~~n~__a!_\(' 11n',',"0;] f ~_Tr _~~r T ln~,'~r '-) :NiH~A_~~_~_~~;l $ S 4 S 5 S 6 S , S ,; 1 I 6 i $ PAABpg96) . .. "...\,. PAABD- IV I g 'j","""" l~.hibi t "F_;!" II CONTINUATION CERTIFICATE AND PREMIUM BILL ~~ ~ FIDELITY AND GUARANTY INSURANCE COMPANY PAGE 1 OF ~3 U S YrG" "A STOCK COMPANY" 1'111'! I PERSONAL AUTO POLICY - DEVIATED BRANCH OFFICE AGENCY PROD ;:C,'-,,, 1 ;:C;;,;;: ARRISBURG P 06 26 63965 PPAI0547975912 12:01 A,M,STANDARDTlME ODIRECTBILL RENEWAL OF: DPA3753572399 FROM 03/06/96 TO 09/06/96 ENDORSEMENTS MADE PART OF THIS POLICY ATTIMEOF ISSUE PP0318, PP0405, PP0423, PP0419, PP0551, PP0303, PP0302,*AUTO 2860,IL0910,PP0001,PP0002.PPOI51 NAMED INSURED MICHAEL E LINTNER AND MAILING 'ODR'SS MELODY LINTNER 1463 PINE RD. CARLISLE, PA 17013 "nUDuCERS (717) 243-2921 N,J,f,IF AND 'I'HESS DARR-THUMMA INSURANCE POBOX 699 CARLISLE PA 17013 COVERAGE IS PROVIDED WHERE A PREMIUM AND A LIMIT OF LIABILITY IS SHOWN FOR THE COVERAGE COVERAGES LIMIT OF LIABILITY AUTO 1 IF YOUR POLICY INCLUDES COLLISION COVERAGE, THIS COVERAGE MAY ALSO EXTEND TO A RENTAL VEHICLE. CHECK YOUR POLICY PROVISIONS FOR DETAILS. A. LIABILITY ~100,000 EACH ACCIDENT C. UNINSURED MOTORISTS STACKING $35,000 EA~H ACCIDENT C. UNDER INSURED MOTORISTS $TACKING $35,000 EACH ACCIDENT BASIC FIRST PARTY BENEFITS (INCLUDES WORK LOSS AND FUNERAL EXPENSE BENEFITS) ADDED FIRST PARTY BENEFITS MEDICAL EXPENSE $10,000 DAMAGE TO YOUR AUTO OR 'RAILER OTHER THAN COLLISION LO~S ACV MI~US ACV MI,mS $25 PER $50 OED $100 OED DISABLEMENT COLLISION 1.0~S TOWI~G & LABOR - ~ENTAL REIMBURSEMENT CUSTOMIZING STATED AMT. $14,420 AUTO 3 (ACV MEANS ACTUAL CASH VALUE) (OED MEANS DEDUCTlBLECO N TI N U EON I OPERATOR'S ~ME TRACE NAME. MODEL ,,-, )-' PREMIUMS AUTO 2 AUTO 3 AUTO 4 $93.00 $103.00 $93.00 $21.00 $21.00 $10.00 $10.00 $54.00 $34.00 $3.00 $2.00 $44.00 $247.00 $2.00 $5,,00 r.: $21.00 $10.00 $49.00 $3.00 $10.00 $75.00 $2.00 $5.00 NCLUDED NEXT PAGE VIN MICHAEL E. MELODY 8 8 9 CHEVROLET CAVALI FORD F150 PLYMOUTH GRAND V IGIJC5110K722612 IFTEF15GOBPAI019 IP4GH44R4SX62371 .-----------------------r---------------.------------------------------------------------------------------------------- KEEP THIS PART : ~ --THIS IS A COpy OF THE BILL-- 07922 FOR YOUR RECORDS i l YOv!: ':.ANCL~EO C...EO: , P:I~~::~E:~E : r SF. G. I , .:, , , , PREMIUM CHANGE SURCHARGE ~PU~N TO NOncE DATE TYPE POLICY BALANCE AGEPtCy coot POllCny"" COMI'lHY POLICY "UNCI _ out MINIMUM DUE SEE NEXT PAGE FOR BIll INSURED POlICY _lEA AGENTS _ DUtEOATE .I DUE 0,\ n: MAKE CHECK OR MONEy ORDER PAYABLE TO AGENT'S COPY EGElVED JAM \ i ~1ij) - - t~ ~,S,,~tq- Automobile Coverage Summary Declarations Page. PEM~CM. '\u:c "c.Cy. QEVIATEiJ pr"JStl nole lhJllnformallon I" pfllvllh~l un lrll~ Iron! JOII t\lr.k ollnls pagt! DIIt>l:! Hill flDEli IY AND IJUARANIY INSURANCE COMPANY A ,lnrkrlllll(1;]nytjrWTllr.IIPl! In IOWA Policy Period (1201 J m 'IJr'<JJ'~ lImet I from 09/06/1996 To 03/06/1997 AGENT 1."111...111"""11.,11.11,,,.11,,1.1,,1,1,,1,1,,1,1,,.11..1 DARR-THUMMA INSURANCE POBOX 699 CARLI SLE Policy Number I PPA10547975913 Reason For Issuance -' RENEWAL NAMED INSURED MICHAEL E LINTNER MELODY LINTNER 1463 PINE RD. CARLISLE. PA 17013 PA 17013 II Coverages limits/Deductibles IACV Means Actuel C..h Velue' , IF YOUR POLICY INCLUDES COLLISION COVERAGE, THIS COVERAGE MAY ALSO EXTEND TO A RENTAL VEHICLE. CHECK YDUR POLICY PROVISIONS FOR DETAILS. A. LIABILITY $100.000 EACH ACCIDENT C. UNINSURED MOTORISTS STACKING $35.000 EACH ACCIDENT C, UNDERINSURED MOTORISTS STACKING $35,000 EACH ACCIDENT BASIC FIRST PARTY BENEFITS (INCLUDES WORK LOSS AND FUNERAL EXPENSE BENEFITS) ADDED FIRST PARTY BENEFITS MEDICAL EXPENSE $10,000 D. DAMAGE TO YOUR AUTO OR TRAILER OTHER THAN COLLISION LOSS ACV MINUS ACV MINUS $25 PER P'Amillm Vehicle 1 Vehicle 2 Vehicle 3 $93.00 $103.00 $93.00 $21.00 $21.00 $21.00 $1 0,00 $1 0.00 $10,00 $49.00 $54.00 $34.00 $3.00 $3,00 $2.00 $10.00 $44.00 $75.00 $247.00 $2.00 $2.00 $5.00 $5.00 INCLUDED + ~j'';' COLLISION LOSS TOWING & LABOR . RENTAL REIMBURSEMENT CUSTOMIZING STATED AMT. CONTINUE ON NEXT PAGE $50 DED $100 OED DISABLEMENT $14.420 AUTO 3 Description 01 Vehicle(s) or Trailer(s} Vehicle 1 Vehicle 2 89 il6 CHEVRI1LET :);EVRClE' CAVALIER CHEVETTE CS I G1JC,110K712t?l llJ1TBOIlC7GA 181!!'J, I 1 PA PA 027 071 ~l'?O ~12~} p 006 A A N .... N N nl ~1 Vehicle 3 % "'.v~l1l:rH :;RANO VliVAGEf\ S lP4:;H44R4SXunllu Year Make Model VIN p, inc ;pel Oper State Ter.itory Rata Cia.. Use Vehicle Type Pa... Restrainl Anri- Thd $,mbol ;JA ,;27 ~81"?'1 p V , \ " .I\,..