HomeMy WebLinkAbout95-05204
3. On February 15, 1996, Defendant's counsel served upon
Plaintiff's counsel Defendant's Interrogatories addressed to the
Plaintiff (hereinafter referred to as "Interrogatories") together
with Defendant's Request for Production of Documents addressed to
the Plaintiff (hereinafter referred to as "Request for
Production"). A true and correct copy of the Interrogatories is
found in the Appendix to Defendant's Motion in Limine to Preclude
Testimony and/or Evidence at Arbitration at #1. A true and correct
copy of the Request for Production is found in the Appendix to
Defendant's Motion in Limine to preclude Testimony and/or Evidence
at Arbitration at #2.
4. Pursuant to the Pennsylvania Rules of Civil Procedure,
Plaintiff was required to provide responses to the Interrogatories
and Request for Production on or before March 18, 1996.
5. By correspondence dated June 25, 1996, Defendant's
counsel contacted Plaintiff's counsel and requested Plaintiff's
responses to the outstanding discovery requests without further
delay. A true and correct copy of the Defendant / s counsel's
correspondence dated June 25, 1996 is found in the Appendix to
Defendant's Motion in Limine to Preclude Testimony and/or Evidence
at Arbitration at #3.
6. In light of Plaintiff's failure and/or refusal to provide
responses to the propounded discovery, Defendant's counsel filed a
Motion to Compel Discovery, to which the Honorable J. Wesley Oler,
Jr., issued a Rule returnable within 20 days. True and correct
copies of the Defendant's Motion to Compel Discovery together with
the Rule as issued are collectively found in the Appendix to
Defendant's Motion in Limine to Preclude Testimony and/or Evidence
at Arbitration at #4,
7. In light of Plaintiff's failure and/or refusal to respond
to the Rule as issued, the Honorable J. Wesley Oler, Jr. entered
and Order dated December 5, 1996 which ordered to Plaintiff to
provide "full and complete answers (without obiectionsl to
defendant's Interroaatories and shall produce all documents
reauested in defendant's Reauest for Production of Documents within
20 davs of service of this Order or suffer further sanctions upon
application to the court." (emphasis added.) A true and correct
copy of Judge Oler's Order dated December 5, 1996 is found in the
Appendix to Defendant's Motion in Limine to Preclude Testimony
and/or Evidence at Arbitration at #5.
8. On December 26, 1996, Defendant's counsel received
Plaintiff's responses to the Interrogatories and Request for
Production. Plaintiff's responses falls woefully short of "full and
complete" responses and fail to provide Defendant with the
requested information which is properly subject to discovery. True
and correct copies of Plaintiff's responses to the Interrogatories
and Request for Production are collectively found in the Appendix
to Defendant's Motion in Limine to preclude Testimony and/or
Evidence at Arbitration at #6.
9. In light of the Plaintiff's failure and/or refusal to
provide full and complete responses, as ordered by Judge Oler,
Defendant's
counsel
contacted
Plaintiff's
counsel,
via
correspondence dated March 8, 1999, and requested Plaintiff to
supplement its responses with full and complete information. A true
and correct copy of Defendant's counsel's correspondence dated
March 8, 1999 is found in the Appendix to Defendant's Motion in
Limine to Preclude Testimony and/or Evidence at Arbitration at #7.
10. Specific deficiencies in Plaintiff's responses, of which
supplementation was requested by Defendant's counsel, include:
Interrogatory 20. State the name, last known addrees. name
of employer and present whereaboute, if known, of each
pereon whom you or anyone acting on your behalf, knowe or
believes to have been a witness to the incident on which
thie euit is baeed.
Anewer. To be provided upon diecovery,
Interrogatory 29(0). The name and address of any person
who has taken any photograph showing the injury,
Answer. To be provided upon discovery,
Interrogatory 30, When, where, and by whom did you laet
receive any treatment from a medical practitioner or
hoepital, whether or not related to the injuries allegedly
sustained in the accident?
An.war. When, to be provided upon discovery, Where,
Orthopedics of Allentown, By whom. to be provided upon
discovery ,
Intarrogatory 31(b) and (a). Are you claiming any excess
or unpaid medical expenses as a reeult of the accident?
If eo, state.
(b) the dates of eervice for each such bill,
An.war. To be provided upon diecovery,
and (a) the amount of each euch bill,
An.war. to be provided upon discovery,
Interrogatory 32. Do you cla1m any aggravation of a
preexieting condition as a reeult of the accident? If eo,
etate,
(a) Ths nature of the preexisting condition.
An.war. I previously injured my foot,
(b) How long had it existed prior to the accident,
Anawar. Since 1983,
(a) The namea and addreeses of all persone and
inetitutions treating you for the preexisting condition
prior to the time of the accident,
An.war. Allentown Orthopedic Associatione (see attached
for address) othere to be provided upon diecovery.
Intarrogatory 37, Are you claiming any excess or unpaid
wage loss ae a result of the accident? If so, set forth
the total amount claimed and how it is calculated,
An.war. To be provided upon discovery,
Interrogatory 40. Identify each person that you expect to
call as an expert witnees at trial ~r arbitration in this
matter and with regard to each euch person state the
following.
Answar. To be provided prior to trial or arbitration.
(a) Subject matter upon which the expert is expected to
teetify,
Anawar. No answer provided
(b) Substance of the facte and opinions to which the
expert is expected to testify and a sunvnary of the grounds
for each such opinion I
Anawar. No answer provided
(a) Qualificatione upon which [expert] intends to relate
in order to quulify as an expert at trial.
Answar. No anewer provided
Intarrogatory 41. Identify with epecificity all ineurance
carriers, government agencies, and/or other sources from
which you are receiving benefits or to which you have made
a claim for damages and injuries allegedly suetained in
the incident in questions, Pleaee supply available policy
number and claim number and describe the benefits received
and/or claims made,
An.war. No answer provided.
Intarrogatory U, For each such insurance policy [as
identified in your reeponee to interrogatory 42] the group
contract or other eimilar plan or arrangement, describe
the nature and terme of the coverage benefite available to
you at the time of the accident or eubsequent thereto,
Answar, See policy (note. no policy was attached,)
11. In addition to Defendant's counsel's correspondence dated
March B, 1999 attempting to obtain full and complete responses to
the previously served discovery requests, Defendant's counsel also
served Defendant's Interrogatories addressed to Plaintiff (Second
Set) (hereinafter referred to as "Second Set Interrogatories") on
March 10, 1999. A true and correct copy of the Second Set
Interrogatories is found in the Appendix to Defendant's Motion in
Limine to Preclude Testimony and/or Evidence at Arbitration at #B.
12. Pursuant to the Pennsylvania Rules of Civil Procedure,
Plaintiff was required to provide responses to the Second Set
Interrogatories on or before April 10, 1999.
13. To date, Defendant's counsel has not recei ved
supplemental responses to the Interrogatories and Request for
Production as requested by correspondence dated March 8, 1999, nor
has Plaintiff received any responses to the Second Set
Interrogatories as served on the Plaintiff on March 10, 1999.
14. Notwithstanding the fact that Plaintiff has not provided
full and complete responses to Defendant's previously served
discovery requests, Plaintiff's counsel has listed this matter for
arbitration.
, .
15. Defendant will suffer substantial prejudice and will be
unablfl to assert a knowledgeable and informed defense in this
matter without first obtaining the discoverable information sought
through Defendant's Interrogatories, Request for Production and
Second Set Interrogatories.
16. Arbitrators have exclusive jurisdiction in matters
regarding the admissibility of evidence in an arbitration
proceeding and great latitude is granted to the arbitrators in
their determination as to what evidence may be presented. ~
qenerallv, Duquesne Liqht Co. v. Pittsburqh R. Co., 400 Pa. 565,
162 A.2d 350 (1960) I Jewelcor. Inc. v. Pre-Fab panelwall. Inc., 397
Pa.Super. 78 579 A.2d 940 (1990).
17. In light of the fact that Plaintiff has had in excess of
three (3) years to provide sufficient responses to Defendant's
discovery requests and has now listed this matter for arbitration,
Plaintiff should not be permitted to present any testimony and/or
evidence beyond what Plaintiff has already produced in response to
Defendant's discovery requests.
WHEREFORE, Defendant, Joseph Ullom, respectfully requests this
Honorable Arbitration Panel to preclude Plaintiff, Glenn Derkosh,
from presenting testimony and/or evidence not previously disclosed
by discovery in light of Plaintiff's continued failure and refusal
to provide full and complete responses to discoverable information
sought by Defendant.
Respectfully submitted,
McKissock & Hoffman, P.C.
Date: ~~~/.97'9
BY~~/
Edwin A.D. SChwa~
Attorney I.D. No. 75902
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
CERTIFICATE OF SERVICE
I hereby certify that I am this day serving a copy of the
foregoing document upon the person(s) and in the manner indicated
below, which service satisfies the requirements of the Pennsylvania
Rules of Civil Procedure, by depositing a copy of same in the
United States Mail, first-class postage prepaid, addressed as
follows:
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2 Box 2287
Jim Thorpe, PA 18229
Ruby Weeks, Esquire
Arbitration Board Chairperson
10 West High Street
Carlisle, PA 17013
Jacqueline M. Verney, Esquire, Arbitrator
44 South Hanover Street
Carlisle, PA 17013
Lindsey Dare Baird, Esquire, Arbitrator
37 South Hanover Street
Carlisle, PA 17013
McKissock & Hoffman, P.C.
BY:
~~uire
Supreme Court I.D. No. 75902
105 North Front Street
Suite 205
Harrisburg, PA 17101
Telephone: (717) 234-0103
DATED:~/ ~ /S7,P?,
Attorneys for Defendant,
Joseph Ullom
3. On October 2, 1993. at approximately 09:20 hours. hereinafter the date of
accident. the Defendant Driver was the owncr and operutor of the vchicle being driven at or near
Space MNI of the fairgrounds. in the County ofCumbcrlund. und Commonwculth ofPennsylvanlu,
4, On the dute and time of the ueeldent, the Plaintiff, Glenn Derkosh. was a
pedestrian standing at or neur Spuee MNI of the aforesuid fairgrounds.
5. It was the duty of the Defendunt Drivcr. Joseph R, Ullom, to operute the said
motor vchiclc with due care and caution in accordance with the upplicable statutes und ordinances,
in effect at the said time and place,
6, The collision between Defendunt's vehicle and the person or Plaintiff, Glenn
Dcrkosh, was causcd solely by the negligcnce. carelessness und rccklessncss of Defcndant. in that
hc, Defcndant:
u, Carelessly. recklessly, and negligently failed to maintuin a propcr
lookout;
b, Carclessly. recklessly. and negligently failed to muintain proper und
reasonablc control over said vehicle;
c, Carelessly. rccklcssly, and ncgligcntly operuted said motor vehicle at
un excessive and dangerous rute of speed in light ofthc traffic then and therc present;
d, Curclcssly, rccklcssly. and ncgligcntly fallcd to sound a horn or
otherwise give timely warning ofthc impcnding collision;
2
e, Carelessly. rccklessly, and ncgligcntly operatcd his vehicle in such
a manner as to cause it to collide with the person of the PlaintiIT,
7. As a dircct and proximate rcsult of onc or more of the aforcsaid careless and
negligent acts or omissions of thc Dc/endant Drivcr. Joscph R, Ullom. thc vchiclc bcing drivcn by
thc Dcfendant Drivcr, Joscph R, Ullom. violcntly collidcd with thc pcrson of thc PlaintiIT, Glcnn
Derkosh, in which PlaintiIT. G1cnn Dcrkosh was a pcdcstrian,
8. As a dircct and proximatc rcsult of the aforesaid. the PlaintiIT, G1cnn Dcrkosh.
was violently shakcn and suITercd severe. scrious and possibly permancnt injurics to the boncs,
curtilages,ligumcnts. musclcs. ncrves and tissucs of the body, PlaintiIT. Glenn Dcrkosh also suffered
a sudden and violent shock to the ncrvous systcm, as well as aches, pains. mental anguish. shock and
disability,
9. As a dircct and proximate result ofthc aforesaid, the Plaintiff, G1cnn Dcrkosh,
incurred in thc past and will in the future continue to incur grcat pain and suITcring,
10, As a direct and proximatc result of thc aforesaid, the Plaintiff, Glenn Dcrkosh,
has incurred and may continue to incur furthcr mcdical expcnse and income loss.
11, As a direct and proximate result of the aforesaid, thc Plaintiff, Glcn Derkosh,
may have suITcred a permanent disability and a pcrmancnt impairmcnt of his earning capacity,
12, As a dircct and proximatc result ofthc aforesaid, the Plaintiff, Glcnn Dcrkosh,
may havc suffered a pcnnancnt disfiguremcnt.
13, As a dircct and proximate rcsult of his injurics, Plaintiff, Glenn Dcrkosh, has
sustaincd a diminution of his ability to cnjoy lifc and lifc's pleasures,
3
WHEREFORE,PlaintiO: Glenn Derkosh. demundsjudgment in his favor and against
Defendunt. Joseph R, Ullom. in an amount in excess of thc arbitration limit. plus intcrcst. costs,
attorncys fccs, and dclay damagcs,
Datc: <"'-'-(,,-"1"
Grego ousscau, Esquirc
Attorncy for Plaintiff, Glcnn Dcrkosh
Attorncy 1.0, # 56530
Pinc Ridge Professional PllIZl\-Routc 903
He 2, Box 2287
Jim Thorpc, PA 18229
717-325-9448
4
b: c') '-
<<='~ C> 1-:
I" ., I ..-:,:
r") _7
UI_c. .-;.
Q-' :.: ). .
If~ .--
"'..... .-j
01
. . CO:> .,
@L. '" i
; "
~.-I , C-' ';",
[.!:. .' . "(...
r" L..
u. ,.... ..'
(.) In .;.;
7. It is admitted that there was some contact between defendant's vehicle and the
plaintiff. It Is admitted further that plaintiff was a pedestrian. The remaining allegations of
paragraph 7 are denied.
8-13. Defendant Is without knowledge or information sufficient to form a belief as to
the truth of any factual allegations set forth in paragraphs 8 through 13 and therefore they are
denied. Defendant specifically denies that he caused or contributed to any h\Juries or losses
allegedly sustained by plaintiff.
WHEREFORE, defendant, Joseph R. Ullom, asks that judgment be entered In his
favor and that plaintifrs Complaint be dismissed with prejudice.
NEW MATIER
14. Plalntifrs Injuries and/or losses, If any, are barred or limited under the
provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law.
IS. To the extent that plaintiff is bound by the limited tort option, plalntifrs claims
for non-economlc damages are barred.
16. Some or all of plalntifrs medical expenses and/or loss of Income have been paid
and therefore are not recoverable pursuant to 7S Pa. C.S.A. ~1722.
17. Plalntifrs Injuries and/or losses, Ifany, were caused by persons or events
outside of defendant's control.
VERIFICATION
I, Joseph R. Ullom, hereby aver and state that I am the defendant in this matter and
authorized to sign this Verification and that I have read the foregoing Answer to Plaintiff's
Complaint with New Matter. The factual statements contained therein are true and correct to
the best of my knowledge, information and belief.
This statement is made subject to the penalties of 18 Pa. C.S. 04904 relating to
unsworn falsification to authorities, which provides that if I make knowingly false statements,
I may be subject to criminal penalties.
$,,""A n VH...,
J6SEPH R. ULLOM
File No.: 8350-19 (JJM)
Lon t. t
~ ." 1L~
.:-..... -a rP
~~ ~. , . ('1_ 00
,
:'~ (t
~ rri :- .~' 0 J n
1..'-"- , 0 0
LO t[) 'J
- 0 l[) - en
en ~ (() lf) 11 tl
hJ :t
.... ~ ~ <:L
~ ,,' "t
.
Commonwealth of Pennsylvania
County of Cumberland
Glenn Derkosh
208 West Railroad Street
Newquehoning, PA 18240
VI.
Court of Common Pleaa
Joseph R. Ullan
3083 Auberle Street
Carlisle. PA 17013
No. m~.?:.!!~9L<<;;!YJ.LT~.mLm_um_ 19____
In m _<.;; y}}.:_ e..9.t!9!l_-":_ ~.!L _ --____m__n___.
To _.J~~P!l_~._YJllQUL______________._________
You are hereby notified thaI
.-----------------..._____________~D_~r~_____.._______.________________________________
the Plaintiff has commenced an action in --CiyJ..l..AC.t:J.ru1.=_.J..ill>'____u_____u_____.___n_._______
against you which you are required 10 defend or a default judgmenl may be entered against you.
(SEAL)
Lawrence E. Welker
'-..----.---.-.---.p~th;~;t;~-----.-.-.------.-
Dale __~<:!,>~~I!,:!__~~!!1____________ 19~~__
C-. r h
By ---LI,..t\.~--u.._D_\w~:J~.!_!:H_":\..J:~_'C~~t
Deputy
December 11, 1995
Wr~t of Sum
,...
'.
\
IP' '.
.ll... rlll: )".,', I';' 11
.!.ll!l;ldn~Li\I.
ttllJ~ T' Ii}'
j'"lltl
,",!;1:
..\'
Hili
tlll:!.!.hl
,
[\;'
1\~:ht'.(.I: II :d.Llltl
\'("
,,'.
lILLLlt!. .1IY;EI. II f.:
ri~ 'qlnm'L h J lIP,'
'ilr; ]
,.
11"" ,
',; t 1 " I " I r 1 ,~ I j II t ::
l.u lAW, :)-IY
Ii 1\
, I'; . , .j , , it' ." , I I .11 j I ilq " I ,
, . "
W I I ,! (In It , I'TII h
Odll\L"j lJl:1'1 'lid ifl1
but "'dU Ulldbl(' 1,(1 l(l" II..
.
r:h.'pt1t.l:.':r-'d t_11'~;! i'l J r
I I ~
WFIT 1iJ. '.I!lliIIIW.
to ~~:l_q\-'," tIll H;ll1lll
Un
tl(!,/,ombPI
1 (.j h, 1 ;':"1",
thr? .'.It.I.!\chl.d {,';',lllll :11'''\
Sh f." r 11' J'
(0;;_.' .,
[:i""I:.,'.t .1/jl!
(-illt (II 1"I'llI1 i'
~::lJrl;tl'J1 Ill:
~~n t ~ I ,.
t\ 1 ti'idll'II\' j i
1- ''''
I I'il,',
1);1
(1;'
I, c,,')
""'-'. (\;,';i
1::
,d
itull
\,1",'
.\
.Ill'l!
I II L
L. (t l. j .... 1;:-' I:.
!\l. t .F(~il!' qy
(,f' I) n t i'.
!, I) ]; "1 t J
'd I ~' ! II
\', 'Iill t, {' !'. 'rill:;)'! VHn 1 d,
. - " '. . i ~ I t I~ \ I
!\l ,! Fe,,;! 'fl\'
o;"'! I, ,It:l !'I'lllflll
t(l!
I )I' .... I ~, I! 1 f I
Ik
hcrC'1flT l;'
":'rlrl:~',' 1'/ 'JIl.l ;1.
// )/)
..~~: //0/ /
~":-:--7 "'
;/E';("" "0"""'"'" ,~"
,/
j d"1 Ihi I'~ lJ,1; t. '! All
}1 -1"';.
OfF': ."
", " " ' L, j"~
OCT 2 7 ~,- ../"
J ". JJ
I',
M
0
0\
21
~
J I
111
I I ~
I !/ .",
m I :'~ ~
:;:j .S
,~ 8 1 ., ~~ ~
U II
.r:: _ ;::j I !5 ~l;;~
.. & ::> ....
0 ... .j..J ~ .~
N M . I .\! if~J~
trl '" I
I I .-j I
trl ~ I
0\ I ~ I '...
I . >
& '... alN I
.-j U/ ,!:j !t!.~~
~ ~ ..., I ", ...,,, I
I I
I I I
._....1
ii=E In ?;
~ <=>
ft~ 8 ::)~
- Ol:~
t :c: ():'h-'
-'I: 8~
E? - ='Y'~""1
- _J.-:.
1lI U C1..--.
turD
;:E lLJ 8Jo...
0
t5 In :8
0"\ (J
IN TilE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY. PENNSYLVANIA
CIVIL ACTION - LA W
GLENN DERKOSII
208 WEST RAILROAD STREET
NESQUEIIONING.PA.18240.
Plaintiff
VS,
NO, 95-5204 Civil Tcm!
JOSEPII R, ULLOM
3083 AUBERLE STREET
MCKEESPORT. PA. 15132.
Dcfcndant
CIVIL ACTION - LA W
WIUT OF SUMMONS IN CIVIL ACTION
TO: JOSEPH R, ULLOM
You arc notificd that GLENN DERKOSII. thc PlaintifT. has commcnced an action
against you,
Datc: 9- J q- 75-
L HUI',,\ t( C !\J f{fqr
Prothonotary
By b_ /.- ( /1. Jf ~t l..~ ~.
~puty (j
(_~I (t 1/1/1 t.-t II /1?J
V . A.(.L--j /L'JI'L/1l1. (
J Al.,t~ n r ) I
' [/~LL:'~_JIU'~
~Q,' I?d~ ~'(). m-
e/ ~~
CAsE:
PROOF OF SERVICE
.
Glenn lJerkosh
95-5204
.1 ., pYln"lfllJ
f,lo No
Joseph H. Ullan
III
11 .1 dol._nl(')
--- . .iciscph R.'Uilcin
SERVICE OF PROCESS ON: _ '__'______. ______
. . ..___.L.~.2t~ll..!.2J.L.1f""1PI ____ ____
- i\l!!n..J.:o.t:riJdc.... _ ___._______. "'_"ll'>4I<I. bOo"ll duly ._n. dopa... .nd "V' ,
tholll h. ~all 011 Ih~ hrrld ~f ,....,..:t', O'tlftr 1M .."", r.1 tWf!,..,y.onf, ....." no'" PfrtV to Ih.s ":1.",.,
DATE OF SERVICE:
-".....-.----..--.-'..-...-.--.......--------
50 ~.doc.l!......M
PLACE OF SERVICE:
.--.
---
Ih., nn fhe .._-'_ dtl, uf _.J;!nll:\'1'
If, 96
,II_L
-....-----...
,----
.----
II --.JOe:! l"lOOrla-.StEeet- III.h. 1:0', ol_Jk:KceSport 1\.111 01 _ PA
~Irit, Sl.il1l11OllS in Civil Action
Ih" :.,tndl'r'-t~I'Wd tr''1('d ft,~ "'lI''';rt-J p.'p~r) ________ ____
IUIf Of Al.U. OGrCUMl..." 54......01
-..-...--. -----.--.-....--------
..ow_..__.________._.._._
-.-------..-.-..-----.
PERSON SERVED
---..--_...._....__r-_
----...-..---...-....-.-.-..--
AND METIiOO
OF SERVICE:
.,. CAilrft.-u# w...
i:r.:;--.1:::;~.. ,It.
-- .. ......
DESCRIPTlflN OF
PERSON RI:CEIIlING
DOCUMENl"S:
PROOF OF
DUE'" DILIGENT
ATTEMPT:
SIGNATlJRE OF
SERVER;
~~r1'''IIC.n
o Required
o Not R.q..ll'ftd
,
---.-.------,'
,
I
._.__1
I
;. 1tU\' i:.,d Cl)'f!('! '~Pl' llf Info ,,1(Jff'.i',.d p~~~', '..ert' ,el\l~d 0(1 ~ht at~",.'n,.mt"c:f pcIt1_' or wl1rt,u. In .tl.t
I"",...",. mAn',., Joseph R. Ullan
t.XK.. PO'\~:1i1l1l' (,eII'olt"nQ ~hCr1'lI"'!,) the ....and:.. at the pe'51on 10 be Ioelvsd _.._..__....____.
*::1 ISut;lS."li.tfC; Etl' lu...ng.. fOp" al h'I/"~' us.,.1 fWace Of aO<A1Il WI(" r.on~ ~'!oOn 0' 5/J.".JI0Je ~ .r.o::
dl~':fell(."" thfn "sldln~ tt".tff(.lIn. I:. ,.....t __..____ .__...__.
o Uv dt.'I,\ Nln~ H"i'~l 10 j)n off,,~~~ ..11 r:"I."'!\g.ng Ig.lnl who,. n.m. .no IllIG d __u_...._____.._._.______
---.-----.------.-------.- .
------------
O,r,d' .u.______....___..._____ .
..-.---..----------. -...--
..._-_..._._--_.__.__.~---
-----.-..-..-.
.-----..-.-------------
.----.---
----..-..,-
n'e pt."Hln '!tc.\'IIi.n;J d<'cum\"u~ It. dc.'SC'IN-d ill fOIiO....'-
5.;. _.._Male.__ S..,., C';Ilar _-White._ Hd" C~Iv'
Aoc 1~loJ : _..__..50_.__ HU'Jht (p;o. I _.6.!n"
__. F.c~1 ti.1I' ~JctlQ ...
. \......hl (pta. I 200
C '" I'" bot., DJf In, lInol".... I owl 1-'..' ....r! ~U., ..... nel ."'..~d ,.. IhI U 5 M,l""", II thII "'"'" ~ ..._..
DAFTER OUE AND Dll.IGfNT EFFOHTS. UNDERSIGNED WAS UNABLE TO EFFECT SERViCE
o FACTS INDICATING DEFEhlDENT is AVOIDING SERVICE ARE _______ ___,____..__.
...-..--..------
... O~TtS OF SERVICE
ATTlMPTEO
iIMf:S
AfTEMPTEO
__. _ _. o'..:1oc1. _ M
__ _ O'Clock _ M
_ . o'clock _ M
AI>rJRESS
ATTEMPTlO
Rt ASON FOR
loION SER\'oCE
U'lde,,'Oned drcLII'e!a un~1 pc:t..Il~ ul pet'JurV
Dt~~]1:~~:~.'=:A=26
r""'mr of WIfVttl ld.l~l
SubloC'lbPd & SWOtt\ to b.lotl "... thIS
4 .Trtnl1:ny ,19 QI\
hl~IIIVJf.rnil"/I",.....,i."-.....;...ol" .~J!!'l
EMPIRE INVESTIGATIONS
"ai' Thl hefl"
.'11'11"""'1 \"I"tlll
I tll',I""'I.1I .-. Pt'l',', WAI"" 10,'0',
IU1. III '0"
I~ <D G
c;:;J .~
.. :71.,..
.:::' <):)
0 u: U:,JI
-c; "
. r... Cl:-.i
0 ~ .. ',.
0; CO ~ "'(n
u. ..J>:;
l~ .
l" ,.'1,.6
F!:: .~ !.J,(l..
-, ~:j
lL \"
0 en (J
McKISSOCK , HOFFMAN, P.C.
BY: John J. McGrath
Identification No. 42389
105 North Front street
suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS.
JURY TRIAL DEMANDED
JOSEPH R. ULLOM
NO, 95-5204 CIVIL TERM
BNTRY or APPBARANCB
TO THE PROTHONOTARY:
Kindly enter my appearance as attorney for defendant,
Joseph R. Ullom, in the above matter.
McKISSOCK , HOFFMAN, P.C.
>- <.0 ',-
cr; "J I::;
i~:
Cl ..
~~" ~"'J ; -~ 7-::
(- ':..
p:~.,! .'.
~. ~.t_ u_ . .'
6L~ ." .
_I!. . ~:, "
1.Z...fL..- I I
u.: :'; ,-:\ ..
LJ , j,.j
. ,.~ L.... : .i....
I.!. ....., ..
\.) f.; \ CJ
McKISSOCK , HOFFMAN, P.C.
BY: John J. McGrath
Identification No. 42389
105 North Front street
suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS.
JURY TRIAL DEMANDED
NO. 95-5204 CIVIL TERM
JOSEPH R. ULLOM
PRAECIPB TO .ILB COMPLAINT
TO THE PROTHONOTARY:
within
of Non
Please enter a Rule upon plaintiff to file a Complaint
twenty (20) days hereof or suffer the entry of a JUdgment
Pros.
P.c.
----------------------------------------------------------------
RULB TO PILB COMPLAINT
AND NOW, this 1{l. day Of.J.l 6-t.u. ot-^.t I , 1996, a Rule
is hereby granted upon pJ(aintiff to file a compLhint herein
within twenty (20) days after service hereof of suffer the entry
of a JUdgment of Non Pros.
~
~.. '-"
c..!~ i'-
.' <'J
," .-
..
we' ,-..:) .. ,
(..:.r."
p:P .)
1.-' "- .'
)?l' 'J..
~i:j:: . It)
I .. ,
L:; ~:.' (.
I"~ ILl '('.1
,..
II.. I.... I.~
,
0 \F) ~-~j
.., C)
. ..
IN THE COURT or COMMON PLEAS or CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LA W
GLENN DERKOSH
208 WEST RAILROAD STREET
NESQUEHONING, PA. 18240.
Plaintiff
VS,
NO, 95-5204 Civil Tenn
JOSEPH R, ULLOM
3083 AUBERLE STREET
MCKEESPORT, PA, 15132,
Defendant
CIVIL ACTION - LAW
PRAECIPE
TO THE PROTHONOTARY:
Kindly substitute the attachcd Vcrification Page to Plaintiffs, Glenn Derkosh,
Complaint which was filed on or about February 28. 1996 in the nbove-captioned matter..
Dnte:2.l11 k~
Grego , ousseau. Esquire
Attorney for Plaintiff. Glenn Derkosh
Attorney J.D. 1/ 56530
Pinc Ridge Professional Plaza-Route 903
HC 2. Box 2287
Jim Thorpe, PA 18229
717-325-9448
McKISSOCK & HOFFMAN. P,C,
BY: John J. McGrath
Identification No. 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT or COMMON PLEAS
CUMBERLAND COUNTY
vs,
JURY TRIAL DEMANDED
JOSEPH R. ULLOM
NO. 95-5204 CIVIL TERM
CERTIFICATE OF SERVICE
I, John J. McGrath Esquire, attorney for Defendant hereby certify that I served
Defendant's Motion to Compel and Brief in support thereof and a true and correct copy of
the attached Rule Returnable dated October 2, 1996 and issued by Judge J. Wesley Oler, Jr.
was served upon plaintiffs counsel by First Class Mail on October 10, 1996 to counsel listed
below:
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229
McKISSOCK & HOFFMAN, P.C.
.' '.
~ <.::
~~: .. . ~ ~~
UJr~ ... 'oJ:-,"
O. ..):~
p.( z.-: \ :.J
.1..-
':.-r "-
(.sc !,) , Iii
c: L. ('..: 1 ~;:~
~I" '.ltiJ
.- I' , L'-
u.: "j (
I.' e
l t~ , " (j
co ,. .
. .
McKISSOCK & HOFFMAN, P.C.
BY: John J. McGrath
Identification No. 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs.
JURY TRIAL DEMANDED
JOSEPH R. ULLOM
NO, 95-5204 CIVIL TERM
ORDER
AND NOW, this ,:i ftday of i)" o....~
, 1996, this court having issued a
Rule to Show Cause upon the plaintiff and it appearing that the Rule Returnable was served
upon plaintiff's counsel and no response filed, it is hereby ORDERED that the Rule is made
absolute and defendant's Motion to Compel Discovery is hereby GRANTED.
It is further ORDERED that plaintiff. Glen Derkosh, shall serve full and complete
answers (without objections) to defendant's Interrogatories and shall produce all documents
wl1i.l.l"I' 2,0
f:' r~vstetin defendant's Request for Production of Documents 'rillllel. (18) days of service
l .. of .this Order or suffer further sanctions upon application to the court.
:~.".....
~.' ~;!_._---::-;
lL ,.'; ',J
, ~
l.
l.
BY THE COURT:
~,-, ,.-~,
}'
,"",",
Z i :: ~
.., )
,
,
McKISSOCK & HOFFMAN, P,C.
BY: John J. McGralh
Identification No. 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs.
JURY TRIAL DEMANDED
JOSEPH R. ULLOM
NO, 95-5204 CIVIL TERM
PETITION TO MAKE RULE ABSOLUTE
Defendant, Joseph R. Ullom, by his attorneys, McKissock & Hoffman, P.C.,
respectfully petitions this Honorable Court to enter an Order compelling plaintiffs responses
to discovery and, in support thereof, avers as follows:
I. On or about September 26, 1996, defendant filed a Motion to Compel plaintiffs
responses to defendant's Interrogatories and Request for Documents, which discovery
requests had been served upon plaintiff on February 15, 1996, A true and correct copy of
defendant's Motion to Compel is attached as Exhibit "I".
2, On October 2, 1996, the court enter a rule upon the plaintiff to show cause why
defendant's Motion to Compel should not be granted, A true and correct copy of the court's
Rule Returnable is attached as Exhibit "2".
3, By letter dated October 10, 1996, plaintiffs counsel was served with a copy of the
Rule Returnable, A copy of defense counsel's October 10, 1996 letter is attached as Exhibit
"J".
. .
4. More than twenty (20) days has passed since service of the Rule Returnable upon
plaintifrs counsel and defendant has not received any response to the Motion to Compel nor
has defendant received plaintifrs discovery responses.
S. Pursuant to Pa. R.C.P. 4019, defendant is entitled to an Order compelling plaintiff
to serve full and complete answers (without objections) to defendant's Interrogatories and to
produce all documents requested in defendant's Request for Production of Documents.
WHEREFORE, defendant, Joseph R. Ullom, respectfully asks that this court make
absolute the Rule Returnable dated October 2, 1996 and enter the attached Order compelling
discovery .
Respectfully submitted,
McKISSaCK & HOFFMAN, P.C.
BY:
,j
J n J.McGrath
Attorney for Defendant
Joseph R. Ullom
McKISSOCK & HOFFMAN. P,C,
BY: John J, McGrath
Identification No. 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs,
JURY TRIAL DEMANDED
JOSEPH R, ULLOM
NO, 95-5204 CIVIL TERM
DEFENDANT'S MOTION TO COMPEL DISCOVERY
Defendant, Joseph R, Ullom, by his attorneys, McKissock & Hoffman, P,C.,
respectfully seeks an Order compelling the plaintiff to answer defendant's interrogatories and
to produce the documents requested by defendant. In support of this motion, defendant says:
1. This action arises out of a motor vehicle incident which occurred on October 2,
1993.
2. Plaintiff, Glenn Derkosh, commenced this action by filing a Writ of Summons on
September 29, 1995.
3. In response to defendant's Rule to File Complaint, plaintifrs Complaint was filed
on or about February 26, 1996,
4. On February 15, 1996, defendant's counsel served upon plaintifrs counsel
Defendant's Interrogatories and Defendant's Request for Production of Documents. A copy
of counsel's cover letter is attached as Exhibit "A",
5, As of June 25, 1996, plaintiff had not responded to defendant's outstanding
discovery requests, By letter dated June 25, 1996, defense counsel requested that plaintiffs
discovery responses be produced without further delay, A copy of counsel's June 25, 1996
letter is attached as Exhibit "B",
6, As of September 23, 1996, plaintiff still has not responded to defendant's written
discovery requests, although the time for responding under the PA Rules of Civil Pr\JCedure
has long since passed,
7, Plaintiff has not objected to any of defendant's discovery requests nor sought a
protective Order,
WHEREFORE, pursuant to Pa, R,C.P, 4019, defendant respectfully requests that
this court enter an Order compelling the plaintiff to file and serve full and complete answers
to Defendant's Interrogatories and to produce all documents requested in Defendant's
Request for Production of Documents,
McKISSOCK & HOFFMAN, P.C.
J n ,McGrath
Attorney for Defendant
Joseph R. Ullom
,
McKIssacK, & HaFFM!
^ n,nt'eUIOHAL (OK rUM Mill,..
ArrllRN~"V1 AT tAW
17'" MARKlIT SfIU!Jtr
SUrf!.! ,)OX)
rtlll.ADl:lJ'IIIA, rr.NNIYl~NIA 1.IO~lOJ
.. SKuce ~llIIOCl
'8TU L fllt'TWAN
lCIlAaD l. Wd4OHfGLe. 'a."
WUD "''''HI MIUJlA
IIU, 'Aun CLAlII
M,Unmt 1 ClllUTIANSeH
PAUL.. llnlOAH
CATHI!.alN8 HILL lUNDA
ntH L ~Anl'
OOK4LD" laoocJ. fl.'
WIWAM .. MUNDY'
.. C"lAta lLACI
DIN.... WIUJr
AMY L CUI.IEA a'
1!JlJ!..E.H LAMPI'
DElU ICHWADOU DUNNB
L .OIUT lokM"'toH'
autl L ua.,,"
CllllSTOfOttaa TlIOMSOH'
r.AnU..!.EH II!.HHA ASHTON
I. IUD UAY"-OOO'
JAI" L ntoMJOtft
MAUUDf P. FTTZCUALD t
ANN" CAllHl
VUOHlCA I!. toOHANO
IAnlLUH IHOf.J!TTB .ua~
DI!.U.A CAPOUJ PAY"'!, a.H,'
'ATaICI" D. U""Eat
IIUTEH I!. 'AUU'
'ASQf4 P. aoa:WN'
It<<;alD & HOtICIHSOHO
. ALSO MEMIU Of' NEW IEIlSIIY IAl
, ALSO Io4I!MIU Of' fWtGJ BAa
I ALSO MEMlal 0' FLORIDA IJ'1
rIION,"UIlI""IIOlI
FAX: llll) 1'''\1''
"'.... lu.n OJ,.....
IIIIUnttm..,
WT, ".n, tU.....
IWI'ltll..
'...JILI....'.,.U
"H~lloAi..A Dff-.:u
NH ..BAam..,.
UIjDnOOl
Pt)VlIl1'QWK 'A I_
lUJl........
'''-.UUIM'''Mf
February IS, 1996
III m.m rJOHT n....
IUITlI"
IIAUUIUIOt'4 'fl.
inri .....1
'AICIUlfllM-UM
DlOIQI W,OVIITOH'
or COO.....
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229
Re: Derkosh v, UlIam
Our File No.: 8350-19
Dear Mr. Mousseau:
I have enclosed defendant's Interrogatories Addressed to Plaintiff, Glenn Derkosh and
defendant's Request for Production of Documents directed to Plaintiff, Kindly respond to
these discovery requests within the time provided by the Pennsylvania Rules of Civil
Procedure,
Thank you for your attention to this matter,
11M/e(
Enclosures
Very truly yours,
,-'. ,/' nltPLtl-,
J~CGrath
ock & Hoffman, P.C,
/.
,-
McKIssaCK & HOFFMM
^ 'RO'P.SSIONAL CORPORATION
^TIORNP.VS ^T L^W
1700 M^RKET STREET
SUITE lOOO
PIIII.^Df:lI'III^, PCNNSVLV^NI^ 19103-39lO
NBW 'IlA.BY OfFICI
JOliN I, McORA TII
DIRUCT DIAL 12m 246-111&
PIIONE: (21l) 1....1100
F^X: (21l) 1....11..
IlSIfIOllmEIIT
MT.ItOLLY. "'0I0e0
ltOIII.",..
'AXll_llt"'lOI
October 10, 1996
fliHHIVLYANIA O,"CU
n N. 1I0AD rrun
IHD noel
DOYLUTOWH. .,\ IItOI
UUI)($.4501
'^~ nUl )lJ.4SOI
Gregory L, Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229
101 ,.,ouu nOHT n"IT
IUmll1.
ItAa.UIUIG, fA IflOI
111111)4.4101
'''X!(7I71Ut-IUO
Re: Derkosh v. U1lam
!lY.r. File No.: 8350-19
Dear Mr. Mousseau:
I have enclosed a copy of the Rule Returnable issued by the Court on October 2,
1996 concerning the defendant's Motion to Compel Discovery.
If you have any questions, please give me a call.
Very truly yours,
~2.)"b'7'd#
for McKISSaCK & HOFFMAN, P.C.
]JM/el
Enc!.
:J i EX tH Ilf[/;'
I \.:'~;'" c,
.,...._"..,'...:.
",:;.::- ',' ::-:":;~~: \'?{~:~:-:n~:t:;
C':'. :, ".'.::._ ,\.:~!...-};
~~
~
'"
-
,., '1
,
II!
I'
I.
,
"
(~ r j
" ,
,
,
,. ,
I
~
I!~~ ~
:cl~~~~
~I~~~~
~f~~ s
i2< - ~
~ ~
...
t'""IU'~b''U.''lInl;'''Il''''' ..
~IWO' O:U\unI "'I)IUilll ",
~ :J
~N
~~
NVl
~~
OJ.l;
if
FlLr:O.(';TI8E
OF T:" '.',,; '):'-JIi'Jrr
99FER21, Mill:S9
CU\I:. ',. ., -. I"""
I" _'4' '-/ ~ '". ,~...'.Jl" j 1
pa~j\':)'fLV,\>!',\
~"--
~
..... ~: (;2 cf
t'( c:; '"
.,. --
1-- .. ::J-:( oJ
llJr~ ...:z I )r;.-; ~ ~
C.) ...-~ ~- (.1:;-.
r-l J
1::,: ci: 'J~ \J ~ "-
Cl(-, N .::~
6'< N ');~ 0
l.ljl._- If .." 1:
Ec\" CO U~m Yl :&
(f:". U.I Q~ 0..
u.. ~
1_~ m :s ;;;
0 C"l U
Y~Y-06-99 THU 04:33 PM
. -.n NII.-oaI
1-.. AlI"I YILUI
nu. MI.A.... cu.all
DClM4UIlllOQU 1&.'
& CI.UO &l-'C'l
...-........
I. IUU KA'YWaDI
""""' .....
ICIWI... w.GU:IllI
............
T.lIDN ... Va&A.H
AkN" CoUDI
......... .--
cau c.uam MYWI'
IIIIfT1ftIl.MUII'
.....-......
~.. talNC>>fl
IDWIIf o\.Dt ICICW\m tt
1ll1WI.....
QCATICoUI&. COCIrIUUW'
"'...." JtCD4'
mcmlYt~N'
"""YUTH&~
~..0V'D'n:W
..-
. ~MllGUCI'".",IUIIY....1
, AU!)....... OP a.&.aaI &A.a
. ALmJatOll or fUMllUt Ma
. AUD NUCIU CII If.. 'n)U AND IQfW lUIB'I' lA,
N .uao &DWIU II' &uraICT or CCU"l_"'.....
RUby Weeke, Eequire
Arbitration Board Chairpereon
10 Weut High Stree:
Corliele. PA 17013
Jacqueline M. Verney, Esquire, Arbitrator
44 South Hanover Street
Carlisle, PA 17013
Lindssy Dare Baird, Bequire, Arbitrator
37 South Hanover Street
Carlisle, PA 17013
MCKiSSOCK HOFFY~N
FAX:7172341350
FAGE 1
McKISSOCK & HOFFMAN
^ norl&lXll'W. coafOl4TIJH
^TTORNlIYI "T LA\\'
I~ llOllT\l FIlan'mwrr
IUITBIOI
Kf.1\A]1Bl.'IlO. '!NNSYUlIIlI^ \lUll
m'DlltClrl'WAN
rDrtn .. ALDar
JOlIN.......,"'
"'lUJAW ... NWl:l'V-
IDIDI' W. WILLII'
11__
NM....... .. nTlQU4lD t
oUtY L.CVUlllt.
ICllIbI....~
,..-r WdU.8:Ir
......", 11aIIOtlt
YIIIClt<<4lGCltWf CLa:l.JrtaI'
\1YlAW .... CMU-V .
Mal" cnruu., UI'
tl1D.UEfac.. CAI.IIlII"
ataIINf.. r. ..u."
I.II<ll< e .....
rr.vp l.lQUUlr
AWWLU.AlIl'
1A1W,1.IYta..D&.1U'
-'Of.IIw.mK.\'
I:'QJ W4Urr rrun
alIlI ..
nm..u:aLIKlA., M 11&1.
Ui.D'.31CO
IIAXlU1l)lo4W)4t
'1lONI!i (111) 2lI40l
Mlt (1\1) \)4.11))
.t H4IlDON A'URJI
1\IlTI'"
"'IInDn'. HI otlM
..........
MXlc..."...
N tranI "AHlUH m.arr
"""'"
DO'tUrIQ'n, r.\'"
WI......
MAI(nll MHID
UlOtmt KDf mm
,AItlIC...
"'ar C1tDrU. M t\111
... ......
"'Xl Ud tlUtJl
/o!oy li, l!l99
Via fax 243-4704
y!. tax 2.3-3518
via tax 243-B1l0
R.. alan" nerkolh Y. Jo.eDh L. Ullom
CCP- Cumberland county
Dockat No.1 95-520.
Arbitration Datsl Nay 17, 1999 at 9100 a.m.
To the Mambers ot the Arbitratlon P~nell
It hao been brought to my attention that the documente that
were recen::ly torwarded to you contained a typographical error that
served as cause tor some concern, It appeare oa thought the
attorney who originally dratted the interrogatoriee ulled a "fom"
and neglected to changed the name of the Plaintiff in the title of
the document, It ie my understanding that the retlect10n of "Lisa
Campbell" as the PlaintHt on the cover sheet ot the
Interrogatories (Appendix doouments #1 & #6) caused lIome concern
regarding a pcooible contlict. Please be advised th~t to the beet
of my kr.owledge, the only parties invclved in this cass are Glenn
Derkosh, ae the Plaintift, and Joseph Ullom, as the Defendant, I
do not believe that anyone named Lisa Campbell is involved in this
matter.
t IaOC1I WcllllOCl
LBlUB ANNH WILLI!I.
JILL IAIATZ C1.AIIB
DONALD 11100I1"",
.. caAI[J ILACI
IlILB8N LAW'H'
E. IUD nAn.DOD"
'URn P. lIlWlI
WDfABL w. McQrIIH
'.wi. t IILBY
""11 t VIIAN
ANN.. CA....
IAnfLSIlH .... LOCIWOOD"
IIIU.I.A CAPOZZI '.WNH'
IIUIllN B..AVel'
lT8VeH lUaoI!II 04'11"
IHOI.D .. IIJPKINION'
RDWIN All ICIIW,urn tt
IUNAII PAil'
IDNAnfAN L. COOPUWAH'
YUWBB A. IIIUI'
nl.lJT1fY llULU\AN'
NAaYalml1. C111lf11ANlIlH
~08 w. OVIlaTOH'
...COlI......