~ J ,jt'')(!ifllUJrliJ! V!:'Jf cllveragl> """,ht' ~""'r:! ';;1 't",;! 'PUHlh · ir.II:CJlf<\ '1t'YW 'II rf>V\Wll 'iolflrp ~'li'r... \'I,t)),1 "',11"'1 A.<,:"' ,'OPI ^;; ~;; ;t.1 4:'\4-,J'lr,; lAil"-Ai '.....NH I"", ....'.r"'."'.. ,ii:' ;"~ i. -;. I'~~~ ~ 1 lf~: >I: 'I j ,}i\(:; , '1i:'H/'l(: Exhibit "(;-2" VBRII'ICATIOH DATE: I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. ~tci.JLd~ Michael E. Lintner 3 - d- \ - 0,-, VERIFICATION I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. section 4904, relating to unsworn falsification to authorities. ,-~~~R~\...~ Melody Lintner DATE: '=)-d-\-q( ..~ ~ .... ~i - .. II CIO a 91 .... ~ i!i :z: i4:! ~ a ~ ~ Ii> W::l1g z:) P CJ I- ... 1~~lf Hi ~ il OWl! Z II: II ~~ . WI 00 ..."'.., ~"T"T tMAT TMI 'MTMIN .. A T ANO coa "teT co,,, 0' TM olltOn'A&. "'-10 . OM ACttQN ... .. BL~ .. \ ....--. (~jJUN 1 7 1997 IAW''>>~Il:'. ...-m,,--~ MANCKE. WAGNER, HERSHEY & TULLY : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA DANIELLE N. UNTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E. UNTNER and MELODY UNTNER, : NO. 95-4912 CIVIL TERM Plaintiffs : CIVIL AC110N - LAW v. TIMOTHY L WELLS Defendant ORDER AND NOW.thls ,I' clay 01 ('/,,- , , 1997.11 Is hereby ordered and decreed that PNC Bank Is authorized to; 1. Pay the sum 01 $10,122.10 as payment for the cost 01 the whlr1pooltube and deck to Pure Springs Construction. 2. Reimburse the sum 01 $2,494.00 for the computer to Michael and Melody Untner. BY THE COURT: /iiL DATED; J. DANIELLE N, UNTNER. Minor. by Michael E. Untner and Melody Untner, her parents and natural guardians. and MICHAEL E. UNTNER and MELODY UNTNER. : IN THE COURT OF COMMON PLEAS : CUMBERlAND COUNTY, PENNSYLVANIA : NO. 95-4912 CIVIL TERM : CIVIL ACTION. LAW Plaintiffs v, TIMOTHY L WELLS Defendant PETT110N FOR RFI FAc:F OF FUNDS OF MINOR SETTLEMENT 1. The Plaintiffs In the above-captloned case hereby petition the Court for payment from minor seulement. which was approved by Your Honorable Court on October 16, 1995 and a copy 01 said approval Is attached as Exhibit .A.. 2. The sum of $135,702.00 has been deposited In PNC Bank pursuant to Court Order. 3. Petitioner Is requesting paymenllor a whlr1poo1tube and deck lor physical therapy for Danlelle LIntner. A copy of esllmate of $10,122.10 Is attached as Exhiblt.B" and a copy of a letterlrom Danlelle's doctor prescribing this therapy lor her Is attached as ExhIbIt .C". 4. Petitioner Is requestlng relmbuniement In the amount of $2,494.00 for a computer for Danlelle and a copy of the invoice Is attached at Exhibit -0.. WHEREFORE. your Petitioner prays Voor Honorable Court to enter an Order authorizing payment of $10.122.10 for the whirlpool tube and deck and 52.494.00 for the computer. Respectfully submitted. MANCKE. WAGNER. HERSHEY, & lUll. V By V"'"L John B. ncke. Esquire AItomey I. . No. 07212 2233 Nonh Front Street Harrisburg PA 17110 (717) 234-7051 DATED: ~-I/;q,] 97-0609 Attorney for Plalntlfls .., " ..,.........................--......--.----..... ...... ....... '.,.,. ,"," ! ... .'.. - ~.._.- ....,-~..-.,_...-.-,....~- . I , , ~- , I , i I i I i I I I , I , I I DANIEUE N. LINTNER, Minor, by Michael E. Untner and Melody Untner, hBr parents and natural guardians, and MICHAEL E. LINTNER and MELODY LINTNER, : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. CIVIL ACTION . LAW Plaintiffs v. TIMOTHY L WELLS Defendant ORDER AND NOW, this -'- day of Dl.