ALIO NBMII!I. CF Naw 'EUBY BAI
ALIO wmcau Of' IWNlQ BAa
· ALIO wmcUl Of' FLOI.ID.\ BAa
N ALIO ..mclU or NHW YOI.I AND New .BUIIY IAa
tt ALIO ..melsa Of' DII1'IItT Of' COlUWIIA BAa
McKISSaCK & HOFFMAN
A 'ROPI!IIIONAL CORPORATION
^TI'ORN~-YS ^T L^W
IDS NORTIII'RONT lITR!!L'l"
SUIT!! IDS
II^RRISDURO, "I!NNsYL\I\NI^ 17101
~r."VF'n MAY Q 6 1999
PE'T1!a t IOfncAN
IflJ"PIUY a AlIEU
.IlIIN t WdJaAnl'
WIllIAN lWUNDY'
OIN.......Il..u..
ClI11rTOr1llla nlOWlClH'
MAUIEBH P. fnUlEUlD t
AMY L. cullma.'
DIN A. nLOlIfTO
1 IOeI!WT WtWAIIDN'
'AIA 1 nllMloN'
V81l*ICA f<<lONAN OUZlIWIll'
ViViAN.... GAUD.
11001' .. O'NEILl. rut
l!l'lAltml,. OAaEtlBI"
ClllarrotllU '.Ieuy'
UND4 Co IINO'
n1IVBH J.IC1IlLbT"
AMY U. FUNlt
lAWU J. IUVfO.DI, Ill'
DOlOIEI M.IPINA'
1100 MAIIST ITIBDT
IUm_
PIllLAIELl'UlA.'A I'm
(JU)I..UOO
FAXl UU) 1...11..
PIIONP. (711) 134.Jl103
I'^X, (711) 23H3JO
II. IIADOON .....ENUS
IUITB ~J
wurncwr. JrQ 01101
(1tOI1ua.liS1
I'AXl(IWMI)ISI.l...
at fU11, nANIUM mtun'
ItIITBJOO
POYU1II'O'ft'H.'AIMOl
UIJ)WJ.4K1
MXlUIJ),....JOJ
JI IOVTJI 11I011 mm
'A IOX);)M
WBlTClIEITBJ.,.A 1..1
(.10)1....10
FAXl(..0)7)f.f1U
May 5, 1999
Ruby Weeks, Esquire
Arbitration Board Chairperson
10 West High Street
Carlisle, PA 17013
Jacqueline M. Verney, Esquire, Arbitrator
44 South Hanover Street
Carlisle, PA 17013
Lindsey Dare Baird, Esquire, Arbitrator
37 South Hanover Street
Carlisle, PA 17013
ReI Glenn Derkosh v. JoseDh L. Ullom
CCP- Cumberland C01lOty
Docket No.1 95-5204
Arbitration Datel May 17, 1999 at 9100 a.m.
To the Members of the Arbitration Panel:
Enclosed for your review and consideration is Defendant,
Joseph Ullom's Motion in Limine to Preclude Testimony and/or
Evidence at Arbitration regarding the above captioned matter. The
basis for the Motion is straight forward. In light of Plaintiff's
failure and continued refusal to provide full and complete
responses to previously served and outstanding discovery requests
as propounded by Defendant in this matter, Defendant s~eks to limit
the scope of Plaintiff's testimony and/or evidence to that which
has been specifically disclosed to date.
r am submitting the enclosed Motion, with accompanying
Appendix, in advance of the scheduled arbitration date so that you
may have an opportunity to review and consider the Motion at your
convenience prior to arbitration,
Ruby Weeks, Esquire
Jacqueline M. Verney, Esquire
Lindsey Dare Baird, Esquire
May 5, 1999
Page Two
Please accept my thanks for your time and consideration in
this matter,
Si~
~A'.r/.~wart;
for McKissock & Hoffman, P.C.
EAs/sg
Enclosures
eCI Gregory L. Mousseau, Esquire
GRBGORY L, MouSSEAU
Anonll)'.AI.Law
Pine Rldp Plote..lonll Bulld1ns.Routc 903
He 2 Box 2287
Jim Thorpe, PA 18229
(J70)m,P#I
FIoX IJ1O) J~MI 10
Inlem.t ..mall ""'..,.....,',4...'
FAX TRAN'811I8810N cowa 8HBB1'
DATB: May 14.1999
TO: Edwin A,D, Schwanz, a.qurle
Ruby D, WeeD. Blqulre
Jacqu.lln. M, Vemey, Esquire
David Schanbacher, BAqurle
BNCLOSURPIJNFORMATIONIMESSAGB
PAX NO,
1.717.234.1350
1.717.24304704
1-717.243.3518
1.717.852.8780
RE: Derkoeh v. Ullom
Docket No, \14.5204
Your File No, 8350-19
Our Pill! Nn QA-OnA2
NUMBBR OP PAOES IN~I UDING COVBR SHEET:..2..
Should Iransmls9loD nol be received or IR illegible, plell$e contllCl Liz Eickhoff or Gregory L,
Mou...au, EsquIre 01570-325.9448.
Original will follow vIa:
.x.. Regulur Mall
_ M....nger
_ Ovemlghl Delivery
_ N/A
........==..~._-----........-- -=========~.....~"'.""'.85.~__
TMlrlfonnlll.,. eOflflt"l4 lIi thll fAettmllt nw.....,. IUOnIO)' rttvllopl &rod oonn6lntlal1r.tlxmAllon lA1tndod mly fbt.. uti or tf\t IedM'""<<
endI)'nlUTlOCfabo..... Ifwnad.elthl.mcuapb nott!l'Il:l'l\d~jrt('lpltlt.)W1N h'~nocJntd lh4: aD)'dlncmlnadM,4lAaib4&t1on Of
ODp)'tftJ 0'\111, c:ommun!ftltioa b Itrlcdy prflt:lhltc4. rr)"OU "-". rt....I\'td .hi. \"OIMlll11h:AlIOflIn fmH'. rtca~ Immo&loll nodfy UI b)' IIlcphMt
lid ftlt\am the orial"lIIMI''''10 u, &I II>> aboto Iddrcn 'II. ,be Unlld ~1Itc.t Po'11I Scrvk'c. Wo Ihlll f1:mh IJOIlaIt ro. the NM'D of M)' .uc:h
-II1\IIlICIlt... nw 7....
------------ --
------.-.....---
..1,1.11
(3\
J-v'1'J.1 oq- ~......:..(
&1 .;t!\ ~
~ '1 A....... 't\ ...t-...tc:.l t)eJl.u..a.1 -
Ilt c..
GLENN DERKOSH,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
v.
I
I
I
I
I
I
I
NO. 95-5204 CIVIL TERM
JOSEPH R. ULLOM,
Defendant
AND NOW, thio Z~! day of October, 1996, upon coneideration
of Defendant'e Motion to Compel Diecovery, a Rule ie hereby ISSUED
upon the Plaintiff to ohow cauoe why the relief requeoted ehould
not be granted.
RULE RETURNABLE within 20 daye of eervice.
BY THE COURT,
J.
Gregory L. Moueeeau, Eeq.
Pine Ridge Profeeeional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229 ,
Attorney for Plaintiff ,.~&/
fAIT'. h.J.0
John J. McGrath, Eoq. 11~ ~ qb
Suite 205 IV~ ~
105 North Front Street .t
Harrieburg, PA 17101
Attorney for Defendant
Irc
>-
~,
~
w'
u
I:,
L'
{
,-
.<;
McKISSOCK & HOFFMAN, P,C.
BY: John J. McGrath
Identification No, 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs.
JURY TRIAL DEMANDED
JOSEPH R. ULLOM
NO. 95-5204 CIVIL TERM
DEFENDANT'S MOTION TO COMPEL DISCOVERY
Defendant, Joseph R, Ullom, by his attorneys, McKissock & Hoffman, P.C.,
respectfully seeks an Order compelling the plaintiff to answer defendant's interrogatories and
to produce the documents requested by defendant, In support of this motion, defendant says:
I. This action arises out of a motor vehicle incident which occurred on October 2,
1993.
2. Plaintiff, Glenn Derkosh, commenced this action by filing a Writ of Summons on
September 29, 1995.
3. In response to defendant's Rule to File Complaint, plaintiff's Complaint was filed
on or about February 26, 1996,
4. On February 15, 1996, defendant's counsel served upon plaintiff's counsel
Defendant's Interrogatories and Defendant's Request for Production of Documents. A copy
of counsel's cover letter is attached as Exhibit" A",
5. As of June 25, 1996, plaintiff had not responded to defendant's outstanding
discovery requests, By letter dated June 25, 1996, defense counsel requested that plaintifl~s
discovery responses be produced without further delay, A copy of counsel's June 25, 1996
letter is attached as Exhibit "B",
6, As of September 23, 1996, plaintiff still has not responded to defendant's written
discovery requests, although the time for responding under the PA Rules of Civil Procedure
has long since passed.
7, Plaintiff has not objected to any of defendant's discovery requests nor sought a
protective Order.
WHEREFORE, pursuant to Pa, R.C,P, 4019, defendant respectfully requests that
this court enter an Order compelling the plaintiff to file and serve full and complete answers
to Defendant's Interrogatories and to produce all documents requested in Defendant's
Request for Production of Documents,
McKISSaCK & HOFFMAN, P.C.
J n J. McGrath
Attorney for Defendant
Joseph R, Ullom
t, "UCO MdClISOCl
PI!'TI!A J.IIJf"FWAH
":IIAlD L MclClH'GU'.. Jl,'
laun ANNO WIlJ.U.
JlU .....An CLAna
WARY'mll CII'IST1ANlfJ4
PAUL "nUkiAH
CAntulHI! UlU lUNDA
JOtIH 1 WdiI...nl'
DONALO J. .aoocs, JR.'
WIW"'M l WUNDY'
.. n...ta 'UoCK
.ofIH .... WIUJr
"'MY L C\1UU!I"
I!JLl!JtHUoNPB'
talA ICItW4l1'J;EJ. OOHHH
J. loaur ~M...ItOH'
X.'J'lIl U.....H
ClllLffOP1l1Ia nCMSON'
l...nlLEEH I~NA "'IITOO
I, lun lI...y-.ooo'
I....A I. nlOMJON'
M"'U'!EH P. f'TnGllJl...LD t
"'NN I. C""'HI
VERON':A C. MKJH.4.H'
lAnlLUH SllaLl!1TS IUINS'
CW"~ C"'fOZZJ P...YNe, JLN."
PAn.IC,... o."II"EJ!.'
l,lSTEH E. ....UEA.
IASOH p, aOSSEUH'
INGRID l.'fOf'llNSOH'
'AUO MI!MIEJ. OF NloW malE'( BAa
t...uo MI!MIEA 0' IWtoOU ua
IAUO MEMIEl 0' fWllDA IIA.
McKISS'OCK & HOFFMI
... 'Mnt'I!sSlnH...I. COR'OMATIUH
A1TOItNI:VS AT I,,^W
17UI,) MA"KI:r STRIU:I'
SUITE 301.1)
I'IIILAI~'LI'IIIA, l'ENNSYlVANIA IO'O}.)OJ<J
IIJIlKiflmlBT
WT,f10UY,HlOI06O
1"'Itl.I.
.....XlCtlMIJn4.JI
NEW Il!AJn OFfICe
l'lll\'''" 11Il) 2<6211>'
FAX, (Ill) !'6.2'"
'f.HNIY~HI'" OFn:u
" It llGAD mlU1T
IND nooa
onyUlITOWH"... IIliOI
UUIWklOl
fAX,!JUI )4J.4SOI
February 15, 1996
10J ""Itlll notrr rrlElf1'
surra ~I
U.....lSIU.a.'A 1ll0l
1111)1JM2IOJ
FAX/lml JJ4.llSO
Gt!Olce W,OVUTOH'
0' COUHSE.t.
Gregory L, Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229
Re: Derkosh v, UlJam
Our File No,: 8350-19
Dear Mr, Mousseau:
I have enclosed defendant's Interrogatories Addressed to Plaintiff, Glenn Derkosh and
defendant's Request for Production of Documents directed to Plaintiff, Kindly respond to
these discovery requests within the time provided by the Pennsylvania Rules of Civil
Procedure,
Thank you for your attention to this matter,
JJM/el
Enclosures
.yery,lruly yours,
L.~ ,., I~/ {
.<}. :' It:~,,;t.,
~ _!,~hr J! cGrath
for M&OCk & Hoffman, P,C.
EllhlbllB
I
McK1S~OCK & HOFFMAN
. ^ I'MIWl!SSltlNAL cnH.PtU'^T1IlH
^l1'OItNCYS AT lAW
1100 MAIlKC"\' >TIlCrIT
SUITC}U(M)
I'IIILADELI'IIIA. Pl!NNSYI. V M"I,\ 1~IU}.l9)O
HaW 'I!UBY OffiCI
JOliN I. McOMATII
DINGCT DIAL (lIS) Jt6-U16
PilON!!. (1Il) 1'..1100
rAX, (lIll14..IIU
lIS ItIQIIITIUT
IolT. IlOLLV, HI 0I0t0
lIOtIIlN.
'A~ 1w.IIU4IJl
PCNNSYLYANIA omca
"H. nOAD ITleET
JHD Jl,OO"
DcJVLUTOWN.,^ 11"1
UUI )41-4101
FAXl(1U) Jt....WJ
June 25, 1996
101 Hoanl FlOHT STllBT
surrettl
UAuIIDu.a,'" 1lI0,
ifill U6-4IU
'AXl (7IJ) 0..1>>0
Gregory L, Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, BOl( 2287
Jim Thorpe, PA 18229
Re: Derkosh v. Ullam
Our File No,: 8350-19
Dear Mr. Mousseau:
On February 15, 1996, I sent you Interrogatories and a Request for Production of
Documents directed to your client. Obviously, the time for responding to those discovery
requests has long passed, [would appreciate it if you would provide me with your client's
interrogatory answers and the requested documents within the nel(ttwo (2) weeks so that we
can avoid the need to involve the court in this discovery matter.
Thank you for your professional courtesy and prompt attention to this matter, I look
forward to hearing from you,
Very truly yours,
~' L ~jf.24i
. J hn 1. McGrath
for Jc issock & Hoffman, P,C.
J1M/el
cc: Mr, Marc Curvan
Claim No,: 38-4309-973
I'"
, .
I .
,
,
(
,
(.
~ ~ !;l ~
~ I!~~ ~~,
II! Fl
:z:
I ! i :t:1~ ~>. ~M
cIi:I~'< ~on~
-r ~I u u ~ ~
o ~ IlIl CIl
.
I ~ ! , ; I ~.~~ ~ ~~
;-
0
., ~ a
I'l
...
.
.
_"It....D5II'..'.
()foIrwo. OO"~''''' UI,..,."UI
_..1'rtllluut-ll'f
l;
RECEIVED MAY 0 6 1999
IN THB COURT OP COMMON PLBAS OP CUMBBRLAND COUNTY, PENNSYLVANIA
GLENN DERKOSH
Plaintiff
DOCKET NO. 95-5204
v.
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
JOSEPH ULLOM,
Defendant
APPENDIX TO DBPENDANT. JOSBPH ULLOM'S
MOTION IN LIMINE TO PRECLUDE TESTIMONY AND/OR
EVIDENCB AT ARBITRATION
tz, Esquire
Supreme Court I 75902
McKissock & HOffman, P.C.
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Counsel for
Defendant Joseph Ullom
,..
.
o
('\
McKISSOCK & HOFFMAN, P.C.
BY: John J. McGrath
Identification No. 42389
105 North Front street
suite 205
HarriSburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS.
JURY TRIAL DEMANDED
NO. 95-5204 CIVIL TERM
JOSEPH R. ULLOM
DEFENDANT'S INTERROGATORIES
AUTOMOBILE/PERSONAL INJURY SET
ADDRESSED TO PLAINTIFF LISA CAMPBELL
You are required to respond to the attached Interrogatories
within the time prescribed by the Rules of this Court. These
Interrogatories are continuing in character so as to require you
to file supplemental response to the Interrogatories if you
obtain further or different information prior to trial. Where
the words "incident" or "occurrence" are used, they refer to
events which took place as alleged in the Complaint.
1. state the following:
a) Full name;
b) Date and place of birth;
c) Home address;
d) Social Security Number.
2. a) List your occupations or jobs for each of the last
six (6) years;
b)
state the name and address of your employer(s);
c)
State the date(s) of employment;
v
2
v
o
('\
d) Describe the nature of the duties performed by you
in each job;
e) Set forth the reason for the termination of
employment, if any.
3. state where you were coming from and where you were
going at the time of the accident.
4. Without incorporating b~ reference the allegations of
your Complaint, state in detail your version of how the accident
happened.
5. Describe in detail the part or parts of each vehicle
damaged as a result of the accident in suit.
J
.
o
n
21. At the time of the accident, did you have a family
physician? If so, what is his/her name and address.
22. Have any person (including yourself and all parties to
this lawsuit) made any statement, written or otherwise, while
being interviewed or questioned by you on your behalf, or on
behalf of any other party? (For purposes of these
Interrogatories, a "statement is that which is described in
Pennsylvania RUles of civil Procedure 4003.4) If so, for each
statement, indicate:
a) The name, address, occupation and relationship to
you, if any, of the maker;
b) Date of making;
c) Place of making;
7
o
n
r
,
I
d) Whether signed or unsigned;
e) The name and address of all persons present at the
making of the signing;
f) The name and address of the person having present
custody and control there.
23. Do you contend that the defendant(s) made any
admissions concerning the accident and/or facts relating to this
lawsuit? If so, state:
a) The exact language and/or the substance of the
statement(s) made;
b) When each was made;
8
v
o
n
b) The identity of the person or persons making,
preparing or submitting same;
c) The identity of the person or persons to whom the
investigation report was directed or addressed.
d) The identity and location of the person or persons
having its present custody and control.
25. Do you claim to be or to have been physically or
mentally injured as a result of the accident herein? If so,
indicate:
a) Each and every part of your body that you claim was
injured;
10
o
n
b) The nature and extent of the injury.
26. Have any X-rays, MRIs, CT scans or EMGs been taken of
you subsequent to the accident? If so, state:
a) The name, address and job title or capacity of each
person taking the study;
b) The name, address and job title or capacity of each
person requesting that the study be taken.
c) The identity of the facility where the studies were
done;
d) The date of each study;
11
o
c) The name and address of any person who has taken
any photograph showing the injury.
30. When, where and by whom did you last receive any
treatment from a medical practitioner or hospital, whether or not
related to injuries allegedly sustained in the accident?
31. Are you claiming any "excess" or unpaid medical
expenses as a result of the accident? If so, state:
a) The name(s) of each medical provider or healthcare
facility whose bill(s) is claimed as excess or unpaid;
b)
The dates of service for each such bill;
c)
The amount of each such bill;
v
13
-.J
o
n
d) Whether each such bill has been submitted to a
collateral source (e.g. insurer) for payment and, if so, the
status of each sUbmission.
32. Do you claim any aggravation of a pre-existing
condition as a result of the accident? If so, state:
a) The nature of the pre-existing condition;
b) How long it had existed prior to the accident;
c) The names and addresses of all persons and
institutions treating you for the pre-existing condition prior to
the time of the accident;
14
~
o
n
34. Have you been involved in any accident or suffered any
injury or illness of any kind since the date of the accident
herein? If so, for each occasion, state:
a) The date and place of occurrence;
b) The nature and cause of the injury or illness;
c) The names and addresses of all attending physicians
and their medical specialties, if any;
d) The name and addresses of any hospitals where you
were treated as an inpatient or outpatient for such injury or
illness;
16
o
n
e) The treatment prescribed;
f) The period of treatment and/or disability.
35. Have you lost any time from employment as a result of
the accident? If so, state:
a) The periods of time you were off work;
b) The names and address of your employer at the time
you were off work;
c) The amount of any income you lost thereby;
17
o
n
38. As a result of any injury received in the accident, has
your participation been restricted in any hobby, sport,
recreation or other leisure activity? If so, state:
a) The nature of the restriction;
b) The reason for the restriction;
c) The duration of the restriction;
39. other than the action herein, have you ever been a
party to a lawsuit or claim (including, e.g., workers'
compensation) against anyone growing out of any personal injury
to yourself? If so, for each lawsuit, state:
a) The date of the accident, injury or disability
involved;
19
o
o
b) The cause of the injury or disability;
c) The nature and extent of the injury or disability;
d) The circumstances under which you made the claim;
e) The hospitalization required, if any;
f) The name and addresses of all physicians or other
medical specialists who treated you for the injury or disability
from which the claim arose;
20
~
~
~
n
g) The date that the claim was filed;
h) The disability rating you were ultimately given, if
any.
40. Identify each person that you expect to call as an
expert witness at trial or arbitration in this matter and with
regard to each person state the following:
a) The subject matter upon which the expert is
expected to testify;
b) The substance of facts and opinions to which the
expert is expected to testify and a summary of the grounds for
each such opinion;
21
Q
('\
43. For each such insurance policy, group contract or other
similar plan or arrangement, describe the nature and terms of the
coverage/benefits available to you at the time of the accident or
subsequent thereto.
44. State whether you received or have agreed to receive
from any party, any sum or thing of value for the injuries (or
damages) claimed, and, if 50, state the amounts received or to be
received, the dates of payment, and the names and addresses of
the payors.
45. If loss of consortium or services of a spouse is
claimed as an item of damages, itemize in detail the nature and
extent of such loss.
23
~
c) were you compensated for the damages allegedly
sustained by the vehicle in this accident from any source, and if
so, name and source and the amount received.
49. state whether you or your attorney are withholding from
production any writings or documents referred to in these
Interrogatories and/or requested in Defendant's Request For
Production of Documents on the basis of privilege or from any
other reason.
If the answer is yes, please identify all such writings
or documents, with a brief description of their nature; provide
the name of the authors of such documents, and dates made;
identify the present custodians of such writings or documents;
and specify the precise privilege being asserted in withholding
these documents.
26
c
n
50. At the time of the accident, were you the registered
owner of a motor vehicle?
If the answer to the above is in the affirmative,
please state:
a) The year, make and model of each vehicle;
b) The name of the insurer(s) providing coverage with
respect to each such vehicle;
c) The tort selection (i.e. full or limited) made with
respect to each such policy of insurance;
51. a) At the time of the accident, were you bound by (a)
the limited tort option under the MVFRL or (b) the full tort
option?
27
o
r
b) Idontify by insurer, named insured and policy
number the policy under which the tort election was made;
Please attach a copy of the declaration sheet for the
above described innurance policy and a copy of the registration.
52. Itemize all damages and losses which you claim to have
suffered as a result of the accident.
53. Is any judgment or settlement in this action subject to
a welfare lien?
28
--I
.
.
o
I'
54. Has any public agency paid any expenses, including but
not limited to, medical bills, welfare payments and/or disability
payments, as a result of the injuries you allege in this action?
55. If the answer to number 54 is in the affirmative, state
the total amount paid by the agency as a result of your alleged
injuries.
a) Pl~ase produce all documents related to such
payments.
McKISSOCK & HOFFMAN, P.C.
BY:
I' /lQ
I ; 1
.~~ l*(tti
Ljiohn J. McGrath
DATE: February 15, 1996
..,..
~,.
,
~
r
,
McKISSOCK & HOFFMAN, P.C.
BY: John J. McGrath
Identification No. 42389
105 North Front Street
Suite 205
HarriRburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
.
.
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS.
JURY TRIAL DEMANDED
JOSEPH R. ULLOM
NO. 95-5204 CIVIL TERM
DEFENDANT'S REQUEST FOR PRODUCTION
OP DOCUMENTS DIRECTED TO PLAINTIFFS
You are hereby directed to produce the following documents
and tangible things within the time prescribed by the rules of
this court at the offices of McKissock & Hoffman, P.C., 1700
Market street, Philadelphia, PA 19103, for inspection and
copying:
1. All documents identified in your responses to
Defendant's Interrogatories Addressed to Plaintiff.