~~ ,1995, the settlementtotaling $175,000 Is hereby approved and the parents and natural guardians are authorized to sign any and all releases to give approval of this settlement and it is further ordered that the distribution outlined in Exhibit A of the Petition is approved and that the sum of $135,702 be deposited in the name of Danielle N, Untner, minor, by her parents and natural guardians, Michael E. Untner and Melody Untner, and such amount shall be deposited in one or more savings accounts in the name of the minor In a bank, building and loan association, or savings and loan association, which deposits are Insured by a federal govemment agency. It is further provided that the amount deposited in anyone such savings institution shall not exceed the amount to which the accounts are insured and further ordered that no withdrawal can be made from any account until the minor, Danielle Untner, has attained her majority except as authorized by prior Order of the Court. It is further ordered that proof of the deposit shall be promptly filed of record with the Prothonotary, TRUE COpy FROr...1 RECORD Testtio',t)ny w~lm~I, i here until sa: my hand ~ the seal 01 ~id Cvur at C,;rlisJe, Fa, ~1i 19 By the Court, 5P~4 ~S~ J. E:ld1ibit "A" All material is gua anteed to be as specific. and the above work to be performed in accordance with the drawings and specifications submitted for above work and completed in a substantial workmanlike maMer for the sum of ($ /O/.;a,/O) with payments as follows O?I . . Any alteration or deviation from above specificati~s involving extra cost. will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon strikes. accidents or delays beyond our control. owner to carry fire, tornado and other necessary insurance upon above work. ~rMtenls Compe~lic liability insurance on above work to be taken out by "1l rl~ . , . Respectfully submitted PURE SPRINGS ~STRucrIOO Per James K. Holder Note- This proposal may be withdr/llolll by us if not accepted within 30 days. Acx:EPTANCE OF PROPOSo\L The above prices. lWKifications and conditions are eatieflllctory and are herebv accepted. You are authorlzed to dO the work as apecified. Payment v,U be IllICle as ~~l~~ ~e. ACCEPl'ED SI~T\JRE (~hl) It. ~ (J DATE ,{- /1- 9 7 SI~'lUU: l::Xhibit "H" h ~ t I", . ! " .....: ',:,: ',,'.! " \.1,/ ? k r- u. 11', .. .. . I"" .. ........:J.. - .. . - P.('l.l\o~ 2000 'j .' ...'....... ~......... ............. ..... "soo:8i6:illoO(USA' rC-~~d'ci)' 605-232-2000 IIntematlonal & Local Main Operaloll t.C~,Z!~-~~~ .~=~.. 800-846'4510 ,Add'on Componenf1) 605-351-1023 (Add-on Compommls Fa~ III I'.~U.'~ UUU-u.l~-l~':~ or W~-':J~-':~U' If quoted, this Is a non-binding quotation for order. Prices and specifications subject to change WllhoUI nolicl! or obllgRtlon. Shlppina ChRI!l~~ Rnd Rny RpplicRbl~ 'R"~~ will b~ Mdl'd \Yh~n 'h~ order Is placed, if requested a formal quote or confirmation of order can be Issued, , , , . . ! ! I ~ ' ! ! ! . ~ ! ! ! I ! ! I I . , I I ! J . I . t ! I ! . , I . , . , . . . , . , ! . . . I . ~ ! . . . I I ! ' ! . ! . ! . ! . I ! ! . ! ! ! -! TO: "T.""" '.I\.'H.I Ler:SCH :rAX: 717:-2J~.5Q;: ~ ~~~t:_..: ~tr:.:,:.;; ~~~T__~T~TTTT_TTTTT+TTT~T+_T_TTTTT_TTT___T+T_T_TT_TT_TTTT-T---TT---.--+TTTTT-TT- '" _t... . . '.'.. ~ "-_...._ ..... ...~_ _..._,.3...._....'__ ...,. ,d.. I. . , . ,d. .......'. '. ,"..... ",' -..........- .., .,", ORDen NUMDEn. OG~188~~ roc. .,,,,,.. DASE pnIC[$~~~3 t"',tITPpnrr.. ~ns ............, ......~n.. . , .~" 1"_" .' - - THANKS V I C!(! , ! ! HAVE;... t-i.:.J1VELOU'3 D!~Y'~' ,.."........., .."........ ,... ," ." 800-946-:04:-:5369 GO~-Z3Z-:~3G fAX NUMD[r )- Exhibit "D" VBRIJ'ICATIOH I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. ~ Melody Lintner DATE: L~.- 10 -q, VDII'ICATIOH I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. section 4904, relating to unsworn falsification to authorities. '-fl!ddc:-L~ Michael r..intner DATE: ~-(C-'\\ er. r:: n I.U.