2. Statements of all witnesses to the accident described
in Plaintiff's Complaint, including all accident/incident reports
and/or statements of claim prepared by or on behalf of plaintiff.
3. All medical bills, records, reports, x-rays, claim
forms, invoices, prescriptions and other documents relating to
plaintiff's treatment for injuries claimed in this matter.
4. All statements of earnings, wage and salary
verifications, payroll stubs and other evidence supporting
plaintiff's claim for loss of earnings and/or earning capacity.
.
.~
('\
5. copies of plaintiff's federal and state income tax
returns for the years 1991 through the present.
6. All photographs, diagrams, maps and/or other
illustrations depicting the scene of the accident or any of the
vehicles involved.
7. Reports of any and all experts who are expected to
testify at trial or arbitration.
8. All documents, records, and/or tangible things which
plaintiff intends to use as exhibits or introduce into evidence
at trial and/or arbitration.
9. A copy of the declaration pagels) for each policy of
automobile insurance under which you were a named insured or
resident relative of a named insured, which policy was in effect
at the time of the accident.
10. A copy of each policy of health insurance and/or all
other documents describing each group contract or any similar
plan/arrangement for the payment of medical and/or disability
benefits, under which plaintiff was covered at the time of the
accident.
McKISSOCK & HOFFMAN, P.C.
BY: .Qi 9ktlii
I'hn J. McGrath
Date: February 15, 1996
.'
,,'
~CKlSSOCK & HOFFMAN ,,-
It 'kO'UIIONAL CORPORATION
ATTORNEYS AT LAW
1700 t.MRKET STREET
SUITE lOOO
PIIILADELPIIl.... PENNSYLVANIA 1910).1930
.
JOHN J. NcORAn.
DIRECT DIAL ('IJ) '~"16
PIIONE: UIl) "6,1100
FAX. (1Il11.6-11..
HIW 'WIY OfJICI
IU HIOH mm
WT. HOLLY, H' ....
<<"'Ihl,._
'AXiltOl)ltl.fU1
.tIHNlYLVANIA ornca
"H. 1l0AD mIlT
IND n.oo.
DOYLU1'Ow"" rA .....
ClUJ ......
'AlCIUUI",...1OJ
June 25, 1996
1'1 HOlnt nGHT mIlT
IVIT1IItl
U"lI"IUla,'1t 17111
f1111 U6-fln
'AXllfl1Ju..uso
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2. Box 2287
Jim Thorpe, PA 18229
Re: Derkosh v. Ullnm
Our File No.: 8350-19
Dear Mr. Mousseau:
On February IS, 1996. I sent you Interrogatories and a Request for Production of
Documents directed to your client. Obviously, the time for responding to those discovery
requests has long passed. I would appreciate it if you would provide me with your client's
interrogatory answers and the requested documents within the next two (2) weeks so that we
can avoid the need to involve the court in this discover)' maller.
Thank you for your professional courtesy and prompt allention to this matter. I look
forward to hearing from you.
Very truly yours,
~' L gii?ht,
I
J hn J. McGrath
for Jc issock & Hoffman, P.C.
JJM/el
cc: Mr. Marc Curvan
Claim No.: 38-4309-973
.,
@
~
.
!J
.
"
i
.~
"
,
J
o
o
McKISSOCK & HOFFMAN, P.C.
BY: 10hn 1. McGrath
Identification No. 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(71?) 234-0103
Attorney for Defendant
(') 1.0
r-; L'l
~[B. m ,.1
- I..: ""
:::;1-' u,
1"':'( ,
:::::. O"tJ
~'C:' :::.:
~~i ':":
~.. e
.~
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs.
JURY TRIAL DEMANDED
10SEPH R. ULLOM
NO. 95-5204 CIVIL TERM
o;RTlFICATE OF SERVICE
I, 10hn 1. McGrath Esquire, attorney for Defendant hereby certify that I served
Defendant's Motion to Compel and Brief in support thereof and a true and correct copy of
the attached Rule Returnable dated October 2, 1996 and issued by 1udge 1. Wesley Oler, Ir.
was served upon plaintifrs counsel by First Class Mail on October 10, 1996 to counsellisled
below:
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Iim Thorpe, PA 18229
McKISSOCK & HOFFMAN, P.C.
~
~~;n
-8
:.~
=to
4ln
Cirn
~
~
n
n
McKISSOCK & HOFFMAN, P.C.
BY: Joh'n J. McGrath
Identification No. 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs.
JURY TRIAL DEMANDED
JOSEPH R. ULLOM
NO. 95-5204 CIVIL TERM
DEFENDANT'S MOTION TO COMPEL DISCOVERY
Defendant, Joseph R. Ullom, by his attorneys, McKissock & Hoffman, P.C.,
respectfully seeks an Order compelling the plaintiff to answer defendant's interrogatories and
to produce the documents requested by defendant. In support of this motion, defendant says:
1. This action arises out of a motor vehicle incident which occurred on October 2,
1993.
2. Plaintiff, Glenn Derkosh, commenced this action by filing a Writ of Summons on
September 29, 1995.
3. In response to defendant's Rule to File Complaint, plaintifrs Complaint was filed
on or about February 26, 1996.
4. On February 15, 1996, defendant's counsel served upon plaintifrs counsel
1-.
Defendant's Interrogatories and Defendant's Request for Production of Documents. A copy
of counsel's cover letter is attached as Exhibit "A".
v
..J
(\
n
5.. As of June 25, 1996, plaintiff had not responded to defendant's outstanding
discovery requests. By leller dated June 25, 1996, defense counsel requested that plaintiffs
discovery responses be produced without further delay. A copy of counsel's June 25, 1996
leller is attached as Exhibit "B".
6. As of September 23, 1996, plaintiff still has not responded to defendant's written
discovery requests, although the time for responding under the PA Rules of Civil Procedure
has long since passed.
7. Plaintiff has not objected 10 any of defendant's discovery requests nor sought a
protective Order.
WHEREFORE, pursuant to Pa. R.C.P. 4019, defendant respectfully requests that
this court enter an Order compelling the plaintiff to file and serve full and complele answers
to Defendant's Interrogatories and to produce all documents requested in Defendant's
Request for Production of Documents.
McKISSOCK & HOFFMAN, P.C.
Jo n . McGrath
Attorney for Defendant
Joseph R. Ullom
~
~
~1V1 c ~r~~,~fa~.~aKIj.,?r.;,~M A N,('
A"ORNEYS AT LAW
1700 MARKlIT STRElIT
SUITE JOOO
PIIILAOELPIUA. PENNSYLVANIA 1~IU}'1910
HIW 'Way 0"1('1
"' HIOH nlln
NT. HDLL Y,"' ....
(..11""1-
'AXle_Jm.-UI
'OUN I. UcOAATIt
DI.ECT DIAL (1lJ) 1"'111.
PHONE: (111) 1'6.1100
r-^X,IlIl)I'60IIU
'ClNNly\'VANIA o,nCl
n H. .'OAD milt
IHD n.oo.
DO'fLUToWH. rA ....
UUIJoIt.4101
'AlClUUI>>4...1OJ
June 25, 1996
101 Hoanl BONT mil
rum...
lI"unDUla.'A 1711I
0111 u..tln
'AXlCml&)t.IUI
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229
Re: Derkosh v. Ullom
Our File No.: 8350-19
Dear Mr. Mousseau:
On February IS, 1996, I sent you Interrogatories and a Request for Production of
Documents directed to your client. Obviously, the time for responding to those discovery
requests has long passed. I would appreciate it if you would provide me with your client's
interrogatory answers and the requested documents within the next two (2) weeks so that we
can avoid the need to involve the court in this discovery mailer.
Thank you for your professional courtesy and prompt allention to this mailer. I look
forward to hearing from you.
Very truly yours,
~ L ~}I.?ki
,
i J hn J. McGrath
for Mc issock & Hoffman, P.C.
JJM/el
cc: Mr. Marc Curvan
Claim No.: 38,4309.973
.,
.
.
n
lit
lit
McKISSOCK & HOFFMAN, P.C.
BY: John J. McGrath
Identification No. 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs.
JURY TRIAL DEMANDEQ
JOSEPH R. ULLOM
NO. 95-5204 CIVIL TERM
ORDER
AND NOW, thisS""-day of dfu~ ,1996, this courl having issued a
Rule 10 Show Cause upon the plaintiff and it appearing that the Rule Retumable was served
upon pJaintifrs counsel and no response filed, it is hereby ORDERED that the Rule is made
absolute and defendant's Motion to Compel Discovery is hereby GRANTED,
It is further ORDERED that plaintiff, Glen Derkosh, shall serve full and complete
answers (without Objections) to defendant's Interrogatories and shall produce all documents
~:2.0
requested in defendant's Request for Production of Documents witll taR (IG) days of service
of this Order or suffer further sanctions upon application to the courl.
BY THE COURT:
Ir 9. !v;41,'l tJA/ (/0.... , J.
~j
TRUE CQPY FROM RECORD
In Teslimcnr \,h;r;or, I h.:re t'lllo SIlt my hand
and fhe seal of sa:d COlJrt af Carlisle, Pa.
~."(P.f!::.,,. dtl oL,~"" 19 q~
. " ..............:...'Y.V'~/' '9~
. . .l/?;Jrr.t"f ~
Prothonotary
" 0
"
McKISSOCK & HOFFMAN, P.C.
BY: John J. McGrath
Identification No. 42389
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
Attorney for Defendant
GLENN DERKOSH
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
vs.
JURY TRIAL DEMANDED
JOSEPH R. ULLOM
NO. 95-5204 CIVIL TERM
DEFENDANT'S MOTION TO COJl.rPEL DISCOVERY
Defendant, Joseph R. Ullom, by his attorneys, McKissack & Hoffman, P.C.,
respectfully seeks an Order compelling the plaintiff to answer defendant's interrogatories and
to produce the documents requested by defendant. In support of this motion, defendant says:
I. This action arises out of a motor vehicle incident which occurred on October 2,
1993.
2. Plaintiff, Glc:nn Derkosh, commenced this action by tiling a Writ of Summons on
September 29, 1995.
3. In response to defendant's Rule to File Complaint, plaintiffs Complaint was filed
on or about February 26, 1996.
4. On February IS, 1996, defendant's counsel served upon plaintiffs counsel
Defendant's Interrogatories and Defendant's Request for Production of Documents. A copy
ofcounsel's cover letter is attached as Exhibit "A".
"
o
rl
5. As of June 25, 1996, plaintiff had not responded to defendant's outstanding
. .
discovery requests. By letter dated June 25, 1996, defense counsel requested that phiintifrs
discovery responses be produced without further delay. A copy of counsel's June 25, 1996
letter Is attached as Exhibit "B".
6. As of September 23, 1996, plaintiff still has not responded to defendant's written
discovery requests, although the time for responding under the P A Rules of Civil Pr9Cedure
has long since passed.
7. Plaintiff has not objected to any of defendant's discovery requests, nor sought a
protective Order.
WHEREFORE, pursuant to Pa. R.C.P. 4019, defendant respectfully requests that
this court enter an Order compelling the plaintiff to file and serve full and complete answers
to Defendant's Interrogatories and to produce all documents requested in Defendant's
Request for Production of Documents.
McKISSaCK & HOFFMAN, P.C.
Jo n J. McGrath
Attorney for Defendant
Joseph R. Ullom
.'
o
,
McKissacK. & Hc!l'M'!
A U'OI'WIOHAL co"'aRAI...."
AlTORNEYS A" LAW
1l000IolARK~ ITREET
SUITE lOOO
rHILAOflJ'HII<. PENNSY'I.VANIA 1910).)9)0
"
&. "I.CI ...11llOC1
,no L tclf1WAH
IClldD L. WtJrClHIOU. '"
LUUI ANHI WIUU
J'Ul4lAT'Z C'-'nl
W"lnln( 1 CHIIJTIANlUI
PAUL I.CUlIOA"
CAntUI"' HIL&. lUNDA
.oHM .. MlQAnt'
DONALD...aoou. Il.t
W!WAW" WUNDY'
..ea"IOIUCI
.oHM K WIUJr
.....y L CUtalU It
IlLU.Jr1u.w,.'
aul" ICK"""DUU DUNN.
&. IGlUT WdoCAHOH'
DUH 4 "alAN
QtlltfOtHU TlCMJOH'
IATHLUH I~NA AnfTOH
L IUD HAV-.ooO"
'AIA L TN:lMIoH'
WAUUaH p, nnCXAALD I
"f'H .. CA.a...
YUOHlCJ" .. toOHA""
IATHLUH ItIOt.IlTa IUINI"
DIU....4 CAPOW PAY"" ........t
'ATaCI" II. 'H,,,g'
III.InH I. 'AUP'
JAIOH p, GOIIWH'
lfofGIID.. HOf'IINSOH'
. AUO WIWIU or HEW 'u.rrt IA'
r ALSO Joe""I... 0' IWNOU IAl
,AUQ w....U. 0' nollDA .~.
PHONE: (Ill) 1.ll-ll00
FAX, ClU) "ll-ll"
....,.1AII't on
IU HiOtt rn.u
WT.tIXJ,.Y,"'M
CNtl ",.,_
F4X,CNtIItf"J
nKltICkDml
JHD~
DO'rWTDWK 'A
IlUl.......
'-'XlIW1.....N
February 15, 1996
10S I'C)mf f'LOHT n
IUITI ...
H"UUIUID.'A t
(?I11 UWiln
'''JClom u..w
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229
Re: Derkosh'v. Ullam
Our File No.: 8350-19
Dear Mr. Mousseau:
I have enclosed defendant's Interrogatories Addressed to Plaintiff, Glenn Derkosh and
defendant's Request fgr, Production of Documents directed to Plaintiff. Kindly respond to
these discovery requests within the time provided by the Pennsylvania Rules of Civil
Procedure,
Thank you for your attention to this matter.
,~~ery}~ruIY yours,
t .... , .
,', :,,;.} It
) '- '. It~dt,
/ Jo J, cGrath
for McIG ock & Hoffman, P.C.
JJM/el
Enclosures
o
Mcl\r~,~~n~~~n.Ijr!MA N
^ '!'TORNCYS ^ T L^ W
1100 .1'IRKlIT lTRalIT
SUITE lunG
PIIIL^OCLrlll~. PCNNS!LV^NI,\ IYIUl-1910
III HlaH nl"
WT. HOLLY,"'.
(...It.'.....
'''XI 1"'1 2U4.
"IW 'wn on
JOHN I. McCRATU
DIRElCT DIAL(:U) :.6-111.
PHON!!: (Ill) 1<601100
r-AX,llllll'6011<4
'I:JrIHI'l'LV"""A Of
n.....OADna
1"D n.oo..
POYLDTQWN. '4
tlu,.......
'''..Uul)l.....
June 25, 1996
111 NOant nOH'T r
NmJl,
""IIUIUIo. 'A
0111 U441Q
'Ax,(lmlUol1:
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229
Re: Derkosh v. Ullnm
Our File No.: 8350-19
Dear Mr. Mousseau:
On February IS, 1996, I sent you Interrogatories and a Request for Production of
Documents directed to your client. Obviously, the time for responding to those discovery
requests has long passed. I would appreciate it if you would provide me with your client's
interrogatory answers and the requested documents within the next two (2) weeks so that we
can avoid the need to )~volve the court in this discovery matter.
Thank you for your professional courtesy and prompt attention to this matter. J look
forward to hearing from you. .
Very truly yours,
L ~JIl1i.
,
i J hn J. McGrath
for Mc issock & Hoffman, P.C.
JJM/el
cc: Mr. Marc Curvan
Claim No.: 38.4309.973
'.
('
(l
GLENN DERKOSH,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
v.
.
.
JOSEPH R. ULLOM,
Defendant NO. 95-5204 CIVIL TERM
AND NOW, this Z~! day of October, 1996, upon consideration
of Defendant's Motion to Compel Discovery, a Rule is hereby ISSUED
upon the Plaintiff to show cause why the relief requested should
not be granted.
RULE RETURNABLE within 20 days of service.
BY THE COURT,
J.
Gregory L. Mousseau, Esq.
Pine Ridge Pr~fessional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA l8229
Attorney for Plaintiff
John J. McGrath, Esq.
Suite 205
./'l05 North Front Street
Harrisburg, PA l7l0l
Attorney for Defendant
.'
TRUE COpy FROM RECORD
In Testimony whereof, I hare unto Ie'l my hand
and the seal of said Court at Carlisle, Pa. "
tl: .~~...... d~. of....&~...:...,. 19.:.'1.&
...~...(I.,,,...I.r~'I'''~
Prothonotary
. .
:rc
~\; E'X'HIBI T :..
'I.:..~I-.~ !ii!)-:!i',
"';-1:"';'1.. ..... -,i;r;';''y>
"." . ~ :: . . ,", ~~.
.~. ::. " " ,...~. . :~~~'f.~'
;j:";'!..~~,,.~.,... ,_.",~r,,..
'.
o
McKissaCK & HanAr
/It n.O'IJIIOHAL COIUORATlOH
ATTORN~YS AT LAW
1100 MARKET STII~ET
SUITE lOOO
PHILADELPHIA, PENNSYLVANIA 19IO),19l0
IOHN' I. McORATH
DIRECT DIAL (1U) U6-Ul6
PHONE: em) 1111-1100
FAX: (11SJ l'lI-m4
October 10, 1996
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2, Box 2287
Jim Thorpe, PA 18229
Re: Derkosh v. Inlam
Our File No.: 8350-19
Dear Mr. Mousseau:
I have enclosed a copy of the Rule Returnable issued by the Court on October 2,
1996 concerning the defendant's Motion to Compel Discovery.
If you have any questions, please give me a call.
Very truly yours,
-,
~21~~dL#
for McKISSOCK & HOFFMAN, P.C.
JIM/el
Encl.
..,,'......,.,.. ..', ,...."...u;
"',EX H I BIT.' ~
,1";::'-~~ i~, ,,~pj'
':' .r:;l;:1=H' . "f'O' ".
.).~. ':.s.., '" i,!;J:..-~
'/I;. " .
~~:71;1,;!i\l. ....t~~.~
".W Iwn orne.
111 HIOH man
WT, HOlLY. fil'.....
IWilIJlN.
'AX.C"'IU",...
,IJolH''nV''",IA D,ncu
n H. '.040 milT
tHO nOOI
DOYLUTOWH..... .....
Iwl........
'AXlI1UI).l.....1
'" ..oaTH nOHT mill
avmm
HAIlLlIUIO,'A 1fIt1
11111u.41t1
'AXe UUl u..UM
.
.,
McKlSSOCK , HOFFMAN, P.C.
BY: John J. McGrath
Identifioation No. 42389
105 North Front street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
" .~ ...'
COPy
Attorney for Defendant
GLENN DERKOSH
.
,
.
.
.
,
CuuRT OF COMMON PLEAS
CUMBERLAND COUNTY
vs.
JURY TRIAL DEMANDED
NO. 95-5204 CIVIL TERM
JOSEPH R. ULLOM
.
.
Ans~e,. 70 DEPENDANT'S INTFR1l0.,'OlU..S
AUTOMOBILE/PERSONAL lNJORY SET
ADDRtlf:;"lm TO PLAINTIPP j"rSA CAMPBELL
You are required to respond to tl.a attached Interrogatories
within the time prescribed by the Rules of this Court. These
Interrogatories are continuing in charucter so as to require you
to file suppll!mental response to thD rr ,'erroCJatories if you
obtain further or different informatic,l. prior to trial. Where
the words "incident" or "occurrence" are used, they refer to
events which took ~lace as alleged in the Complaint.
'1. State the !ollowing:
a) Full name;
Glenn Edward Derkosh
b) Date and place of birth;
-4-5-1954, Palmerton, PA, 10071
cj Home address;
289 WeDt 10th Street
Jim Thor~e, PA 18229
d) Social Security Number.
171-46-0121
2. a) List your occupations or jobs for each of the last
six (6) years; Wold".
bj State 1 he name and address of }'our employer (s) ;
Kovatch Corp., Nesquehoning, PA, 182.10
Hauto Welding, Nesquehoning, PA, 1B24J
c) State tI,e date(s) of el..ployrnent;
Kovatch-Sept. 1990-Apri1 1992
Hauto Wu1ding-october 1992-Present
2
"
.
6. Describe the position, movement and direction of the
defendant's vehiclo when you first saw it.
I was on the ground and to my right side I saw the van leaving the scene
of the accident.
7. How many pen .:IS, other than yourself, were in the
vehicle at the time of the accident and state their position in
the car and their names and addresses.
None.
None.
8. At impact, w~n each vehicle stopped or moving? If
moving, in what direction and at what speed?
Hovin<;j and at an unsafe speed for traveling through spectators.
9. Did your vehicle leave any skid marks?
None.
10. If answer to preceding I~terrogatory is in the
affirmative, state the measurements of the skid marks.
4
~
'01
'11. state the distance your vehicle traveled after impact
and the geographical direction it moved.
None.
12. Did you take any drug, narcotic, sedative,
tranquilizer, medication or alcoholic beverage within the 24 hOUI:
period preceding the accident?
None.
13. At the tin,~ of the accident, did you own a pair of
eyeglasses or other corrective lenses?
No.
14. If so, were you wearing them when the accident
occurred?
No.
15. If no, explain why you were not wearing them?
nle
5
21. At the time of the accidont, did you have a family
physician? If so, what is his/hQ~ name and address.
Dr. Thomas, Broadway, Jim Thorpe, PA, 19229 (Now Deceased.)
22. Have any person (including yourself and all parties to
this lawsuit) made any statement, written or otherwise, while
being interviewed or questioned by you on your behalf, or on
behalf of any other party? (For rurposes of these
Interrogatories, a "statement is that which is described in
Pennsylvania Rules of civil Procedure 4003.4) If so, for each
statement, indicate:
a) Thenamo, address, occupation and relationship to
you, if any, of the makeri
I made a statement to an insuranc~ adjuster a long time ago.
b) Date of makingi
c) Place of making;
Law Office of Robert T. Yurchak, 1 East Catawissa Street, Nesquehoning,
PA, 18240, over phone.
7
d) Whether signed or unsigned;
Taped.
e) The name and address of all persons present at the
making of the signing;
n/e
f) The name and address of the person having present
custody and control there.
Unknown.
23. Do you contend that the defendant(s) made any
.
admissions concerning the accident and/or facts relating to this
lawsuit? If so, state:
He stated he was in a real hurry and had to set up a stand and was
going to leave the scene.
a) The exact language and/or the substance of the
statement(s) made;
He just wanted to go. Nothing else mattered. to him.
b) When each was made;
Day of incident.
8
c) Where each was made;
At acane.
d) The names and address of all persons present.
Me, Hr. Ullom, maybe others (names to be provided upon discovsry,
24. Were any investigations, examinations, inspections,
tests, experiments, reports, and/or studies made, prepared, or
submitted by you on your behalf in the regular course of business
or in preparation for litigation arising out of this accident?
(These Interrogatories may be answered without revealing the
mental impreSSions, conclusions, opinions, memoranda, notes of
summaries, legal research or legal theories of your attorney or
those of your representatives ONLY in regard to the value, merit,
strategy or tactics of this lawsuit). If so, for each of the
above, state:
a) The subject matter c~ntained therein;
Accident report made up that same day, It was given to me at my
request by Carlisle Security at Fairgrounds.
9
.
w
. 27. Are you still sUffering from any effects of the
accidsnt? If so, what symptoms, what complaints or other
disability do you now have that you claim resulting from the
accident?
Yen, left foot pain, loss of work hours due to taking sneaker
off and elevating foot to reduce swelling.
28. Do you claim any permanent injuries liS II result of the
accident lind, if so, what is the nature and location of each
permanent injury?
Left foot.
29. Do you claim that any of the injuries sustained by you
as a result of the accident have resulted or will result in
scars? If so, for each scar, disfigurement or other cosmetic
defect present or potential, state:
a) The area of the body effected;
Left foot, a very bad limp and loss of balance.
b) The approximate dimension of the length of the
area;
Size of my left foot.
12
d) Whether each such bill has been submitted to a
collateral source (e.g. insurer) for payment and, if so, the
status of each sUbmission.
...
Unknown.
32. Do you claim any aggravation of a pre-existing
condition as a result of the accident? If so, state:
Yes, addsd to pain a1rsady having.
a) The nature of the pre-existing condition;
I previously injured my foot.
b) How long it had existed prior to the accident;
Since 1983.
c) The names and addresses of all persons and
institutions treating you for the pre-existing condition prior to
the time of the accident;
Allentown Ortopedics Association (See attached for addrees)
Others to be provided upon discovery.
14
d) The dates of treatment for the pre-existing
condition prior to the time of the accid~nt.
1983 to preeent.
33. Since the date of the accident, have you ever worn any
brace, support, or other form of orthopedic device?
Foot and leg brace.
a) The nature of the appliance;
To support and lift left foot 2" to compensate height LIS to RIS
b) The part or parts or your body on which you are
wearing or wore the a~pliance;
Left foot
c) The period of time you wore or will wear the
appliance.
Till death or amputation of foot,'
...
15
I
I
I
I...,
I
~
'34. Have you been inVolved in any accident or suffered any
injury or illness of any kind since the date of the accident
herein? If so, for each occasion, state:
Noen.
a) The date and place of occurrence;
None.
b) The nature and cause of the injury or illness;
None.
c) The names and addresses of all attending physicians
and their medical specialties, if any;
None.
d) The name and addresses of any hospitals where you
were treated as an inpatient or outpatient for such injury or
illness;
None.
l6
e) The treatment prescribed;
None.
f) The period of treatment and/or disability.
Non..
35. Have you lost any time from employment as a result of
the accident? If so, state:
Yes. Had contracts to fu1lfil1 and had to have hired help to make
ends meet.
a) The periods of time you were off work;
Six months.
b) The names and address of your employer at the time
you were off work;
Hauto Welding, RDi1, Hauto, PA, 18240
c) The amount of any income you lost thereby;
Approximately $7,500.00
17
d) The actual number of working days you were off
work;
Had to be there to supervise worker's to put out work involved.
e) The name and address of your employer at the time
you claimed to have lost income;
Hauto Welding.
f) The reason for your absence trom work.
See 35 d} above.
36. state your gross annual income for each of the last
four (4) years.
See attached tax returns.
37. Are you claiming any excess or unpaid wage loss as a
result of the accident? If so, set forth the total amount
claimed and how it is calculated.
To be provided upon discovery.
18
b) The cause of the injury or disability;
Motorcycle accident.
c) The nature and extent of the injury or disability;
Left fcot crushed, left knee pulled and left hip out of socket.
Left foot, heel and ankle.
d) The circumstances under which you made the claim;
Accident.
e) The 'hospitalization required, if any;
About' 10 years.
f) The name and addresses of all physicians or other
medical specialists who treated you for the injury or disability
from which the claim arose;
Dr. Vernick, address
Dr. Keblish, address
Dr. Dicksnson, address
to be provided.
to be provided.
to be providsd.
20
g) The date that the olaim was filed;
TO be provided.
h) The disability rating you were ultimately given, if
any.
$25,000.00 Settlement.
40. Identify eaoh person that you expect to call as an
expert witness at trial or arbitration in this matter and with
regard to each person state the following:
To be provided prior to Trial or Arbitration.
a) The 'subjeot matter upon which the expert is
expected to testify;
b) The substance of facts and opinions to which the
expert is expected to testify and a summary of the grounds for
each such opinion;
21
. 47. Were the damages alleged to have been caused by this
accident repaired? It so, state:
None.
a) when, by whom, and the total cost;
b) with particularity, each repair made and the cost
incurred, or in lieu thereof, attach a true and correct copy ot
the itemized repair bill.
n/a
48. If the vehicle was not repaired,
n/a
a) has it been sold since the accident?
n/a
b) if so, state when it was sold, the sale price, and
the name and address of the person or firm to whom it was sold.
~a
25
~
c) were you compensated for the damages allegedly
sustained by the vehicle in this accident from Any source, and if
80, name and SOUrce and the amount received.
None,
49. State whether you or your attorney are withhOlding from
production any writings or documents referred to in these
Interrogatories and/or requested in Defendant's Request For
Production of Documents on the basis of privilege or from any
other reason.
None.
If the answer is yes, please identify all such writings
or documents, with a brief description of their nature; provide
the name of the authors of such documents, and dates made;
identify the present custodians of cuch writings or documents;
and specify the precise privilege being asserted in withholding
these documents.
26
50. At the tirn~ of the accident, were you the registerGd
owner of a motor vehicle?
Yee
If the answer to the above is in the affirmative,
please state:
a) The year, make and model of each vehicle;
76 Chevy Van
Perhaps 1983 Monte Carlo
b) The name of the insurer(s) providing coverage with
respect to each such vehicle;
am
c) The tort selection (i.e. full or limited) made with
respect to each such policy of insurance;
See attached.
51. a) At the time of the accident, ware you bound by (a)
the limited tort option under the ~FRL or :J) the full tort
option?
See attached.
~
27
w
.'
..
w
b) Identify by insurer, named insured and policy
number the policy under which the tort election was made;
See attached.
Please attach a copy of the declaration sheet tor the
above described insurance policy and a copy of the registration.
52. Itemize all damages and losses which you claim to havu
SUffered as a result: of the accident.
To be provided.
53. Is any jUdgment or settlement in this action subject to
a welfare lien?
No.
28
..
54. Ha. any public agency paid any expenses, including but
not limited to, medical bill., welfare payments and/or disability
payment., a. a result of the injuries you allege in this action?
No.
55. It the answer to number 54 is in the attirmative, state
the total amount paid by the agency as a result of your alleged
injurie..
a) Please produce all documents related to such
payment..
McKIssaCK' HOFFMAN, P.C.
BY:
DATE: February 15, 1996
INVENTORY
I Accident Repon of 10-2-93
2 CNA Insurance Information
3 Transcript of Glenn Derkosh Interview with Thanh Tran of 1/27/94
4 Taxes Returns for 1993, 1994, and 1995
5 Medical Bill Summary
Copy of Prescriptons
Onhopaedlc Associates of Allentown, Ltd.
Johnson G. Coyle, M.D.
Valley Nuclear Medicine Associates Account No. RV 31885452
Invoice date of 1/17/94 for services of 11/30/93
Copy of Notice of Doctor's Lien
Lehigh Valley Hospital Account No. 31885452
Invoice date January 5, 1994 for services of 11/30/93 $280.50
Patient Accounting Services, Inc. (Carlisle Imaging Associates), Account No. 693084-00
dated 1/17/96 for services perfomled on 10/2/93 $54.00
Carllsle Imaging Assoc. Patient/Guarantor # 693084-00
Copy of Patient Ledger of 10/22/96
Carlisle Community Ambulance Account No. 932168-90
Statement Date of 12/8/93
Onhopaedic Associates of Allentown Invoices
10/4/93 Patient No. 157850, copy of Prescription
10118/93 .. .. ..
12/10/93 .. .. ..
1/3/94 .. " "
1120/94 " " "
2/18/94 " " "
Copy of CVS Phannacy Receipts
10/15/93 Epoxy-N/Apaap 100-650 Tab Mylan
10/29/93 20LOFT 50 MG Tablet
11/5/93 Epoxy-N/Apaap 100-650 Tab Mylan
Copy of Jim Thorpe Pharmacy Receipt
1On/93 Propoxy Nap Tab apap 100
10/8/93 Anaprox OS Tab 550MG
10/8/93 Amitriptyline Tab 10MG
RWC Emergency Physicians Account #6930846
Invoice for 10/2/93 Statement date of ] 0/12/93
$100.00
$225.00
$35.00
$25.00
$94.50
$35.00
$35.00
$97.25
$10.09
$15.09
$10.09
$9.65
$26.63
$4.01
$96.00
"",..".... uuu ....I.UU..I.. I
2727 FOXIANNA KD.
HIDDLETOWN,PA. 17057
717-944-4752 OK 717-243-3201
ACC I D~:NT R~:PORT
I.OCATION: ",...-::
COUNTY:Cv tIZ
DRIVER: jo~E.f'1-i 1\ uLLoM AJlIlRI~SS: s-r
STATE: PA ZIP: IS-I 3 ~ :. b n -J3J'=- OI.N: /8"8" lib :1
EXPIRES: 10-9, RESTIlTC1'IClNS: Y -fP CLASS c... SEX: ([)F Don: 10 I~~) ;:
II
OWNER: t. AIlDR~:SS: STATE: Ii
Ii
Ii
I
Ii
h
PHONE:
VIN: I G-GEG-a.SijL.O 71%33lr(TI"'I,Ii:
REG: VlL(lM I n:AR: 1~'8.3
INS. CO. STATE FfYZ,"1
TOWED BY:
3 r I..$'('" vg 300 2.
MAKE: C~(?r(t()u;r
i
POL. NO. 'IS I'B 7C; Ie s
II
II
'I
Ii
,
'I
il
,
,I
,I
!I
STATE: fP.
HODEL: SI.tJ
'TOWED: Y ~
r""!f~~,' VEIIICLF. NO. 2 ...;...-"
OLN:
STATE:,
CLASS: EXPIRES:
DRIVER:
STATE:
ADDRJ~S3 :
~IP: PIIONE:
1l0R:
SEX: H F RESTRICTIONS: V N OWNER:
ADDRESS:
STAn: :
ZIP:
PHONE:
VIN:
R~:G:
~I
:j
!!
TOWF.D: Y N "
II
i
I
"
I
II
I
TITJ.~::
STATE:
YI~AR :
HAKJ'::
HOD:
INS. CO.
POL. NO.
,
~ TOWED BY:
i NAR~IVIl:
I o'f" w \
IJJ fh en (V\ r>\ ''''1
OS5
,:)
~L~IG
I kEPORT TAKEN BY: .:4;- n.1J,~ ~
II
DATE: In, ~-erJ II
III
I,
!I
"
"
"
II
!i
II
!'
II
II
"
'.
.
I
,
,
.
I
I
I
,
,
,
,
I
I
,
,
I
,
,
I
,
,
I
I
I
I
,
,
,
I
I
,
, D-mN.o
------------------------------------
- .-. . - - - - - --"--.
""'A PIMIylvIllil FinInc:iol RNjlClflIIbjljI. NI/lClI
~.... ldenklcalian CIII!. TIIIa cord IIIUI1 be --.. III Illy low
.........r_. ,,,"_ enllllCllllenl oIf_ upon reqtlell.
mo 0 Conllnenlll c.....,ty Company 1771 0 T'InIpOrIlUon Company
IUI 0 Nallonol File _.11<01 CGmpon, '7~ 0 T'InICOI1'-1I1lInout.... Company
DUO 0 -Un c......ty Company '~IO l>> V...... 'OfIllInNI/ICO Company
PclicvNU/llbot AD 93:20705 E'*MDale 07/01/93
ExpirallOn Dill 12/30/93
GLEto.N E DERKOSH
208 W RAILROAD ST
NESQUEHONING, PA 18240
OffICI IIIUIng Catd READ I NG . P A .
APPI.1CA8UI WlTllIU!8PECT TO TliIi FOLLOWING IAOTOA VEHICU!
VahIcIIldentiflClllon Numbot 101 A23793DB132897
DMcriPlian a-lEV MONTE CARLO
TVIlA 01 Cae Name
Producing Branch . P_ Code 470-0:24965
V_83
I
I
I
I
I
I
I
-----..
lEI! IIoU'OATANT MESS4ClE ON REVERSl! /llOE
cr~ .,tc:p_
Autharized Re_1aIive
.
..
.
c
c
"IlI!,
;E.NA IN~URANCE C,..yPANJES
CN" ~~.c:nu,o, III/noli ID6U
. fI"
~.J
J. G"
'.
.. 1,/
~)
.
Oate:
Claim No.
Insured:
Cate of Lon:
",'
Cllr
Tht Irtacnld has tllln dlrlc:ld to our artlntlon II plnalnlng to I losa or accident of In Inlurld 01 CN":
"OWIVIt. without Iddltlonal InformatlClo, Identification can not tlo "!Ide.__
c
c
c
c
c
c
c
Naml at Pollcyholdlr
Addrl.. ot policyholder
Policy numblr
Aglnt Clr broker
Cltl at Iccldent or 10ls
PIICI of accldlnt (city & ltate)
If automobile Involved.
name ot driver
Claim numtllr
Type 01 claim
OTHER We can not oroeess this mall without a claim number. If vou can not oroylde
us with I claim number, please lend UI I copy of the first report_
Thank Vnu
Claim Representative
CN"
Claim De:/lnm.nt
ed
CG.3132B.D
CNA
'.,.11."'''.''''''''''' 'Ie""
J'
~ ATErfnh'(!x>"0 .J~~I"Q. ,....'-1,)
.~I t.OC ~ HE':tE'tmNSiliiANCE CLAIM FORM
I MfD.cARl I Y(DUIO CHAt.lPU5 CtWolPVA QROUP fEe" OTHER 'I IN$UREOIHD NUWUER
1_ ..,....,._ _ n"'Al'"PLAN_I\l.KLUNQ~
I 1f-"I 1'-'11 I'_'SSN) I I/VAF"') ISSN"WI II'SSN) 111(10) NEED INFO
I a PATIiNTI NAMi lLulHlml, fnl NamI. ~"""I I'. P~IEHT&rIRIQ.fATi au 4. ""'$UREDI NAWllLall NatN. ,." NMnt. ~ ~I
OERKOSJ.l GLENN E 04 : 05 : 5" .. 1\11 , n SAME
(. p"TIIHr.ADOftlIS (No.IIIMt,l . P"TiINT RELATIONSHIP TO IN&uRED 7.Ii&URiO'lADORUa lNo.IIIM)
209 W RAILROAD ST "'00 -0 """0 ""*0
CITY ISTATE . PAlLENT 6TATUG
IJESr.lUI"J.lOIII t IIIn I PA -00....... 0 Oht 0
zua COOl IllUPHONE Ilnl:*.lcN AIM CoOII
19240 1/717\ 669-6416 tml*>Todn ~~~n ~~""n
......I...._~'..._,_.....I ,......''''Nro'''''M
.'
,
.
flplC'
,.
t. OtHER W5URED'I PClUCY Oft GROUP NUMIlR
.. ..".
D. OTtttR IHSUN:O" DATI 01 IIR.TH i lEX
aAl1DD.vy .._
I ! "'1 I
C. UlPLQYiA'S HAWE OR SCHOOL frWI,Ii
. EYP\.OYIJ,EHT7ICUftRENT OR PREVIOUS)
DYES []NO
b, AUTO ACtlDlNn hACllS&aI'1
[] YES DNO l.EAJ
c OTHER -'CCIDENn
DyES []NO
IOd RE5ERVED fOR LOC'" USE
'n
BOX 99005 CAMP HILI PA 17099
a lH$uRANCf. PLAN HoWE OR PROQAAW HN4
PA BLUE SHIELD
RUD ..eM. Ofl fOAM lUORI COWPLI'TVtO , "GN&NQ THIS fORM.
la. PA,.rHTSOR AUTHORiZED PfRSOf(I SIGNATURE I dlCWI ChI'.1M 01 an, ~ 01 ONf 1l'II0I1I\&IIllI'I"''''''
to plllClIM" ctam.I_114'HI P'rf'*'I ot ptrrm.na benltu..,., IG m,... Of MI h pIi1y wno ~ a.uqvnenl
MW. SIGNATURE ON FILE 10/06/93
SIGNED __ DATE .---
,.. DAti OF CURRENT: ~ ILL.HE&S ~~rmcMOITlI OR 'I. IF PATIENT HAS HAD SAME OR SIUU.AR UNE$S.
i~ I _DQ ! rc INJURV I riu Oft GivE FIRST DATE Y'" I DO , yy
I n I n? I g-.. PREGNAHCYILUPI I I
17. NAMI QlII REflRRIHQ Pt1Y&IC~ ORClHER SOURCR 17a.I,D. NUMBER OF REfERRING PHYSICIAN
,.. RUIRVED FOR LOCAL USE
at. DLAGNOSISOR NATURE Of II.L}jEaS OR I~URY.IREL.ATE ITEMS U,3 OR" TO ITfM 24E BY LINE) t
,.,929 ,~O . !--.-
" .!-- .
. . . c 0
,,~TEt"'" .ERVICEr. PIKe 'roo PROCEDURES, 6ERvlCliS, OR &uPPUES DIAGNOSIS
.. .. IE_pia'" ~W&lu~lIn~'~'1 COO,
.... ";:~ ~ .... 00 vv
In I^A b"> I I I" I~~~.~ I I I
, ' I I I
, , I I
, ! ! ! !
.
I I I I
I I I
.
I I I ,
, I I I
.
, , I I
I , I ,
I
I I
I
I I 'Ill /1
^n'" CJ ~. -<01"
{""I : "O_
J I , TV
I
H I , i. I
,
Iv
I
I
ill
I N
.~
i~
I ::.
, co
, ~
i ~
,I ,
I I ,
· n. ffDlFW. TAX l.O NUYBER
'>"l_'A"71"l0
31 SIGNATURE OF PHYSIClAN OR SUPPLIER
~ ,~OlNaDEaAEE. CREDENTIAlS
./'1"1:41 t\tl ,l.Ile nttDl'llNfI"""
.... .1"" . """'.pon...... ,
LAW NC~ MD
"'"Ilt1o
26 PATlEHT'S ACCOUNT NO II ;:{7_ A:CCEPT ASSIGNMENT?
FOf gcwl ~I.... l**)
YES LJ tiC)
32 - ~~' ADDRESS Of FACILITY WHERE SERVICES WERE
RENDEAtb IIIOlhlflln.&nhcln'lfOfOnlC81
ORTHOPAEDIC ASSOC ALLF-NTO
1730 CHEW STREET
~~TOWN PA lel04
&SN fiN
nlVl
A_...
DI':rt'E~I'
, s'.U,- .
IAPPROVID BY NlA COUNCil. ON ..IDICAl.lIliRVICE I/NI
PLEASE PRINT OR TYPE
'~A fTT
lFOR pAOQl\Alll 6H ITU.I 1)
CITY 'ITATI
ZIP CODE. I'E'(- )1HCLUDl AlItA COOII
It. U\lSUREO'S rQ,ICY QAQUfI OR fiCA NUYBER
C
I'
..
.
ii
c
~
.
C
"
e
~
.
!
.
.
'INSUR'BJ j'&"': II)'.}'"
, I
D lloll"LllTWR'1 NAY!
110
NAIl.
...
'0
c.INSURANCE PLAN MAME OR PROQfWI NAME
COMMERCIAL INSlIRANCE
d.l! THERE NiOTHER HEAL. TH 81NEflT Pi.AN1
IXJVEB 0 NO '....",.-n.IO,..__h4.
1:!.INSUREO-S OR AUTHOfUZED PiRSOH'S ~TURf.lllAhllNl
p'ymerI~~DenIllUto""~ph,..:wnOf~1oI
MIVlCet dMQ1l:IIId below.
SJGNATURE ON FJIE
t
t
I
.
.
8IGNED
'I. OATES PATIENT UNABLE TO WOf\K IN CURRENT OCCUPATION
..!'~ I 1'2. In .... , 00 I TV
fflOtl,ll (] lll::.,l ICiJI~ TO I I
II. HOSPITAUZATIOH DATlS RUATED rOCURRENT &ERVICEI
ww,DO,YV .....jDD.YV
fAOtrol I I TO I I
20. OUTSIDE LAB? . CKARGES
nvu NO I I
Z2 .,.l:PICAID RESU&I.IISSIOH ......'^ NO
CODE I _IIW. RE'. .
2:1, PRIOR AUTttOfUZATIOH HUYSER
. CHARGES
Q "
OR FIlM' ,.~ COB
UNITS Pian .....
K
RlIERVIO FOft
LOCAL uBI
..
,
".lo;lnn 1
,
I
,
,
I
I
I
,
I
I
I
,
,
,
I
,
,
,
I
I
28. TOTAl. CHARGE 121 AUQUNT PAID 30. BALNiCE DUE
I "l!; inn II 0 :00 I 35 00
33 PHYSICIAN'S. SUPPLiER'S B!UING NAWE. ADDRESS, liP CODE
l PHONE'
ORTHOPAEDIC ASSOC ALLENTOWN
1730 CHEW STREET
AI.LENTOWN PA I' e1Cl4
P,N. GRP' 2~-1 957130
'OR~ HC".'IOO 11'"'01
'OR~ OVICP.11OO PORIlIUII,IIl>.
\V
CllfforalS. Vernick, M.D., F.A.C.S.
Peter A. Kebllsh, M.D., F.A.C.S.
Tho'mas B. Dickson, M.D., F.A.C.S.M.
Patrick B'. Respel,' M.D.
Thomas D. Meade, M.D.
Steven J. Lawrence, M.D.,
.-, ,.
..
. ORTHOPAEDIC EVALUATION,
October II, 1993
5S/f/7/.I./~I~J
Re~
Clenn had a IOvere left lower extremity Injury back In 1983. Thll consllted of a commInuted left dlltel
. tlblalflbula fracture, compartment Iyndrome. He allo had a hip dlllocatlon. He allo had levare
probleml with healing and with loft tlllue coverage. In 1985 he had an ankle arthrodllls and has had
lome probleml with paIn track Infection. The patient relates that on Saturday a 3/4 ton van ran over
hll left foot. He wal leen at Carlllle hospital and x-raYI were negative. He Is now on crutchel and
II concerned about ~II foot Ilnce his pain II severe.
. On phYllcal exam, he hal tendernllu over the cuboid and lateral aspect of the calcaneus, as well II
over the retromalleolar and Inframall~olar area on the medlalllpect of his ankle. Tlnelllgn II pOlltlve
over the tibial nerve and over the sural nerve. There doel leem to be lome boney tendernell over.
the lateral most alpect of the calcanllul.
X-rIYI are negative.
IMPRESSION: PlItlent appelrs to have I levere crush Injury to hll foot, Ilthough there II very little
ecchymosll and no frileturel Ire preMnt.
I do think he II lufferlng from somll neuritis. Thll may have actually predated hll mOlt recent InJurv..
For that reason, I have put him on Elavll, 10mg, p.o., qhs and llxplalned the Ilde effectl, which are
common. He II allo placed Into a walking brace and he h to lIart with weight bearIng al tolerate~.
Steven J. Lawrence, M.D.