~. ( I" p:" <,:' I. I ~ I "I' ~ .. ',1. , LJ <.> C") ..:l is '" l~' )~ '.' W , '. , ".,' ... 'L1 0:' -, C:1 :.t: l- eT- ", ~ . .id .. ..:1- ~'J U @ ",a 00 "I".... Cn.'tfl' hut 'WI WITHIN .. ... ,....,. "fifO COIl "'Eel' co~, Of' 1MI O'''OI.dl ,It..lo.. fMtIAC.flOJill Iv MANCI<f WAf;NfH IifHSIif) & "'ll 'r l~~ Ii> W..J Z..J C)=> . < ~ ~~cll Lu~ ~ ~ J: Um Za: <(W ~J: ~~ ~~ ~~ . " ii ~i ft C ft X " "II. ... .....~ ......". '~I . ."'l"" "'...."'..U . '.:,,_t' ..,_ t"-fr;".1O> 1'.... ."'... ....... ".UI (llIII. 1\.1I"_'" .........,...."..-..,.. .. .. .~. 9 \.../ DANIELLE N. LINTNER, Minor, by Michael E. Untner and Melody Untner, her parents and natural guardians, and MICHAEL E, LINTNER and MELODY LINTNER Plaintiffs : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 95-4912 CIVIL TERM : CIVIL ACTION. LAW v. TIMOTHY L. WELLS Defendant ORDER AND NOW, this ZI&dayof /tI~ ,1997, upon consideration of the within Petition, It is hereby ordered and decreed that a hearing be scheduled for the 5'" day of December, 1997, at 2:30 pm in Courtroom 4 of the Cumberland County Courthouse, Carlisle, Pennsylvania. By the Court, /IlL Respectfully submitted, MANCK ,WAGNER, HERSHEY & TULLY By: Joh B, Mancke, Esq, 10 No. 07212 2233 N. Front Street Harrisburg, PA 17110 717-234-7051 DATED: JI./L/.Q1 Attorneys for Plaintiffs Strickler Agency, Incorporaled Strickler Agency Darr-Thumma CMC Associates Ullited to selve your illsurance needs October 3, 1997 Michael E Lintner Melody Lintner 1463 Pine Rd Carlisle PA 17013 . Re: Policy' XK -PPA10547975915 (AUTO 95 PLYM GR VOYAGER) Effective September 6, 1997 to March 6, 1998 As you requested, here is the cost of the 1995 Plymouth Grand Voyager. From 9/6/96 to 9/6/97 the premium was $976.00 for full coverage including the customizing equipment. If you need anything further, please let me know. Sincerely yours, lJ~~"~ck: Elaine Fahnestock, CISR XF(B)/pe Stritkltr ApllC1 IIIe, t2O(J E. MrKinl.." 51. "011 OW<< 80x J07 C""mbm/Iwr."A 1720141.107 I'Iton,: (7171 26J.4179 F.... f1l7,26.I-02'6 Da".l1tumIlUlI/lSu",II" 95 Alt'la,.d,., Sp"", RCHid Po" Of/ht Itu:{ 699 c.",,},. ".4 1701.1.060<1 rlw1tf' (;'17} ~4J.J911 fh..., ,7171 697-H6H FI" (7111 ~4-'-tl.f{4.' CMC Associ.,,, .121 W. s.hfmMt SI. p,,,, Offic, ... 87 G......'UIIt,,.A 17213__7 1'1<<>.,. (717/ '91.1$26 Fn f717/ "7.'2811 Exhibit ^ " 4, Pay the sum of $976.00 for reimbursement of insurance to Melody and Michael Lintner for the 1995 Plymouth Grend Voyager for the period of September 6. 1997 to September 6, 1998, and further, to pay the sum of $350 to Melody and Michael Lintner to cover the period from September6. 1998 to December 29, 1998 for insurance on the 1995 Plymouth Grand Voyager. 5. Pay the sum of $164.22 per hour to HealthSouth (Mechanicsburg Rehabilitation) for racreational therapy which shall be used for a period not to exceed six (6) hourly sessions. 6. It is specifically ordered that if any amounts as directed to be paid above are not incurred, then in such case the balance of any of the amounts shall be given to Danielle Lintner on December 29, 1998, the date of her majority. The Court will consider a Petition conceming the need and payment for a new wheelchair upon further Petition in this matter. By the Court, 4\~,.. ,4~ . J. / >- en (': 9.e c.r: , ,- 8 ~- ~n ~~ .-t: , ...- ~~i .,- : ~<(.l <: ~-," .poj '. . .~;.. ('. a. "', /,.., u. . )',: tY. -t- ." u.: ~lJ : . ~ i.j fl:- or. ~~ ci. :c 1-1. C'.;, ~.', 0 C1' 0 'Ill' 00 """.' Cltli,.f-Y '"A' ,... .IlKHI ,. " '''vi .1oIn C(]III ~:jri 'lit:?:; Af~~..,,'~i a.un'.....' .. MANt':"':! \/'jAtiN'H tnfF"H'~.w,. II/tl' ..TtOillltrlr... ....... c ci~ w -' ~ 0 Z -' . ~ Cl ::> ~ .. .<{~j .. ~ ~ ~ ~ ~ . d ~ W ~ ~ ~ :> j :.!: J: ~ .. " U en " ii' Z a: :: ~ <{ W " % ~J: '0 .;:11.;.... ...... .....t.,.~ .,. ht . .M."'" ". ~".,"'.I' "" ~~~r...,.." ..".'