SJLmal
,
Trauma. Reconslrucllve Surgery' lolal Jolnl Replacemenl . Sports Medicine. Arthroscopic Surgery' Surgery 01 Hand/Fool
1730 Chew ?Ircet AII~nlo\\'n. PA 18104.5595 (215)433.6045
r
~
'~
Page 1
THIS IS THANH TRAN INTERVIEWING GLEN DERKOSH IN THE PRESENCE OF HIS ATTORNEY
UM, ROBERT T. YURCHAK UH, CONCEIUIING AN ACCIDENT THAT OCCURED ON OR ABOUT
OCTOBER 2, 1993, UM AT OR NEAR 'J'HE CARLISLE FAIRGROUNDS, IN CARISLE PA TODAY' S
DATE IS JANUARY 27, 1994 THE APPROXIMATE IS, UM 1:34 PM.
Q: CAN YOU PLEASE STATE YOUR NAME AND SPELL YOUR LAST NAME PLEASE.. .MR. DERKOSH.
A: OM, GLEN EDWARD AND UH THAT'S D-E-R-K-O-S-H.
Q: O.K AND MR. YURCHAK, CAN YOU UM IDENTIFY YOURSELF AND STATE YOUR NAME PLEASE.
A: ROBERT Y-U-R-C-H-A-K.
Q: AND UM, MR YURCHAK AND DERKOSH,
YOUR FULL KNOWLEGE AND CONSENT?
A: UM-HtlM, YEA.
Q: UM, MR DERKOSH WHAT IS YOUR AGE?
A: 39.
IS THIS RECORDED STATEMENT BEING TAKEN WITH
Q: AND ARE YOU MARRIED SIR?
A: NO, I AM SINGLE.
Q: WHAT IS YOUR HOME ADDRESS?
A: 208 WEST RAILROAD STREET, NESQUEHONING PENNSYLVANIA.
Q: O.K, UM, AND HOW LONG HAVE YOUR BEEN AT THAT ADDRESS?
A: OH, ABOUT UM, 25 YEARS~
Q: AND ARE YOU CURRENTLY EMPLOYED SIR?
A: YES.
Q: O.K AND WHAT TYPE OF WORK DO YOU DO SIR?
A: I'M A WELDER.
Q: AND FOR WHOM DO YOU WORK FOR?
A: HONNA WELDING
Q: AND UM, WERE YOU INVOLVED IN AN ACCIDENT ON OR ABOUT THE UH, SECOND OF
OCTOBER 1993?
A: YES, I WAS.
Q: AND WHERE WAS THIS ACCIDEN'I'?
A: CARISLE PENNSYLVANIA.
Q: O.K, DO YOU REMEMBER UH, IN CARISLE PA, THAT THIS OCCURED AT?
A: OM, I WAS STRUCK RIGHT IN FRONT OF GAT~ 1.
.
.....,
..;.,I
Page 2
Q: O.K AND WHERE IS THIS GATE ONE SIR?
A: IT'S AT A FAIRGROUNDS IN CARISLE, WHICH IS A CAR AUCTION, THAT WAS UH
HAPPENING AT THE TIME.
00 YOU KNOW WHAT THE NAME OF THIS CAR AUCTION THAT WHERE THIS OCCURED
AT?
Al YES, IT'S CARISLE, THAT'S THE WAY IT IS CARISLE CAR AUCTION.
O.K ALRIGHT, UM, AND UH THE DATE OF THE ACCIDENT AS UH, OCTOBER 2, 1993
IS THAT CORRECT SIR?
THAT'S CORRECT.
Q: O.K WHAT WAS THE APPROXIMATE TIME OF THE ACCIDENT?
A: IN THE MORNING SOMETIME, LIKE 9:00ISH, WHATEVER.
O.K AND WHAT TYPE OF ACCIDENT IS THIS SIR?
UH, I WAS STRUCK UH, IN, ON THE LEFT FOOT, BY UH MAN.
QI SO YOU WERE A PEDEDTRIAN AT THE TIME SIR?
A: YES, I WAS WALKING.
AND UH, THE VEHICLE WAS A VAN?
YES IT WAS
00 YOU HAVE ANY OTHER DISCRIPTION OF THE VEHICLE SIR?
UH, IT WAS OCCUPIED, BY I THINK FOUR INDIVIDUALS, AND IT WAS LOADED WITH
CAP PARTS TO BE SOLD, AT THIS AUCTION THAT WAS GOING ON.
00 YOU KNOW WHAT WAS THE MAKE, AND THE YEAR AND MAKE OF THE VAN, WHAT KIND
OF VAN IT WAS?
IT WAS A CARGO VAN, THAT COULD BE, YOU KNOW THAT PEOPLE COULD SIT IN THE BACK
IT WASN'T JUST LIKE UH, YOU KNOW LOADED FOR UH.
Q: O.K IT'S A CARGO VAN.
A: YEA.
00 KNOW WHAT WAS THE YEAR AND MAKE OF THE VAN?
UH, I GUESS IT WAS UM,
Q: O.K IF YOU DON'T KNOW JUST SAY YOU DON'T KNOW.
A: I THINK IT WAS A CHEVROLET VAN.
O'K' WAS IT A NEWER MODEL, WAS IT AN OLDER MODEL?
IT WAS LIKE A, I WOULD SAY LIKE IN THE BO'S.
Q: O'K' ALRIGHT, DO YOU KNOW WHO THIS VEHICLE WAS BEING OPERATED BY AT THE TIME
OF THE ACCIDENT?
A: NO, NOT AT THE TIME.
~
.".1
Page 3
Q: O.K DO YOU KNOW WHO WAS THE OPERATOR OF THE VEHICLE?
A: NO I NEVER MET THE INDIVIDUAL.
Q: O.K ALRIGHT UH, NOW DID VOU HAVE ANVTHING TO DRINK OR DRUGS PRIOR TO THE
ACCIDENT SIR?
A: NO.
QI AND YOU MENTIONED THAT VOU WERE STRUCK AS A PEDESTRIAN, DID THIS ACCIDENT
IN IT, IT'S AT A GATE, WAS THIS IN A PARKING LOT THEN SIR?
AI WELL IT'S A, A FAIRGROUNDS.
Q: O.K, UM THE VAN WHERE WAS IT TRAVELING, SIR WAS IT TRAVELING?
AI IT WAS COMING, IT WAS COMING FROM THE HIGHWAV, AND PROCEEDING TO COME THRU
GATE 1, WHICH IS A MACADAM PAVED STREET.
Q: SO GATE 1, THAT, WHERE THIS ACCIDENT HAPPENED AT WHERE YOU WERE STRUCK, UH
WHERE THE VEHICLE WAS TRAVELING ON IT IS A PAVED ROAD THEN?
A: YES, IT WAS A PAVED STREET, YES.
Q: O.K, AND UM, HOW MANY LANES ARE TRAVELING, IS THAT A ONE WAV OR TWO WAV
STREET?
A: WELL I WOULD SAY THE WIDTH OF IT, UH, TO.
SO YOU SAY IT'S ABOUT, IS IT.
YOU KNOW THAT A UP, IT'S A PAVED HIGHWAY, WELL NOT A HIGHWAY THAT A, THAT'S
BEING TRAVELED ON ALL THE TIME, IT'S JUST A YOU KNOW TO AND FROM.
SO IT'S A PAVED ROAD?
YEA.
Q: O.K AND IT'S A TWO LANE, ONE IN EACH DIRECTION?
A: I WOULD THINK THAT TWO PEOPLE ( INAUDIBLE) SIDE BV SIDE ON IT.
Q: O.K NOW THIS STRETCH OF THIS ROAD, UM NOW ON THE OTHER SIDE OF THE ROAD IS
IT THAT THE PARKING LOT, IS THIS THE, IS THIS WHERE THIS ACCIDENT HAPPENED
THIS ROAD, IS IT LIKE THE ISLE DOWN THE PARKING LOT?
YES, THERE'S MANY DIFFERENT, UH YOU KNOW ROADS THAT UH, MAKE UP THIS A I
WOULD SAY 18 ACRE FAIRGROUND.
Q: O.K DOES THIS PARTICULAR ROAD THAT, THAT, THAT THIS ACCIDENT HAPPENED ON THE
OTHER SIDE OF THE ROAD, WHAT, WHAT ARE ON THE OTHER SIDE OF THE ROAD?
THERE WERE VENDOR'S, I MEAN UII, VOU KNOW NEXT TO EACH OTHER, THRU THE WHOLE
ENTIRE FAIRGROUNDS.
Q: NOW, NOW WHERE
A: THERE WERE SEVERAL THOUSAND VENDORS, VOl) KNOW NEXT TO EACH OTHER, SELLING
THESE CAR PARTS.
,.7/
.,/
,.J'.~ I
--.
.:.;
Page 4
QI O.K SO THIS ROAD IS PAVED, ALHIGHT NOW WHERE THE VENDORS ARE IS THAT PAVED?
AI WHERE VENDORS ARE, THERE'S LIKE SOME IS A, IS LIKE DIRT, AND SOME IS LIKE A
YOU KNOW LOOSE GRAVEL, FROM TillS PAVED.
O.K THAT ROAD IS CLEARLY IDENTIFY ED AS A ROAD THEN, IT'S NOT LIKE AN ISLE
IT'S NOT, IT'S NOT LIKE A PARKING LOT, TYPE OF, TYPE OF ISLE?
AI THE ISLE WHERE I WAS, LIKE STRUCK AND ALL WAS LIKE A MAIN GATE.
QI O.K, O.K SO THIS IS A MAIN GATE, O.K ALRIGHT NOI'I WHERE, DO YOU KNOW THIS
ROAD WHAT DIRECTION IT RUNS NORTH, SOUTH, EAST, WEST?
NOT AT THE TIME I DON'T KIlOW WHAT, KIND OF WHATEVER.
QI O.K NOW, WHERE WERE YOU AT THE TIME OF THE ACCIDENT?
AI I WAS ON, UH, WELL IF YOUR COMING IN THE GATE, IF YOU WOULD BE COMING TO
THE DIRECTION OF THE ROAD, COMING THRU THE GATE I WOULD BE ON THE RIGHT
HAND SIDE, ON THE VERY EDGE OF THE ROADWAY.
O.K SO WERE YOU STANDING ON THE PAVED ROADWAY, 'I'HEN SIR?
YES, I WAS.
QI O.K AND HOW FAR, ONTO THE ROADWAY WERE YOU STANDING?
AI UH, I WOULD SAY THAT I WAS...MABYE...ENOUGH TO PUT MY LEGS AT ALL ON, YOU
KNOW I WAS STANDING THERE, AND THERE WAS OTHER PEOPLE, AND
Q: HOW FAR, FROM THE EDGE OF THE ROADWAY WERE YOU?
AI SIX INCHES.
Q: ABOUT SIX INCHES, INTO THE ROADWAY, O.K NOW IN WHAT DIRECTION WERE YOU FACING
SIR, PRIOR TO THE ACCIDENT WERE YOU FACING
WHAT WAY DO YOU WANT ME TO SAY, LIKE NORTH, WEST I DON'T KNOW.
QI O.K NOW IF, WERE 'YOU FACING IN THE DIRECTION THE VEHICLE WAS COMING FROM,
WERE IN THE OPPOSITE DIRECTION?
AI NO I WAS, I WAS FACING.. .UH, THE VEHICLE I~A!: COMING STRAIGHT AT ME, OR
COMING DOWN THE ROAD I WAS ON THE RIGHT HAND EDGE OF THE ROADWAY.
O.K, NOW WERE YOU FACING III THE DIRECTION 01-' THE ROADWAY, WHAT WERE YOU DOING
PRIOR TO THE ACCIDENT, SIR?
AI I WAS, I WAS WATCHING A VENDOR EXTRACT A ClIHOME PARTS FROM HIS VEHICLE.
Q: SO, SO YOU WERE STANDING ON THE RIGHT HAND SIDE OF THE ROADWAY, WATCHING
VENDOR'S, AND WHERE WAS TillS VENDOR, WAS IT ON THE OPPOSITE SIDE OF THE
ROAD, OR WAS IT ON THE SAME SIDE, ON THE RIGHT SIDE OF THE ROAD.
IT'S ON THE SAME SIDE OF THE ROAD.
QI AS YOU WERE STANDING, SO YOU WERE FACING THE UM, VENDOR THAT WAS OFF ON THE
ROADWAY?
A: NO, WHAT... THE VENDOR ACTUALLY HIS TRUCK WAS IN BACK OF ME, ALRIGHT NOW HE
IS TAKING THESE PARTS OUT OF TRUCK WALKING DIRECTLY IN FRONT OF ME AND GOING
TOWARDS THE RIGHT OF ME, ~lD THEN HE WAS STOCKPILING THESE ON THE SIDES OF '
THIS ROADWAY, WHERE I WAS STANDING.
.
'"
./
-
Page !l
QI O.K SO IF YOUR STANDING ON THE ROADWAY AND YOU WERE NOT FACING THE ROADWAY
WERE YOU FACING, YOUR BACK WAS TO THE ROADWAY THEN?
NO, I WAS LIKE, LIKE, LIKE FRONT OF MY BODY WAS TOWARDS THE FRONT OF THE
ROADWAY.
Q: a.K
AI MY BACK WAS TO THE BACK OF HIS TRUCK, AND WHEN HE WAS EXTRACTING THESE PARTS
HE WAS LIKE, PULLED THEM OUT... WALK AROUND THE TOWARDS THE FRONT OF THESE
TOWARDS THE FRONT OF ME, AROUND THE FRONT OF MY BODY, WALK TOWARDS TO RIGHT-
HAND SIDE OF MY BODY, AND STOCKPILE THESE PARTS,
QI O.K NOW IN REGARDS TO THE ROADWAY WHERE, WHERE THE VEHICLE, THE VAN, THE
VAN WAS TRAVELING, WHERE, WERE YOU FACING THE ROADWAY, WHERE, WHERE, WHERE
WERE YOU FACING, IN REGARDS TO THE ROADWAY, I'M NOT CONCERNED ABOUT WHERE
WHERE, WERE YOU FACING ON THE ROADWAY SIR?
...1 WAS FACING THE, FROM THE SIDE OF THE RIGHTHAND BERM OF THE ROAD FACING
UH... UH... (WHISPERING. . . INAUDIBLE.. . WIDTH PART OF THE STREET), THE WIDTH
PART OF THE HIGHWAY.
Q: NOW WHERE WAS BACK THEN?
AI ~OWARDS THE BACK SIDE, OF THIS TRUCK THAT WAS EXTRACTING...UM... THE PARTS
SO I WAS ACTUALLY LIKE I WOULD SAY TWO FEET FROM ACTUALLY SITTING ON THE
TRUCK.
QI O.K NOW WELL HOW DID THE ACCIDENT HAPPEN, CAN YOU TELL ME HOW THE ACCIDENT
HAPPENED?
A: WELL I WAS STANDING WATCHING THIS VENDOR, WITH THESE CHROME PARTS, TAKE...
UNLOAD HIS TRUCK, AND STOCKPILE THEM TO THE SIDE, THERE MIGHT HAVE BEEN, I
WOULD SAY, STANDING WITH ME, IN THE, IN THAT SURROUNDING AREA, SIXTY PEOPLE,
AROUND SIXTY PEOPLE OR SO ALL AROUND THE AREA.
Q: O.K
AI AND UH...THE VENDOR WAS TAKING HIS PARTS FROM HIS TRUCK AND STOCKPILING THEM
TOWARDS MY RIGHT.
O.K
THE NEXT THING I KNEW I JUST FELT EXCRUCIATING PAIN IN MY LEFT FOOT, PULLING
BACK AND UH. ..1 WAS UH.. . CAUGHT BY AN INDIVIDUAL, HE BROKE MY FALL, AND I
LAID ON THE GROUND IN BACK OF ME, NOT LAYING ON THE MACADAM NOW BUT LAYING
ON THE BERM OF ROAD.
O.K SO YOU WERE, YOU WERE JUST STANDING, JUST STANDING STILL THERE...
STANDING STILL LOOKING ACTUALLY...
Q: AWAY FROM THE ROADWAY THEN.
AI LOOKING TOWARDS MY RIGHT WHERE HE WAS STOCKPILING THE PARTS AT THE TIME ImEN
I WAS STRUCK.
.i
Page 6
QI O.K AND WHAT PART OF YOUR BODY WAS STRUCK?
AI WELL MY LEFT FOOT WAS RUN OVER BY HIS FRONT RIGHT... TIRE HIS MIRROR ON THE
PASSENGER DOOR STRUCK ME IN THE CHEST AND MY RIGHT HAND... NEXT TO THl PINKY
UH... FINGER WAS HIT BY THE MIRROR BRACKETS THAT HOLDS THE MIRROR IN PLACE,
AND I PULLED BACK AND I WAS CAUGHT BY AN INDIVIDUAL THAT UM...WENT AND
WITNESSED THE ACCIDENT, AND GAVE A STATEMENT ALSO.
QI O.K YOU SAID THAT YOU WERE STANDING STILL AT THE TIME, YOU WERE NOT MOVING
AT THE TIME, YOU WERE STANDING STILL FACING THE VENDOR TO YOUR RIGHT.
I WAS FACING OUT TOWARDS THE ROAD AS HE WALKING IN FRONT OF ME STOCKPILING
HIS PARTS, I WASN'T TURNED AROUND FACING LOOKING AT HIS TRUCK.
Q: O.K SO...
AI HE HAD A TRUCK THAT HE WAS PULLING PARTS OUT OF AND FROM THE SIDE AND WALKING
PILING THESE PARTS.
DID YOU SEE THE OTHER VEHICLE, DID YOU SEE THE VEHICLE THAT STRUCK YOU AT ALL
SIR?
A: UH... WHEN HE LEFT THE SCENE OF THE ACCIDENT I SAW IT, FROM LIKE LAYING DOWN
YEA, I SAW HIM LEAVING, AND HE WAS APPROXIMATELY, HE WAS LEAVING THE SCENE OF
THE ACCIDENT.
O.K ALRIGHT, O.K NOW MY, MY TAPE HERE IS, JUST ABOUT TO END I AM GOING TO
PUT ON ANOTHER TAPE, O.K I JUST WANTED TO ACKNOWLEDGE THAT AND THE APPROX-
IMATE TIME NOW IS UM, 1:49 PM, O.K AND UM, ARE YOU AWARE THAT THIS TAPE IS
GONNA END HERE, I'M GONNA PUT ON ANOTHER TAPE O.K
AI O.K DO THAT.
O.K UH, ATTORNEY YURCHAK CAN YOU ACKNOWLEDGE THAT.
SURE.
QI O.K THIS THEN CONCLUDES SIDE, THE FIRST TAPE
UH, THIS IS THANH TRAN INTERVIEIUNG GLEN DERKOSH, UM, IN THE PRESENCE OF HIS
ATTORNEY ROBERT T. YURCHAK, CONCERNING AN ACCIDENT THAT OCCUR ED ON OR ABOUT
eeCTOBER 2, 1993, UH AT OR NEAR THE CARISLE FAIRGROUNDS, IN CARISLE PA, TODAY'S
DATE IS JANUARY THE 27 1994, UM AND THE APPROXlMAT TIME IS 1:50 PM.
QI CAN YOU STATE YOU FIRST NAME AND SPELL YOUR LAST NAME PLEASE.
AI GLEN EDWARD DERKOSH D-E-R-K-O-S-H.
AND ATTORNEY YURCHAK CAN YOU IDENTIFY YOURSELF PLEASE.
ROBERT YURCHAK.
Q: O.K AND UM, ATTORNEY YURCHAK AND MR. DERKOSH IS THIS RECORDED STATEMENT BEING
TAKEN WITH YOUR FULL KNOWLEDGE AND CONSENT?
AI YES, IT IS, YES.
~
~
"
Page 7
O.K AND YOU ARE AWARE THAT THIS A CONTINUATION OF THE TAPE IN WHICH THE OTHER
ONE JUST RAN OUT.
YES.
01 O.K UH, I WAS JUST ASKING YOU DID, DID YOU SEE THE OTH~R PRIOR TO UH, PRIOR
TO THE IM?ACT SIR, DID YOU SEE THE VEHICLE PRIOR ~'O IMPACT?
Al ( PAUSE ), BY THE TIME I WAS HIT... LIKE YOU GOT, HOW MANY SECONDS TILL YOUR
RUN OVER AND YOU GO, AND LIKE, LIKE DROPPING TO YOUR, YOU KNOW KNEES OR
THROWN BACK, AND I LOOKED LIKE I WAS FACING, MY HEAD TURNED LOOKING TOWARDS
THE RIGHT, YES I SAW A VAN...
· ATTORNEY INTERRUPTS. GLEN HE'S ASKING YOU IF SAW ( INAUDIBLE ).
QI PRIOR TO HE HIT YOU DID YOU SEE THE VAN COMING AT ALL SIR?
AI NO I DIDN'T.
O.K AND, AND WHERE WAS, WHERE DID THE VAN COME FROM?
FROM MY LEFT, THRU THE GATE, HE'S COMING THRU THE GATE AND I'M APPROXIMATELY
I WOULD SAY 20,25 YARDS FROM THE GATE ENTRANCE.
QI O.K IS HE APPROACHING TOWARDS YOU OR WAS HE COMING FROM BEHIND YOU?
A: HE COMING FROM... ( PAUSE) LIKE...{ WHISPERING) ... THE SIDE OF ME
HE'S COMING...
HE'S COMING FROM MY LEFT SIDE.
0: HE'S COMING FROM YOUR LEFT SIDE.
A: LEFT SIDE, YES.
O.K SO HE'S NOT COMING, SO HE'S COMING FROM YOUR LEFT SIDE NOT IN FRONT OF
YOU OR IN BACK OF YOU?
AI NO, MY LEFT SIDE~
01 O.K ALRIGHT, AND YOU DIDN'T SEE THE VAN PRIOR TO, TO, TO THE IMPACT.
AI NO, I DIDN'T.
O.K NOW AFTER THE IMPACT YOU MENTIONED THAT HE WAS, WHERE DID THE OTHER
VEHICLE END UP, AFTER THE IMPACT WHERE DID THE OTHER VEHICLE END UP?
AI HE JUST KEPT ON GOING.
QI O.K AND HOW FAR DID HE GET?
AI I WOULD SAY MABYE ABOUT 25 YARDS.
HE KEPT ON GOING FOR ABOUT 25 YARDS?
RIGHT
01 WHERE DID HE FINALLY END UP?
AI HE ENDED UP DOWN THE ROAD TOWARDS MY RIGHT.
'.;J' ..../.
/"
,
.."
, Page B
O.K AND WHAT DID HE DO WHEN HE STOPPED?
WELL ALL THESE PEOPLE THAT WERE STANDING AROUND WITH ME WERE JUST YELLING
YOU JUST RAN THAT GUY OVER, YO AND SCREAMING AND YELLING, YO YOU JUST HIT
THAT GUY, SO THEN HE STARTED BACKING UP,
QI O.K NOW HOW FAST WAS HE GOING, WHEN HE WAS, WHEN WAS, WHEN WENT PASSED THERE
AFTER YOU SAW HIM.
OH.o. UK... I HAVE NO IDEA, I DIDN'T SEE HIM.
O.K NOW AFTER HE HIT YA, YOU SAID THAT YOU HIM KEPT ON GOING...
YEA.
QI HOW FAST WAS HE GOING?