>.'f'''''' -.....- ...-,. ,... ~......... ......f.......'...._..." .. ..t.,...... I DANIELLE N, LINTNER, Minor, by Michael E, Lintner and Melody Lintner, her parents and natural guardians, and MICHAEL E, LINTNER and MELODY LINTNER Plaintlffs : IN THE COURT OF COMMON PLEAS , CUMBERLAND COUNTY, PENNSYLVANIA : NO. 95-4912 CIVIL TERM : CIVIL ACTION - LAW v, TIMOTHY L. WELLS Defendant QRDER AND NOW, this %. ,>'! day of ......~ that PNC Bank is authorized to: ,1998, it is hereby ordered and decreed 1. Pay the amount of $182.00 to Intemal Revenue Service for payment of Danielle's Federal taxes. 2. Pay the amount of $52.00 to PA Department of Revenue for payment of Danielle's State taxes. 3, Pay the amount of $2,840 to Central Medical Equipment Company for payment of an Easy Stand for Danielle. By the Court: ,1J J. DANIELLE N, LINTNER, Minor, by Michael E, Lintner and Melody Lintner, her parents and naturel guardians, and MICHAEL E, LINTNER and MELODY LINTNER Plaintiffs : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 95-4912 CIVIL TERM : CIVIL ACTION - LAW v, TIMOTHY L. WELLS Defendant PETlTIQN FOR REI,.EASE OF FUNQS OF MINOR SETTLEMENT 1. The Plaintiffs In the above-captioned case hereby petition the Court for payment from minor settlement, which was approved by Your Honorable Court on October 16, 1995, for the Danlelle's Federal taxes Danielle's State taxes Easy Stand frame $182.00 52.00 2.840.00 $3,074.00 exhibit A Exhibit B Exhibit C following: WHEREFORE, Plaintiffs prays Your Honorable Court to enter an Order authorizing payments in the amount of $3,074.00 for Danlelle Untner's Federal and State Taxes and for an Easy Stand from Central Medical Equipment. Respectfully submitted, MANC GNER, HERSHEY & TULLY L...-----' By: John B. aneke, Esq. Attorney I No. 07212 2233 N. Front Street Harrisburg, PA 17110 717.234-7051 DATED: g lie tI€', Attorneys for Plaintiffs VERIFICATION I verify that the statements made in the foreqoinq . document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. section 4904, relatinq to unsworn falsification to authorities. :!l~U. <<L ~ ~ . \~~CC~:J ' . ~ DATE: 3.\~-(1<=6 IRS UMt Onty~-Oo not """IIf! UI -'l,1plfl III 'hl~ r,rJ,'~n OMn tIt) '5"500n~J ITIiJjjItJ [[jJjjijjj o Head of household (with qualifying person). (See page 15.) If the qualifying person is a child but not your dependent, enter this child's name here. ~ o Qualifying widow(er) with dependent child (year spouse died ~ 19 ). (See page 16.) Yoursetf. If your parent (or someone else) can claim you as a denendMt 011 hlo; nr her taJl. return, do not } check boJl. Ga. No. 0' boles checked on b 0 Spouse 60 ond &b C Dependents. If more than six dependents. 5ee page 1 G. Fnrm 104tJA"' Label '500 Ottp3flmenl of the Iteasury-lnll':moll f1.wonuo Sorvlt;n U.S. Individual Income Tax Return CHI 1997 '4 Use the IRS IReL OllMtfWl$8. HW fl' In AlL CAPITAL LETTERS. DV 198-66-7713 DANIElLE N LINTNER 1463 PJNE RD CARLISLE PA 17013-9321 S28 75 I R S ""'m ,- Presidential Election Campaign Fund (See page 14.) Do you want $3 to go to this fund? . . . . . . . . If a Joint return, does our souse want $3 to 0 to this fund? 1 IiJ'Single 2 0 Married filing joint return (even if only one had income) 3 0 Married filing separate return. Enter spouse's social security number above and full name here. ~ Yes No 4 5 6a , Fn1 name La,;, nart'll! (21 Oependenfs soc1dl security number (3) OcpentJent's relat.onshlp tuyou 1"lNG.ol monlt1s ived in yOU" home '" 1997 - .- .- - d Total number of exemptions cla,med Sa b 9 . - iii ~ - - - ~ - === !!!! = !!!! -- !!!! 7 Sa ._____.~IIIJJII] 9 .1.......~a~~, salaries, lips, etc. Attach Form(slY'-2c________.____ Tallable Interest income. Attach Schedule 1 If r~"ed. T811-ellempt Interest. 00 NO.!~lude on J!!1e 8a __ Dlvldend_~. t-ttach Schedule!_'!.regul~~.__ 10a ~~~~I,~~ons . _~~______ 10b ~:;:;;:9~~~;n' 11a Total pensIons . rrTTT'"III 11b 1"ax,OO, Ie amou,nt and annUitIes ____~~ ' (see'page .191.. ___ 11b 12 12 138 Unempl()ymert G()m!"'r:~at~n _ SOCIal sec\Jnty benefits. 