AI OH, UK I HAVE NO IDEA, LIKE HOW FAST, HOW FAST
WAS
LIKE I REALLY DON'T KNOW, BECAUSE LIKE HEY I WAS IN THE MEANS OF, OF LIKE
FALLING, UH GRABBING MY FOOT, LOOKING PEOPLE AROUND AND SEEING LIKE, LIKE
LIKE THE VAN JUST GOING DOWN THE ROAD.
* BOTH CLAIM REP AND MR. DERKOSH TALKING AT THE SAME TIME I CAN'T UNDERSTAND ·
.01 WAS IT SPEEDING AWAY OR WAS IT JUST CONTINUING ON IT'S PATH?
AI IT WAS JUST CONTINUING DOWN THE ROAD.
QI WELL HOW FAST WAS liE GOING?
AI I TOLD YOU THAT I DIDN'T KNOW THAT.
O.K WELL, WELL.
YOU ASKED ME THAT BEFORE, AND I SAID ~HAT I DIDN'T KNOW
;
QI WAS HE GOING FAST; WAS HE GOING SLOW?
AI I DON'T KNOW THAT I JUST TOLD YOU THAT.
.* ATTORNEY YURCHAK, AT WHAT IN POINT ARE YOU TALKING ABOUT, WAS HE GOING FAST
OR SLOW'"
Q: AFTER, AFTER THE IMPACT TOOK PLACE, HE SAID THAT HE CONTINUED ON, HE LEFT OR
IS LEAVING THE SCENE, IT APPEARS THAT HE WAS LEAVING THE SCENE OF THE
ACCIDENT, BECAUSE YOU DID NOT SEE HIM PRIOR TO THE IMPACT, YOU SAW...
.*ATTORNEY YURCHAK, HE ALREADY ANSWERED THAT BY SAYING THAT HE DID NOT KNOW WHAT
THE SPEED WAS, HE JUST SAW HIM CONTINUING ON.
01 ALRIGHT, BUT WELL I WAS JUST ASKING WAS HE GOING, DID IT APPEAR TO BE HE
WAS SPEEDING AWAY, OR WAS HE JUST... .
AI WHAT DO YOU WANT ME TO SAY YES, HE'S FLOORED IT AND TOOK OFF.
""
""
....,'/
/
."
,-,;
-
,
,
PlIge 9
* ATTORNEY YURCHAK, HE ALREADY ANSWERED SAID THAT HE DOES NOT KNOW *
AI HE JUST PROCEEDED TO, TO, TO BEAR DOWN THE ROAD TOWARDS THE RIGHT, AND
THE VEHICLE WAS MOVING, HOW FAST IF I SAID HE WAS GOING 40 MPH, I'D BE
LYING, IF I SAID HE WAS GOING 30 MPH, I'D BE LYING BECAUSE I DON'T KNOW
QI O.K ALRIGHT, UM.. .AND WHAT PART OF ~'OUR FOOT WAS RAN OVER?
AI IT WAS UM... MY LEFT FOOT THE FRONT PART, LIKE FROM THE ANKLE TOWARDS THE
TOES.
QI O.K... ALRIGHT WELL UM, YOU SAID THAT YOU WERE WATCHING THE VENDORS, WHERE
WERE YOUR TOES POINTING?
AI TO THE FRONT OF ME, ( CHUCKLE ), YEA ( WHISPERING IN BACKROUND )
QI ALRIGHT, YOU MENTIONED THAT A, AFTER THE IMPACT A GENTLEMAN GRABBED YOU, DO
YOU KNOW THE NAME OF THE GENTLEMAN THAT GRABBED YOU THERE?
A: UM...{ LONG PAUSE )...{ WHISPERING IN THE BACKROUND ) JOHN CREW.
QI O.K DO YOU KNOW HIS ADDRESS OR TELEPHONE SIR?
AI { LONG PAUSE )... UH, 850 OAKLAY RD. BALTIMORE ZIP 21234, UH, YEA
ALRIGHT WERE THERE ANY OTHER WITNESSES THAT YOU KNOW OF?
YEA, PROBALLY ABOUT 60 OF THEM.
QI DO YOU KNOW THE NAME OF ANY OF THESE WITNESSES?
AI JUST JOHN CREW, HE WAS THE ONLY ONE THAT GAVE A WRITTEN STATEMENT, AND A, YA
KNOW, AND WAS, WAS THE INDIVIDUAL THAT BROKE MY FALL.
O.K, ALRIGHT DID THE POLICE INVESTIGATE THIS ACCIDENT?
UM, THERE WERE UM, POLICE THERE WERE UM, YEA I WOULD SA" 'I'HEY WEI<E El'j'IlEI<
POLICE OR THEY WERE SOME KIND OF HIRED INDIVIDUALS TO RUN THIS EVENT AT THE
FAIRGROUNDS. .
UM... DO YOU KNOW IF THE MADE ANY WRITTEN REPORT AT ALL?
YES, THERE WERE REPORTS WRITTEN UP... UM...ABOUT THE INCIDENT.
QI WERE THERE ANY COMMENTS MADE AT THE SCENE OF THE ACCIDENT, EITHER BY YOURSELF
OR ANYONE ELSE?
A: WELL THERE WERE UM... INDIVIDUALS ALL AROUND SAYING, WHEN, WHEN UH I WAS
STRUCK AND THE VAN WAS GOING DO THERE YELLING AT HIM, YO YOU JUST RAN THAT
GUY OVER.
WERE THERE ANY OTHER TRAFFIC ON THAT ROAD, ANY OTHER CARS, TRAVELING ON THA'l'
ROAD?
A: UM,...THERE WERE VEHICLES LIKE IN THIS WHOLE AREA, LIKE, LIKE UM.
..
~
::~./
/
"
,
-
,
Page 10
QI ON THE ROADWAY IT SELF YOU SAID THAT THIS WAS, THIS WAS ON THIS ROADWAY
WERE THERE ANY OTHER CARS TRAVELING ON THAT ROADWAY SIR?
UH, YEA I WOULD SAY THERE WERE VEHICLES GOING UP AND DOWN YEA.
QI IS THERE A POSTED SPEED LIMIT ON THAT ROADWAY?
AI I DON'T KNOW I WASN'T DRIVING.
AND THIS STRETCH OF THE ROADWAY IS IT STRAIGHT, CURVED ON A GRADE?
IT WAS STRAIGHT, IT WAS LIKE A, WELL THE ROAD WAS FLAT BUT IT WAS...
Q: AND HOW WIDE IS THAT ROAD?
A: OH...
· ATTORNEY YURCHAK, I THINK THAT INDICATED EARLIER THAT IT WAS WIDE ENOUGH FOR
TWO CARS.
O.K ALRIGHT, UM... AND HOW WERE THE WEATHER CONDITIONS LIKE AT THE TIME?
DRY.
QI O.K AND HOW WERE THE ROAD CONDITIONS LIKE?
AI THE ROAD CONDITIONS WERE DRY.
eQ: O.K THIS IS A RE-CAP HERE YOU WERE STANDING STILL, UH, WATCHING A VENDOR THAT
WAS TAKING SOME STUFF OFF OF HIS CAR, THE VENDOR, THE CAR WAS TO YOUR RIGHT IS
THAT CORRECT?
AI ( SILENCE )
AND HE WAS TAKING STUFF OFF HIS CAR AND STOCKPILING UM, WALKING IN FRONT OF
YOUR STOCKPILING TO YOUR LEFT.
HE WAS STOCKPILING THEM TO MY RIGHT
Q: OH, TO YOUR RIGHT
AI YEA, HE WAS LIKE GOING FROM BY BACKSIDE, UM MY BACKSIDE TOWARDS THE LEFT
GOING AROUND ME STOCKPILING TOWARS MY RIGHT, SO I'M LIKE STANDING WITH MY
BACK TO HIS TRUCK AND HE'S LIKE WALKING OUT AND AROUND, AND HE'S PUTTING THEM
TOWARDS TO RIGHT AND, AND I MEAN PUTTING SO LIKE A, I GUESS SOME TO MY LEFT
ALSO BUT AT THE TIME WHAT HE WAS DOING WAS, PILING, EMPTYING HIS TRUCK.
QI HOW LONG WERE YOU STANDING THERE SIR?
AI OH, MABYE AROUND ANYWHERE FROM AROUND 5 TO 8 MIIlUTES.
AND WERE THERE ANY OTHER, ANYBODY ELSE STANDING, UH AROUND YOU?
UH, A LOT OF INDIVIDUALS.
QI UM...I ALREADY DISCUSSED EVERYTHING AS FAR AS THE ACCIDENT?
· ATTORNEY YURCHAK, I THINK YOUR ASKING THE QUESTIONS HERE IT IS, YOU ASKED fOR
THIS OPPORTUNITY TO GET A S1'ATEMENT REGARDING THE ACCIDENT.
YEA, UM, AFTER THIS INDIVIDUAL,UM, THIS OPERATOR OF THE VAN... THE PEOPLE,
STOPPED HIM, THEY WENT AND ASKED, HEY YOU RAil THAT GUY OVER, AND THEN HE
BACKED UP, AND, AND AS HE BACKED UP HE'S IN FRONT OF ME, AND I'M LAYING ON
THE GROUND ALREADY WITH MY SHOE AND SOCK OFF, SEEING HOW MUCH DAMAGE WAS
DONE TO MY FOOT AND HE JUST SAT IN HIS VAN, AND HIS, EITHER HIS GIRLFIREND
OR HIS WIFE, OR WHAT EVER ON THE PASSENGER SIDE SITTING TWO INDIVIDUALS IN
THE BACK, I COULDN'T SEE CAUSE IT WAS LIKE A WINDOW VAN TYPE AND A, THEY
NEVER GOT OUT, THEY JUST LOOKING AT ME, AND A SO FINALLY THE WOMAN IN THE
//.
"
Page 11
Q: ALRIGHT THEN WOULD LIKE TO ADD ANYTHING ELSE IN REGARDS TO THIS ACCIDEN1'?
AI YEA, UM, AFTER UM THIS INDIVIDUAL UH, THIS UH, OPERATOR OF THE VAN, UM
THEY, THE PEOPLE STOPPED HIM, THEY WENT AND ASKED HEY YOU RAN THAT GUY OVER
AND THEN HE BACKED UP, AND AS, AND AS HE BACKED UP HE IS IN FRONT OF ME,
AND I'M LAYING ON THE GROUND ALREADY WITH MY SHOE AND SOCK OFF, SEEING HOW
MUCH DAMAGE WAS DONE TO MY FOOT, AND HE JUST SAT IN HIS VAN, AND EITHER IT
WAS HIS GIRLFRIEND, OR HIS WIFE OR WHATEVER, ON THE PASSENGER SIDE SITTING
THERE, TWO INDIVIDUALS IN THE BACK, THAT I COULD SEE LIKE IT WAS A WINDOW
VAN TYPE AND A, AND THEY NEVER GOT OUT AND THEY JUST LOOKING AT ME AND SO
FINALLY THE WOMAN IN THE VEHICLE ROLLS THE WINDOW DOWN AND A, SAID LISTEN
HE GOES I'M IN A REALLY BIG HURRY, HE GOES I RUNNING LATE HE GOES I'LL BE
BACK IN ABOUT HALF AN HOUR, AND I LOOKED AT HIM FROM THE GROUND LOOKING UP
AND HE IS LIKE STOOPING OVER TOWARDS THE HOMAN SPEAKING THRU THE WINDOW
LIKE I SAYS, YOUR GONNA WHAT, YOU JUST RAil ME OVER AND YOUR GONNA LEAVE, AND
GO SET YOUR STANDS UP, I SAID BUDDY YOU GOT TO BE KIDDING ME, I SAID, AND,
AND, AND THEN THEY JUST SAT THERE, FINALLY HE GOT OUT OF THE VEHICLE AND
COME AROUND AND NEVER APOLOGIZE, NEVER SAID LISTEN HEY I'M SORRY I NEVER
SAW YA, I YA KNOW, NOTHING VERY, A STRAIGHT STANDING AWKWARD LOOKING GUY,
AND I WAS PRETTY TICKED OFF ABOUT THIS AND A THE FIRST AID PEOPLE WERE THERE
TAKING CARE OF ME, AND TAKING MY PULSE, AND THERE WERE THINGS LIKE THIS, AND
THEY SAID CALM DOWN, CALM DOWN, AND A... I SAID CALM DOWN, I SAID DO YOU
BELIEVE THIS GUY, I SAID FIRST HE RUNS ME OVER AND THEN HE HIT AND RUN ME,
AND GOES DOWN THE ROAD, IF IT WASN'T FOR THESE PEOPLE TO SCREAM AND YELL, AT
HIM, SAYING HEY YOU JUST RAN HIM OVER, IT COULD HAVE BEEN A LITTLE KID ON A
VEHICLE, OR A LITTLE BICYCLE OR SOMETHING, HE WOULD HAVE RAN HIM OVER AND
KEPT ON GONING THAT HOW I FEEL AT THIS, THIS INDIVIDUAL WAS, AND UH JUS'!'
KEPT ON GOING IF IT WASN'T FOR THESE PEOPLE THAT'S THE WAY IT WAS, AND NEVER
MADE ANY KIND OF STATEMENT TOWARDS AN APPOLOGY, UM HEY, IT'S NOT LIKE HEY I
DIDN'T SEE YA, YA KNOW, I'M REALLY SORRY, SO YA KNOW LIKE, I HAVE NO FEELINGS
FOR AN INDIVIDUAL LIKE THAT.
QI O.K UM,... ALRIGHT IS THERE ANYTHING ELSE THAT YOU WOULD LIKE TO ADD IN
REGARD TO THIS ACCIDENT?
AI WELL THEN THE AMBULANCE CAME, THEY HAD.
e. ATTORNEY YURCHAK, I DON'T WANT TO GO INTO IT WITH THE AMBULANCE, AND EVERY-
THING ELSE, WE ARE JUST TALKING ABOUT THE INCIDENT.
A: WELL THAT WAS IT, THEY HAULED IT OFF IN THE AMBULANCE.
QI ALRIGHT, ONCE AGAIN JUST AS RE-CAP YOU SAID THAT YOUR STANDING THERE WATCHING
ON THE EDGE OF THE ROADWAY, UM... WATCHING THE VENDORS, THIS VENDOR WORK ON
HIS VEHICLE, AND A VEHICLE CAME FROM YOUR LEFT SIDE, IS THAT CORRECT...AND
RAN OVER YOUR VEHICLE, RAN OVER YOUR LEFT FOOT?
A: YES.
QI AND HE CAME DIRECTLY FROM YOUH LEFT?
AI YES.
01 ALRIGHT WHERE YOU WERE FACING ( TAPE RAN OUT ).
.",
'"
'-
Page 11
QI ALRIGHT THEN WOULD LIKE TO ADD ANYTHING ELSE IN REGARDS TO THIS ACCIDENT?
AI YEA, UM, AFTER UM THIS INDIVIDUAL UH, THIS UH, OPERATOR OF THE VAN, UM
THEY, THE PEOPLE STOPPED HIM, THEY WENT AND ASKED HEY YOU RAN THAT GUY OVER
AND THEN HE BACKED UP, AND AS, AND AS HE BACKED UP HE IS IN FRONT OF ME,
AND I'M LAYING ON THE GROUND ALREADY WITH MY SHOE AND SOCK OFF, SEEING HOW
MUCH DAMAGE WAS DONE TO MY FOOT, AND HE JUST SAT IN HIS VAN, AND EITHER IT
WAS HIS GIRLFRIEND, OR HIS WIFE OR WHATEVER, ON THE PASSENGER SIDE SITTING
THERE, TWO INDIVIDUALS IN THE BACK, THAT I COULD SEE LIKE IT WAS A WINDOW
VAN TYPE AND A, AND THEY NEVER GOT OUT AND THEY JUST LOOKING AT ME AND SO
FINALLY THE WOMAN IN THE VEHICLE ROLLS THE WINDOW DOWN AND A, SAID LISTEN
HE GOES I'M IN A REALLY BIG HURRY, HE GOES I RUNNING LATE HE GOES I'LL BE
BACK IN ABOUT HALF AN HOUR, AllO I LOOKED AT HIM FROM THE GROUND LOOKING UP
AND HE IS LIKE STOOPING OVER ~OWARDS THE WOMAN SPEAKING THRU THE WINDOW
LIKE I SAYS, YOUR GONNA WHAT, YOU JUST RAN ME OVER AND YOUR GONNA LEAVE, AND
GO SET YOUR STANDS UP, I SAID BUDDY YOU GOT TO BE KIDDING ME, I SAID, AND,
AND, AND THEN THEY JUST SAT THERE, FINALLY HE GOT OUT OF THE VEHICLE AND
COME AROUND AND NEVER APOLOGIZE, NEVER SAID LISTEN HEY I'M SORRY I NEVER
SAW YA, I YA KNOW, NOTHING VEIlY, A STRAIGHT STANDING AWKWARD LOOKING GUY,
AND I WAS PRETTY TICKED OFF AuOUT THIS AND A THE FIRST AID PEOPLE WERE THERE
TAKING CARE OF ME, AND TAKING HY PULSE, AND THERE WERE THINGS LIKE 1'HIS, AND
THEY SAID CALM DOWN, CALM DOWIl, AND A... I SAID CALM DOWN, I SAID DO YOU
BELIEVE THIS GUY, I SAID FIRS1' HE RUNS ME OVER AND THEN HE HIT AND RUN ME,
AND GOES DOWN THE ROAD, IF IT WASN'T FOR THESE PEOPLE TO SCREAM AND YELL, AT
HIM, SAYING HEY YOU JUST RAN 111M OVER, IT COULD HAVE BEEN A LITTLE KID ON A
VEHICLE, OR A LITTLE BICYCLE OR SOMETHING, HE WOULD HAVE RAN HIM OVER AND
KEPT ON GONING THAT HOW I FEEL AT THIS, THIS INDIVIDUAL WAS, AND UH JUST
KEPT ON GOING IF IT WASN'T FOR THESE PEOPLE THAT'S THE WAY IT WAS, AND NEVER
MADE ANY KIND OF STATEMENT TO\~ARDS AN APPOLOGY, UM HEY, IT'S NOT LIKE HEY I
DIDN'T SEE YA, YA KNOW, I'M REALLY SORRY, SO YA KNOW LIKE, I HAVE NO FEELINGS
FOR AN INDIVIDUAL LIKE THAT.
QI O.K UM,... ALRIGHT IS THERE ...IlYTHING ELSE THAT YOU WOULD LIKE TO ADD IN
REGARD TO THIS ACCIDENT?
AI WELL THEN THE AMBULANCE CAME, THEY HAD.
. ATTORNEY YURCHAK, I DON'T WAil',' TO GO INTO IT WITH THE AMBULANCE, AND EVERY-
. THING ELSE, WE ARE JUST TALKING ABOUT THE INCIDENT.
A: WELL THAT WAS IT, THEY IlAULr.lJ IT OFF IN THE AMBULANCE.
Q: ALRIGHT, ONCE AGAIN JUST AS ~E-CAP YOU SAID THAT YOUR STANDING THERE WATCHING
ON THE EDGE OF THE ROADWAY, l:I~... WATCHING 1'HE VENDORS, THIS VENDOR WORK ON
HIS VEHICLE, AND A VEHICLE CMIE FROM YOUR LEFT SIDE, IS THAT CORRECT... AND
RAN OVER YOUR VEHICLE, RAN OVER YOUR LEFT FOOT?
AI YES.
Q: AND HE CAME DIRECTLY FROM YOUR LEFT?
AI YES.
I.QI ALRIGHT WHERE YOU WERE FACING ( TAPE RAN OUT).
!
,
I
j
,
1"
'W
.'/
'-
v
"
Page 12
THIS IS THANH TRAN INTERVIEWING GLEN DERKOSH IN THE PRESENCE OF HIS ATTORNEY
ROBERT YURCHAK, CONCERNING AN ACCIDENT ON OR ABOUT OCTOBER THE 2ND 1993,
TODAY'S DATE IS UM, JANUARY THI, 27TH 1994 AND THE APPROXIMATE TIME IS A 2:05
PM, CAN YOU STATE YOUR NAME AND SPELL YOUR LAST NAME PLEftSE.
AI GLEN EDWARD DERKOSH D-E-R-K-O-S-H.
AND ATTORNEY YURCHAK CAN YOU IDENTIFY YOURSELF PLEASE?
ROBERT YURCHAK.
AND IS THIS RECORDED STATEMENT BEING TAKEN WITH YOUR FULL KNOWLEDGE AND
CONSENT?
AI YEA, YES
AND ARE YOU AWARE THAT THIS IS A CONTINUATION OF UM, THE TAPE THAT JUST
RAN OUT?
YES.
QI AND THIS IS THE THIRD TAPE.
AI RIGHT.
O.K UM, I'M JUST GONNA CONCLUDE THIS UM, IS THERE ANYTHING ELSE THAT YOU
WOULD LIKE TO ADD?
AI NO.
QI AND ATTORNEY YURCHAK...
AI ( INAUDIBLE ), EITHER 11 TRANSCRIPT OF THIS TAPE OR A COPY OF THE TAPE.
O.K THEN UM, ONCE AGAIN WAS ARE THE REMARKS THAT YOU MADE IN THIS RECORDED
STATEMENT YOU TRUE VERSION TO THE BEST OF YOUR KNOWLEDGE.
A: YES IT IS.
QI ALRIGHT WAS THIS RECORDING p~DE WITH YOUR FULL KNOWLEDGE AND CONSENT?
AI YES.
O.K THANK YOU VERY MUCH, UM, MR. DERKOSH AND ATTORNEY YURCHAK THIS CONCLUDES
THE RECORDED INTERVIEW
STATEMENT WAS TRANSCRIBED BY ERICA TIMMS, AT '!'HE WESCOSVILLE CLAIMS OFFICE.
.i
~
J1040
Label
lSM
lnalruclionl
on pagl 12,)
U.a th. IRa
lab.l,
OlhllWl."
pl.... ptlnl
or Iypa,
"..Id.nll.,
EI.allon C.mp.lgn
8M .. ,~.
Filing Stalul
(SH I'Ig. 12,)
ChICk on/y
one box.
EXBmpllons
(SH p.g. 13,)
II mot. th.n .Ix
d.pIfld.n,.,
... p.g. \4,
--.--..-- ......
SIngle
MItT1Id IUlng !<>llll I.lum (.Vll'l H on/y 0IlI had incom.)
MIn1Id IIIOlg 11011II11 rllum. Enllt 1jlOUM'. IOCiIIlICIM11y no, allOw ond fill MInI hIr., ..
HOld 01 houl.hold (with qUllltylng pallO/l),lSH p.g. 13.) lithe qUllltylng patIOflla. child bu1 nol yoUl dlp.ndIIll,
11'I1., ~'IlI chJI~'. nama hili, ..
Quall In widow. with d. ndlnl child .111 aull died .. 18 , S.. .. 13.
Vourelll, " your p".m lor 1OIl\1O/l. II..) can claJm you II . dtPl/ldltlI on hII or her ...
I.IUln, do nol chick box 61. 1M bI .... III choclc the box on IinI 33b on pag. 2 .
b au........ .........
o Dapalldant., I I ~ I 01 CIJtI, I No. lIIOlIIlI
III klllllUltlllnlU&I, 1M ~ll ..mIl 1Io1lt_,'1 ~ _Illy IotcII "'"
DePMmMI 0' 1M T,...ur;-tnletnat R.v.~ a.n,6G. <ltm93
U.S. Individual Income Tax Return (8) U<SI
'Of lhI ~ Jan. 1..o.c. 31. 1883, Of 01'* 1&.1 yHI btO~
'Your 'ltIt nama Ind nllaJ WI nama
L
A
a
I
L
CAR-RT-SORTMMCR02
S28 Al I
K
1ol>I,/lO,
082 S
.' II,
kollOMMM
VI 171-46-0121
GLENN E DERKOSH
208 W RAILROAD ST
NESQUEHONING f'A
18240
H
I
R
.