13b Taxable amo\Jnt ,see palle ~ 11 ..138 CD ! : (I] Add Itne~J through T3b (Tar nyilt CUIJllIlii TIll';" VUUl ~ 14 t5 IHA dt:'ductIOl.l _(~~ Jjdqe :' 11 A .~ AH5lA1t'INTlRNATVJNAL For Privacy Act and Papcorwork Reduction Act Notice, see page 42, Note: Checking .Yes. will not change your lax or reduce ur refund. o No. 01 Vo.... .-on on k who: . hed with you D . did not live with wou duo 10 '"-"" Of separation D (...p_l7J ~..... onlcno1 D entered above Add numb.... ..- .. r-::-1 .... bolles.bove L:;...U Dollars Cents ~ 10b ITIJIIIJ DIIIIIJ ffiffiB ~ [J]JHJJ n! i CJ 13b 14 15 'J 1('( ,v'A "O~ 'i't~;', "\,)'Q "OA. ", ,../, ....,.. 'I.' ~., .~ "'l, 'Q V'L "". "" r. IJ I,: 'r.,'. J' '~'1 ", ~ V .", /' 'l'~J ~ "0 /'(';,' / ,-, I"" J~"";.:;t~"',,,:, '''1'10. IJ, '" 'V., 0, ',,' f', ..,~ ". "'I,." ~"> ......'. " "'''~''' ~ JI.~" '\",' ""'7 "'" . . , 1997 Form 1040A page 2 17 Enter the amount from line 16. -.-.-- 18a Check { 0 You were 65 or older 0 Blind Enter number of D if: 0 SpOUIO was 65 or older 0 Blind boxes CheCke~,,~~~, b If you are married filing separately and your spouse ,temizes deductions. ~,ee.page23andcheckhere . . . . . . . ',_' . . . . . . -" . ~ 18b 0 19 Enter the standard deduction for your filing status. But see page 24 if you checked any box on line 18n or 18b OR someone can daim you as a dependent . Single-4,150 . Married filing jointly or Qualifying widow(er)-6,900 . Head of household~,050 . Married filing separatelY"',3,450 Subtract line 19 from line 17. If line 19 is more than line 17. enter O. Multiply $2,650 by the total number of exempllons claimed on line 6d. Subtract line 21 from line 20. If line 21 IS more than line 20, enter O. ThiS is your taxable income. If you want the IRS to figure your tax, see page 24, ~ 22 23 20 21 22 23 Find the tax on the amount on line 22 (see a e 24 . 24a Credit for child and dependent care expenses. Attach Schedule 2. 24a b Credit for the elderly or the dlsab~ed.. ,6,ttach Schedule 3. c Adoption credit. Attach Form 8839. d Add Ilne~ 2,'!.;; 24b, and 24c. These are your total credits. 25 Subtract line 24d from line 23. If line 24d IS more than line 23, enter O. 26 Advance earned Income credit payments from Form(s) W.2. ~ousehold employment taxes. Attach Schedule H. 28 Add lines 25, 26, and 27. This is your total tax. 29a Total Federal income tax withheld from Forms W.2 and 1099. 29a 24b 24c 24d 25 26 27 ~ 28 b 1997 estimated tax a ments and amount ap led from 1996 retum 29b c Earned income credit, Attach Schedule EIC rt au have a quali I 29c d Nontaxable eamed income: amount ~ and I e ~ e Add lines 29a. 29b, and 29c. These are your total payments. ~ 2ge 30 31a If line 2ge 's more than line 28, subtract line 28 from line 2ge. ThiS 's the amount you overpaid, Amount of line 30 you want refunded to you. If you want It directly deposited. see page 33 and fill in 31b. 31c. and 31d. b ROJtlng 0IIIIlJJJ number C Type: U Checking [J Savings 30 31a d Account number 17 19 I t_. ""<..; 20 21 c:ILIJlilim DJ:I:lUJIIJ <;:: (h~ l i2n ,Al1\';~;~ of line 30 you want applied to yo~1998 esli'!l"ted tall:'~ ;;;;; 33 If line. 28 IS more than line 2ge. subtracl hne 2ge trom hne 28. ThiS IS the amount you ~ ~ : 9ft. Frio details on how to pay. see page 34. ... 33 ~ = 34 'EStImated ;a. penalty (see pag~'34):-n__n'_'- :)4'-- - C:mJ ;;;;; S' '1'1r1t" I,...""tfll"" '11 11e<f\11V I \It....tttf> 11\,\' t n:Nt' ..."'1""..,, ".,., ,..I,"" :-"'11 t, . ""~':I'lV,rlll ", tw.;1tl~" ;'lflll,t,ihtu-."h .tI\l1 hIli"" _ Ign ~50lll ,1\'1' \';t...,Vrok.l\.k.f.' .,JI." 1.4."-1 !+,,;, .If\! tn....' ,I'q~,! .".t .1", "r.tl'~r 1;<0' all 1""'Hlll'; .l,.t ';0.111' .-,~; d ;rr'O"",'llf,,\"'~'PC'! c1I.If!flq === here tflt'I,1:Jl ',lAd! ~_Ltl,tl,."j,,! p,,,,,<J.!.., ",(10..", nlooill\l,,' :-l'........'II.~I.l..t~....l"'.' .1111'1',,,,,,,,1..,; 'I! VitI'"d,!t l;.j'!~.',il.'1 h"5_lr'~ k!~'wk"""t;" = .~'_. _ :,'UI ',..14".':'.1'" I (\;,,~ ! "';\111 . "p.ltll)" = """,.. ''''~\ "I f1}j -, . -.,' 'ti === ,",!_, 'Pt\I'I' ,,",f -~.pt",~. '. "''1l'1..,tUle "lU,..t '~"j'" WHu 'llu..l '.H11' ,. 11,lhl j "1t~'lu;;';~;-;'W'n""'lll;' -- , :: ~':i~"'"'''' I P'" -1 I "f""l"<~' , !!! preparer's 1:1-",;,: , l ~r:~~"':"'~>'\1rl.J : ~ W : ; I I ~ \; I _ -- r. ...-,...-~ l~p.llll11,-'nlll11tl" hlJa"u'y-lnlot"kll n~VAllIjA So"",I( f' (1m 1040A) Interest and Dividend Income for Form 1040A Filers 1997 !HI OMU ~j(J 1~)..&'1 OOtta Your soc... HCUftty number ~'llneC,)!,hown on rorm 1040A, Fllsl and IMIaI(sl Las' :....ci n le.I ( c' /..-,,, -h-, <:, Part I Interest Income (See pages 18 and 49.) Note: If you received a Form 1099-INT. Form 1099-01D, or substitute statement from a brokerage f"m. enter the firm's name and rhe rotal in/eres' shown on that form. 1 List narne of payer. If any Interest is from a seller-financed mortgage and the buyer used the property as a personal residence, see page 49 and list this interest first. Also, show that buyer's social security number and address. p/ve t) IJ. IV /e.:..' 1 Dollars CentJ ! 2 3 2 Add the amounts on line 1. - - Excludable interest c,n series EE U.S. savings bonds issued alter 1989 from Form 8815. lone 14. You must attach Form 8815 to Form 1040A. Subtract line 3 from line 2. Enter the result here and on Form l04OA, lone Ba. 3 4 4 Part II Dividend Income (See pages 19 and 49) Note: If you received a Form 1099-DtVor substitute statoment from a brokerage firm. enter the flnn's name and the total dIVidends shown on that form. 5 List name of payer OoUars Cents 5 ~ - ~ - . - - WI!! WI!! ~ ~ - ~ - = - ~ "AV IO'J 'J11 '997 PA-V Commonwoal1h\11 PA y'P~~~""'" VI ,1ivonue ~~se~~ :!~~~! PY2~~!lR~U~ -, ----..----.- -----. -.. .-- ..---.... 700914 ENTER THE AMOUNT OF YOUR PAYMENT. 19/1-bb-7713 LI DANIELLE N LINTNER 14b3 PINE RD CARLISLE PA 17013-9321 ~ :;oI~ll+> "II'~' _, O"C....I'.-l ~ "' .)0<.. .GO $ MI Make check or mon~y orde!_payable-.!o. t~e PA Dep' 01 Re,,-enu~ DO NOT WRITE IN THIS SPACE MI L 3001/11196bb771300039199712310000000000000005 01 Code os ~ la Gross PA Taxable CompensalJOn from W.2lorms and othe, wage statements. ............. .. .. la 1b Unr9tfl1bursed Employee Business Expenses horn PA Schedule UE. ........................ lb 1e Net PA Taxable Compensallon. Subtract Une 1b from la. ,..............,.,... Ie 2 PA Taxable Interest. Complete PA Schedule A il over $1.000 ..,...,..,.,...... 2 ':' ( , ~ U',) ~~. ; 3 PA Taxable Dividends. Complete PA Schedule B if over $1,000. , . . . , . . . . . . . . . . ., 3 U"l M C C M 1TI C C l'- rr 4 Total PA Taxable Income, Add L>ne. >c. 2. & 3 ............................... 4 / 8b3 €t r:J 5~ 1..": (_'J . 5 Total PA Tax Uablllty. Multiply Une 4 by 2.8% (0,028), . . . . . . . . . , . . . . . . . . . . .. 5 6 Total PA Tax Withheld from W-2 forms and other statements. , . . . . . . . . . . . , . , . , ., 6 Total PA Estimated Payments and Credits See Inslrucllons. ,..,.......,..,..., 7 Sa Dependants I""" PA Schedule SP. P.~ B Line 2 ............. 8b Total Ehglbitity Income from PA ~ SP Pa~ C. Lone 11 ..... Be Tax Forgiveness Credit I,om PA Schedule SP. Part D. Une 16. . . . . . . . . . . . . . . . . . . . . . . ... Be 7 'aa 8b 9 Total Paymenta and Credits. Add LrMl. 6. 1...><1 Be ,.......,.................. 9 10 TAX DUE. II Une 5 is more than Une 9. enter the difference here 10 __~_~~payallle~ DE_~.D!_~~~.f.'_~.~ PA-Y ~~~~~'~ns""~!~ PA!._ S,) C. , (' , 11 OVERPAYMENT. Ifllllll 9 IS mole than Line 5 ente,lha difference here .. . .. . .. . . . . . .. . . .. .. 11 12 Relund-Amounlolllflellj1JUwanlasa_maoIedlolOO ................................ 12 13 Credil. AlOOIInr at Lilt! 11 you .""' as a tradi1lO your 1998 ES11Maled Ta, Actourl ........ 13 14 Donation - Amount 01 LIne II yOU .ilI~ rogiftlo "'" WIld R"_ ConseNalion Fund. ... 14 15 DonalIon - _. oil... 11 yOU .....10 gift 10 1ho U.s. OlympIc ComMIllte. PA Division. 15 16 Donation - Amoont oil... II Y<lU w""' ro gift 10 1ho Olgan Donor __ TNSl Fund. 16 17 Donation. AMoon1oll.", 11 ;uuw..~ro....I"I"" 1l0lUlV_ Memona11nc. 11 6 18 00nIti0n. Amount cI LInt 1\ 't'Oll lItan1 10 ... 10 Brtast & Cervk:11 Canter Research. The 10'31 01 ltne 12 ,nrouQh 18 mU'il e-q\',llltrM~ 11 18 AU...rAlIeWIM4'F1Ofl6M. -1 PA 40EZ I A I B I UE.2. 1997 PENNSYLVANIA INCOME TAX RETURN. Page 2 9700420012 -L r-~ .,. -.-------... "-'-.'-- . - - __".__.._.._._H ---.-..---.. .-..----..-~-.-.-.----...------~-~ ...-.---. ". i Locallnformalif'i EIt., W~Y.d" ul DOC.. mile' 31.1997 I MuniCIpality 12 r1 f1 I L:.t...) n., I~ , J) County: C'U''h h.., .../{I /'1. I ~_.._._----- --- ,..-.--' . ....-.-------. _._-.._.:-=-::[.~_.__....- .-- .... - -~--- . - - -~_..._--. '.-' -. . '. SIGII fIlUlIlT\llll......... It..."."". MIl....,. iIIdIM all' (wI)... n................ II......,...............................,...,..........., Wnd" CIilIIIlIII"t (f) Y -lirepdiefo~ompany N.ime~Othei'u\oinT.i-'p.iveijsl,b.1scifOn-ali lIilormal.oo'oI which prrp~,pihasaniknow~- __. ..__ '_ __ .. n_' _ ..'.____________. . .___~____.n ...--.--_.!...._-.--. Name(s) as shown on your PA lax return Your Social Security Numbe, PA SCHEDULE A - TAXABLE INTEREST PA SCHEDULE B - TAXABLE DIVIDENDS It yOUf PA taJable InteresllntO!M IS O~r S 1 ,000, comptele In.S sched\H See the IftstruChOM In JOU' PA tal bol*lel tor whal IfItlfeSlIS laaablt Of eaempl AnKh additimal schedules " needed It 'fOUl PA I.Ulbte c1ividend income is over S1.ooo, eornrfete this schedule See the instructlOl"ls In yOUf PA W: ~let for whl1 dlV'" must be repor1ed aslal- abIfo Anaeh IddttionII ~ If needed Name ollhe Payer Name ollhe Payor ---Pt.-it Amount Amount s s s s s S $ S~'-}... $ $ $ $ $ $ $ r\J ..... C3 C3 r\J :r Tot.1 PA T..,bee 'nter..' Income C3 C3 l'- PA SCHEDULE UE.2 109 "1 cr ~ame at taxpayer ctaimtng these expenses Total PA r...ble Dividend Income ~ ~.JI 0C. ALLOWABLE EMPLOYEE BUSINESS EXPENSES tu~"E'A'S SOC&Al S(ClRTY M.NBfR '997 Employe"s Name EMP1.0I'rMS fUlf.RAlIU tUaR Emplore'"s Address Describe thp duhes ot the rob tn whICh yl)u Incu"Pd these e.penses see in."ucUona tor ..ch type of ..pens. in ,our ..oo.....t. Elpett... mu.t be required .. . condition 01 your employment and are not relmbur..d A A UNION DUES. list tne name ot each UntOn and .mount paNt to ,ItCh UniOn Ent., total ""-m" a Arnow"' "-_ .. Amount A .......&~"1 ffa...." "",,}unl PAHI B WORK CLOTHES AND UNlfOfUIS. Ot:SCllptIDn and .mollnls pald Clot,,"n!] ""utt nol bP. sUII.blf 1m eyerydtlY use B PART C SMAll TOOLS ."0 SUPPLIES ee"L'tphon .lId ..~ounh paid Touls afld ~UWIlf!:-' mu~1 !'tel be f1Tn\l~ by lte flmpl<lY'" c PART 0 PROFnSIONAL LICENSE FEES. llaLPIlACTICE "SUAANC' allD FIDElITY IOND PRfIlIUllS o.~crlplWJn .."" amount patd o PARI f TRAVEL AND MilEAGE. Enlll!! 1i1lT10Uflt hU1l1 ",ll.:l..;flt:(] r Olm <(\(Hi ,. rl;:tI""fi'l nthl" "'pf'''~fl'' l'Ullll"'t!' 4 l" fo'"' :~O(. Ju::,(flbl' E ,~'" ' ".' ~'.' ,~. '. Back Option . lhl' B.uk (Jplion b lor individu,ll~ who ch'~irl' I'\lr.l support, h,\\'(' Iil11il(.d "plll'r hody h,d.IIU (' .lI1d .\1111 ~lllmglh or nl~l'd .1~~i~I,Ulll' Ir,lII\fl'rring. Ihe Back Option includes .1 pJdded b.ld whil h l'.ISdv .Idiust~ tor ~l'.ll dl'pth. II ,lbo irHludl'~ .1 Vdcro@ seat belt. Addition.11 support oplion\ .11(' aVililahl1' dl'pl'lllling on your Ill'l'd\. It\(' !I.u ~ h(,I.~hll" Ill" lIolllll\(' .,t,..1 ,lnd II ,ldIU" 101 '>(,..1 dt'l>ch III.n (1lIlJPIOd,ll( I/uIiVKlu,d.. !rtJlll ,11)4II1I1\U11.1It'l-.. .n," 10 h'-,.' " ,., 1!:/' t~...-.,IIr1. 11.,tt'.-Q',I','-'. Ihp FasySland SOOO f\IOWS with you. TIll' ,ldjustable fr.llll'" Lan he used by individual~ Irolll 4'(," 10 ("S". Thl' klll'P \UPIKlIt .lI1d lront support p,ll! arc' .IV.lil.1hle in .1 sllldller 5Lll' lor ,hurter IIldividu.1"- I hI' I asvSt.md 'l00U will gro\\' ,l~ vou do. l.eah Bllune. .tuae^t , ''J~,.-,.........t.,.,~.