Doyau wanl 13 to go 10 Ihll lund? . , . . , , , . .
If . t Filum, dOli ~iIJr. UII want S3 to 0 to thll fund? .
8
Sa
" jOur eIlIld llJdnl U.. w,th IOU bul II clIImad u 10lII dllltndanl undll I p".IN5 11I'11"""1, _11II1 .. 0
Tolat numbe, of ..em tlonl clalm.d . . . . . . . . . . ,
Wagll, ""'"1, Upa, etc, Attach Form(l) W-2 . I . . . . I .
Taubla Int.,lIllncom. (HI ;;.og. 18), Altach Bchtclul. B " ...r $<400 .
Tu.......pllnl.,.11 (... p.g. 17). DON'T Includ. on 1in18a 8b
Dividend Incom., A<<lth Bchedul. B If ..., $<400 . , . , . , .
Taxabl. IIfundl, cr.d,", or oH1I1I 01.11'. and IocAIlncom...... (I.. p.g. 17) .
AIImonV rec,lved . . I . I I I . . . I
8uaJnae. Incom. or (1011), ....t.ch Bch.dul. C or C'CZ . . .
C.pllal g.1n ., (loll), Atl.cn Bch.dul. D . . . , . . .
Cepllal gain dllltlbuUcnl nolltpan.d on Una 13 10 I. pagt 17) . . .
QIhII gw ., (101m), AnlCh FOtIl1 4787. . U ' . . , . , . . . , .
Tolal 1M dl.lrillllllon~, I.1!!J . . _ b TwDI. amounl (III pig. tl)
TolII plntlonllnd II\nu,till Lrl!.J b T_. amoun'llll pogo II)
Rentalllal 111.1., 101,'11.., panntllhlpl, 8 eotpO..l.onl, INIII, .10, AItlCh Bchtclul. E
Farm Income 01 ~Ollil. AIIA:h Schedule F . , . . . . , . . . .
lJnemplovtnlnl comr.ull,,~llon (IN plge 18) . i . . . . . . . . . . .
Boclal HCullly blno",. I 21. I '_ I b T_. amoun' (III pag.18)
Othtr Incom., Uall,.. I,nd emOUnl-MI page 20....................................
Add Ih. .mounlllt1l~u II" rl hi column lor IIn.. 71h h 22, Thll" OUI loullnoom. ..
YoutlRA deduc'lon ,... p.g. 20) . , . . 24.
SpaUII'. IRA dedu"I,on '"" p.g. 20). , . , 24b
On..half 01 IlIf..n,plolm.nlllll (I" pag. 21), 25
Salf.employed halollh InIU1I1lC. deduction II" p.g. 2J) 20
Ktogh Ittirltl1trtt pllll and IIIf.employed SEP deducllo,) 27
P.nally on early wllhdllwal of IIVlngl, . , . .. 211
Almony paid. Rtclpiun"1 6SN .. I I 2D
Add IInll 24. Ih,ou h 2g, Thll. .r. ou, \oulad UIII,,,n, , , . , , , , ..
btrlcllml30 rom 1in123. Thil I. your .dju.ted grOIl I.lt~'..j,,-:II fMlmOUnr" ~1I1h1n
123,050 tIIIJ . CilI/ff _ ...Ul )'flU, "" pa(1l E/C.' 101M oul " )'011 COIl cJtIm UlI 'E"'*'
IncOIM CrwdI . on 'If" !6 ...
..... .... apace
,110MB No, 11'1-001'
V.... NCloIIt.oirtly numb..
,
I
'POUH', ~ IIcurlIV numlNr
I I
For Prlv.ov Aot .nd
Paparwork R.duollon
Aot Nolle., .a. ag. 4.
V.. No Holt' CIltWlQ 'Yu'
wllno'~104II
.....,-1lIUI
Itlunrl,
NI, ".....
..w. 1111
.., II
NI, "I'u/
U1"". 1111
...,
. ""hili I"
. .u.'1 Ut' .I~
'161'11111
.win."
..,."III1IH'
..11111 _
De"..'IlI'lIk
III ....,., ..... _
AU lU.hl1
....It~ ..
lIH'..... .
-L
,
, .
oc
8
o
1
2
3
14
1
lOb
17b
''l
Cal, No, 12SGIV
------
,
,.... 1040 flltJ)
.
. ''-dx '33 Atnoiml from lint 31 (ldJullld grolllncom.) , . . . . , , , . , . .
Compu- lI3I, Clltck It; CI You -I e5 01 Older, CI Blind; d 8po11" wu e5 01 Older, CI Blind,
lallan Add lIII numbe, 0' bo..1 eneckld lbovt .nd .nllt lIIIlol., h.,., , . ,~:131
II "~!WIn1 (0I1OItlIOnI .11.) "" claim you II I daptnd.nl, CI1eck hi" . ~ ~
o H you I.. man1acf IIlIng ..paraltly and \'OUr 1_ ".mln. dlducllolll or
you ... I dual....lua llIan, III PIIII 24 and enlCk hara. . . . . . . ~ 330 CI
1'lIm11ed deduoUona lrom Bchadu" A, Nnl ae, oA )
.. tit ."n""lII daduoUon IIlown b.low 'or \'OUr nllng .lllu., 8ulll VOU ohio kid
1_- r any boJr on II.. :131 0' b, go 10 pag. 24 10 find vou, .I.ndlrd dlducllon,
0i.1 II you CIlIclcId boJr 330, you, Illndlrd dlducllon II nro,
)'OUr: I 81ng1t-t3,7oo I H..d 01 hou'"hoId-Ia,460
I lo4arr11d 1I11ng JaInII\' or Cullllylng wtdow(1!HI,200
· lo4arr11d llJing llparal'lr-a3,loo
Subtract h,S4 tram h 32 . . . , . . . . . . . I . . . . . . I
" IIr.I 32 II "1,3aO 011111, multiply 12,360 b)'lh. 10111 number 01 1.lmplionl c1a1m.d on
Ifna e., "lnl 32 II - "1,3aO, III ilia WOI1<ah..1 on p.g. 25 lot Ih. III10Unl 10 .,,1., ,
TI.lbl. Inoome, 8~ Una 3e from 1In. 35, " IInI 3111 mora Ihln line 36, anllt .1). .
T... Chack "from I ~ Tabla, b CI T.. All. SChadul.., 00 Sohldula 0 T.. Wottc.
1hH1. or dO Fcnn ee16 (I" p.g. 26), Amounlfrom Form/.) elu ~ I I
Addnlonall.... 'III 'Igl 2e), ChIck lllram I CI Fann 41170 II 0 Fcnn 41172
Atld IIn.. 31 .nd 3D
CrIdIlIcr child and clIpand."I .... uptl\lll, AlIlen Form 2441
Ctldn 10I1ha lldaIlV 01 the dillblld, Alllen Schldull R " 4
Fcralgn I.. Ctldn, All.." Form 111 I , . . , . " 43
01"., Orad/I. (_ Pll/I ae), Chick n from I 0 Fann 3100
b 0 F""" 53D1 0 0 Fonn 1801 d 0 Fcnn (.pocilil_ 44
Add In.. 41 through... . . . . . . . . . . . f . .
SUblraolllnl 41 lrom linl40, " 11n. 45 II mora Ihln IInl 40, Inllt .0. .
lIaI'.amploymanll... AlIach Sch.dull BE, AIIo, ... IIn. 25. . . .
AhImlUve minimum tax. A<<lch Fonn 8251 . . I . . . . . . . . . . .
Aacaptura IU. (1M PIl/I2IJ. CIIIcIc n from 10 Form 4265 b 0 Form eel 1 00 Form 8121
SocIal NCUtlIy and 1041d1c1r.1U on lip Incoml nclrapol1ld 10 .mploYl', AlIlen Form 4137
T.. en qUliItlacl rat_t plano, including IRAe. " raqul..d, .1I.ch Form 532D , ..
Advanc. lamld 1nc0llll crldn Plrm.nl. from Form W.2 , . . . . . , . , .
Atldlln..41Ih h52,Thllll 1011111."", ."... ~
fldlnJ InclllllllP wtlhhlld, "Iny Is lrom form(11 1099, ell," ~ 0 14
lDD3 1I1kN11d lax PI)mIIllllllllllllOUlllappllld Ircm 19112 "'um , 65
limed Inoome oradlL AlIlen Schldul. EIC , . . " ee
Amount plld wllh Form 48e8 '1.II..1an requI.I). . " 67
ExCIIIIOCIIIIIClIrtIy, MldICl/I, .nd RRTA IP wtlhlltld (III p.JgI 21) , 58.
Delarral oIldd111onallD83 lUll, Altach Form 1841 . . , , 58b
Dthlt JlI)'I1lIIlII ('11 PIl/I 28), CIIIcIc 1I Ircm I 0 Form 2m
b CJ 'onn 4138 I . I . I I I . I I . . " aD
Atld IIn.. 64 Ih h 5D, Th.11 ... r 10111 I Inll , , , . , ...
n... eo Is rnctIlhan ... 53, SIAlI,1CI inl5.l lrom lint eo, TIllllllhllll1OUl1l you OVERPAlO,
Amctlnl 0111.. 11 you wlnl AlnJNolo TO YOU, , . , , , , . , , ,
NnDllnl ul unlll you Wlnl APPlIED TO YOUR '"UITlMATED TAX ~ , 03
I' I.. 5311 mora than lint eo, IUblraelll.. 50 I,om IIn. 53, Thllll Ih. AMOUNT YOU OWl,
FOI dll.1I1 en how to paV, inclUding Whallo wrll. on vour Plym.nl, III p.g. 2D , . ,
Elllmllld II' .nll II. I. 29 , A110 Includo on IIn. 14 15
311
:18
If~wlnl n
Ih. IRS 10 31
"gurl \'OUr
.1'" II. '
rig. 24. "
40
Credits 41
42
43
44
41
41
47
...
411
60
If
U
53
paymenll 64
e5
. 61
Alllen
F cnnl W.2. 17
W.2QIl and ...
10119. on
Inllronl, b
ID
. 60
Illlfund or II
Jlmount u
You Owe N
..
.
Sign
Here
K.lp I copy
01 Ihll ralum
for your
.Icordl,
PaId
f'rllparer'l
UIIl Only
,- ~
15
.
~
31 ~6::.1) lrV
37
38 ro
3D
40
, .
..
45
41
47
41
48
60
11
52
53
.-0
. ~
(j
o
lind" ptl\llUet of pttfury, I dIdn ChIli hlvt 1111"lntd Ihl, ,.ILWn and .ecom~n)'ln" IChldul.. and 1111.menl,. Ind to thl bell of m)' knowltdge and
belli,. InIy III WI, r.orrect, Ind compltll. OtcIa"li~n of pt.pltl( (Olhtt It\an l'IPI)'II) II bued on an InIOfmll1on of whiCh pttpllll hu any kno~.
~ 'f04Jlllgnllurt Oil' You, occupIUon
~ 'POUII'I ligllll"'", II . Jolnl re'um, BOTH mUll Il{ln,
0.1.
SPOUII', DCcuplllon
Prtp&ttI'. ~ '
1Igna1'" r I
'Irm'. name lor~,. ~
N IIn.ompIoyod) '""
"
ll..u.t. ,~"'" ,
"06
0'1'1
'l (,"/
.o,~ ~
,~
ChOCk K /
ull-.mplevet'
1.1. No
ZIP COdI
4' .IUWlIo .........
'u.S. Gow.IM1llnlJl,WiUIl; 0I1lCe: I~ _ :14..017
'2 u
.i!t:'~llI'onn lOClIl 1813 OMI No, "41-0074 Plgl 2,
"',,",,(1) uer ff' !onn lIMO.., Do ""JAI111t """l"_1Ild -IflllOUltly nu,,',; "u "- on _ 1Idl'I Vour 100I1' I_ly '"""bt.
~ C.~ . .\'11 i% 1012..1
,
Schedule B-Int<. rast and Dividend Income
e Add thl arnountaon line 5 . . . . . . . . . . . . . . .
7 Capilli gain dlatrlbutlona, Enta. her. .nd on Schedul. 0'. I-L-l--._,
8 Nont&x&bl. dlalrlbutlona, (See lhe Inll, 10. Form 1040, Hn. B,) l...L.L-..__
g Add IIn.a 7 and 8 . . . . . . . . . , . .'. , ,
10 Sublrect IIn. BIram IIn. &, Enler the ..aull her. .nd on FO'nI lL J, I,ll B . ~
'If you rec.lved c.plt., g./n distributions but do nol ne.d SC""t. .. D to repoll
.ny other II./ns or losses, .ee Ih. Instructions (or Form 1040, lint. I" .nd 14,
"you h.d ov.r $400 01 Inter"t or dlvld.nda OR had a foralgn accounl or ." rlJ ., grantor 01. or a Iran,'aror
to, a lorelgn wal, yotJ muat complela Ihla part.
lla At any tlm. during lBB3, did you have an Inlerest In or a slgnalure or olher aulhorlty over e IInenclal
.ccount In . foreign country, tuch aa a bank accounl, aocuritlaa eccounl, or othar Iln.nclal
account? See page e.2 lor .xceptlona and filing requirements lor Form TO F BO'22.1 . , . .
b "'V.a,' .nterlh. n.me of the I ""gn counl'Y ~ .......................................................
I~.. 1 a Wer. you th. grantor aI, or tren, loror 10, a lorelgn trusllhal oxlsl .d during 1 BB3, whether or not
M.g. 8.2,) you have any beneflclallnleresl.: dl? If 'Ves' au ma have to I.., ,,,rm 3520, 3520.A or B28.
fo, P.p'#worle R.duoUon Acl NoUol, '"" Form 1040 In.,,",,'.nl, Schldulll (form 1040) 11lG3
Part I
Inlll...1
.lnhome
r:i:' I
rl lS
o 8.1.)
11011111 yotJ
'.111vod . form
.101l1-INT. Form
IOIlI-OIO. or
auballtul.
.lalllTlenllrom
I bioIclregl linn,
lilt 1110 linn'.
r,arne u lhe
,,"yo' and ani..
...l~1 ,ol.,lnllrul
"'lOwn on thet
101m.
Part II
DivIdend
Income
/lolllll you
I;.~lved . Form
..l OIB.DIY or
"!ub.II\u11
ct.tom.nt from
a btoker.gl
l"m,lIlllhl
'i,m', nam. ..
I~I Plyer and
antlr Ihl lotal
,hvld.nd.
.~own on thaI
t:mn,
Part III
ForeIgn
^ccountl
;,nd
i'rusls
.
AttaClvnlnI
ilIQuance No, 08
Noltlllf hid 01'1/' 1400 In laIt.bIo hllorasllncoml mu.,.I.o com II Poll /II.
Int.....llncom.
1 UoI nama 01 ~" II any Inl....t I. lrom . Milar-financed mortg.go .nd th.
~, Uled th. property u a pereonll '''Id.ne., 1M p.g. e.l and lIalthla
Inte...t ""1. AIIo &how th.t ~r'I .oclll aecur1ly numbe, and Idd..... ~
n'\.((U:ct\'..~....A,........A....A.~................................
\~..\.........I......................~...~.,..............................
~......... ... ...............c:::1.(C...............~....:.......T....................
" '0' . a.....~....\!:\.I.t).M...P.~~..................
.......... ..................IJ.......................f.....................................
Amount
............................................................................................
1
............................................................................................
............................................................................................
............................................................................................
.....................~......................................................................
............................................................................................
............................................................................................
............................................................................................
2 Add thl emounta on IIn. 1 . , . . . . . . , . . . . , , , .. 2
3 Exclud.blelnla,.,t on ..rI.. EE U,S, IIvlnga banda Issu.d a"er 19J9 I, ~m Form
BB15, line 14, You MUST aUICh Form 881510 Form 1040 . . . . . .. 3
4 Subtract IIn. 3 m line 2, Enl.r the ..sull h.re and on Form 1040 line Ba ~ 4
o I: If u do r 00 In "'" dlvfdands .ndl r fh.r dlstrlbu/lons on sl ek u mu.' ,/so e
Dlvld.nd Inr-ome
5 Lbt nlm. of ~r, Includ. gross dlvld.ndl Ind/or olh.r dlatrlbullona on Itoek
here. MY capital gain distribution" and nonlaxabl. dlstrlbutlona will be d.ductad
on linea 7 and B .. .....................................................................
~ 0
3!::i' )(;1
l.f.Pa 11/,
Amount
............................................................................................
............................................................................................
............................................................................................
............................................................................ ..............
............................................................................................
8
............................................................................................
............................................................................................
............................................................................ ...............
............................................................................................
............................................................................. ... ..........
............................................................................................
............................................................................................
B
'U.S.GO\IeIIYNNPmiIngOtU: UIIl3- 3A6-OIl
~r"'''''',,",,'''J
_....TIMIOIV
. ....................... 1IQ ~ Atllch to Fonn 10olO 0' Fonn 1041.
· ~Olpt~ioIOl ~,ea..y\ 2: D~h
A Pr1nClpaJ bu.In... prol..slon, Includlllg producl or IIIVIc. (... p.g. C'l)
\,) t.. '
C Butln.1I 1IItll. If no IIPIllI. II~ neme, IeIv. blank.
.. "I ) "
. lluelnell_", (including .u1I. or 0,) ~ , ..l."".
CI lowr, 01 .. offiCI .1.'" and ZIP I
AccounUng molhod: 1111il.CUh (2) 0 AcctuaJ (3) 0 01har (apeclfy) ~ ..................................................
Mllhod(l) ulld 10 Low... 0' ....t 0111... (anach ~ Oat. nol apply VI
valUa cloaJng lnv.nlOry: 111 0 eoSI (2) 0 01 mar1<t1 131 0 ..planation) (4) ~ chIcl<Id, Ildp Un. HI VII No
H Wu \hll' any chang. In dllIImlnIng quanlltl... COlli, 01 vaJuallonl belwelll opening and cIoaIng InvenlOty1l1 "Y.... atIIch
I
i
I
I
I
I-
I
I
I-
I
F
o
uplanaUon.. I.... "'...........,............
Old you "malltlally pII1iclpel." In /he operation 0/ IhII bualneu dutlng 1193111'No,' IN pagl 0-2'or UmlI on ......,
II au .l&r1ed 01. u~ed \hI. bu.ln... dwfn 1193, check har., , . . . . . . , . . , . . . . ,~
Income
5C:C';)
1 Groll ,ec.lpll OII1l.L CautlOl\l U /hi. W:orne "'II reptlIlld lo)'OU on Fonn W.2 and /he "St.llJlory 0
ampJoYM" bo>t 0/1 /hat Ionn "'II -111, IN 1"'~ C.2 and _".,. . . . . . . . ~
2 RllutnI and aUOWInCt. . I . . . I
I BublraclUna 2 from Un. 1 . . . . . I
4 Coal of gooda sold (from Una 40 on page 21 4
1 Gra.. pronL BublraCI Una 4 from Una 3 . 5
1 Olhar Income, including Fedltlland .111. luoUna 01 full \ax ClIdJI 01 refund (I" pe~ C'21 .. 5
7 Oroll Incoml. Add line. 1 and 5 . . . , . . , . . . , . . . . . " . ~ 7 - 1:10
Ex .n.... Caullon: Do nof enfer ex enses (or business use a our home on lines 8-27, Insfead lie line 3D.
8 Adyartlalng , . . . .. 8 11 PIIlIion and pront-lharing plana 18
I Bad dabll 'rom ..... 01 lID Renl 0I1aua (IN pill' C04):
1ItV1c.. (... pegl C'3) .. I . VtIlldoI, mad1InoIy.1Ild oquIjlnwIl .
10 Car and INck ..pan... L I ,.., ';'> '7 b Olhar buaInaaa prcparty .
(II. peg. C-3). . . 0 r.:::..:. ) 11 ~paIra and malntananc. .
11 CotM\IaaJona and f.u, . . 11 22 BuppiIIII'loI R:IudId ~ Pili UQ
1a DtpllUon. I . . . .. 2 a:I Tax.. and Ik:8I\MI. . .
11 OIproclatlon and aaclIon \78 24 Trlyol, mull, and anlOl\llnmenl:
axpanaad.ducUon(llo11nclud1d '. 'i.."2.. ~ 15b . Traval . . . . . . . , 241
In Pili UOCIH pag. C.31 . . --' b MoaII and en-
1. Employ.. banent programa t.l1IInmInl .
(0\h...1han on Un. Ill. . . 0 Enlat 20" 01
11 Inauranca (olhar Ihan haaJlhj. ~ 2~=
11 Inl....'!: (1M psg. C-4).
Mor1glg. (paid 10 banks, lie,) . d SubIlKIIInt 240 from lint 2411
L !5. :.0
o
Z)t:J
llOa
20b
I
:l2
13
2
vo
.
b oan.,. . . . . . 21 UUUU.. . . . . . .
17 Lag" and profolllonal II w.gll (loll lobo oredJU . .
1IIV1cea. . . . . . , 17 OthItupeI\MI(fromUl\e48on
'8 Olflce.. nll. . . .. 5 -,/ 'r J I pag.2).....
II Total __I before _.. for bullnoll u.. 01 hams, Add Uf>u 8 through 27 In cclulMl, . ~
28 TenlaUY. pront (Iou~ Bublracl Una 28 "om Un. 7 . . . " .
30 Expenu.a tor bua1nNa UM 01 ~ home. Altach ronn 8828. . . . . . . . . . .
II Nal pronl at DOlI). Bublracl Una 30 'rom 1lne21.
. If. ptOn~ enter on Fann 10olO, Una 12, and Al.SO on 8chadulo II, IInl 2 (1lIlulory omploYOO"
101 page 0-5). FIducla1Iaa, enter on Form 1041. Un. 3,
. ~ . Iou, you MUST go on 10 Una 32.
32 ~ you have . Iou, cIlack ilia box thaI daicl1baa ~our Invulmanlln 1hlI1CIIv1l'( (101 peg. C-5),
I I' you checked 321, enter tha Iou on Fonn 1L-lO, Una 12, and Al.SO on 8cIIodul. BE, Una 2
(Il1lulory .mpIoY"I, IN pag. C.5~ F1ducI3lll., onler on Form 1041, line 3,
. If you cIlackId 32b, you MUST .tlIch Fonn 81:.a.
For P.perwork Raduotlon Act NoUc., HI F0lIlI1D4<llnllNoUona.
113
24d
27
25
2lI
30
. .
}
}
31
32.37
bO~
Ita 1rl AlIIIW..lmlnl I. .1 ,Ilk,
32b lJ" 80m. Invlllmlnl Is ncl
., rllk,
Sch.dul. C (Form 104011883
CIl. No, l1:l34P
0... t1~iJJ
.'
-C.......,04C1,111l:1
~
eolt 01 Ooodl Sold (see plgl C-5)
il:I Invw1klty AlIlognMlo 01 \'Ill. If ell'''''''' ""'" III' yoat. -.g in_lOt)'. .If.." uplonauon
;N PuroIIoHo .... _ 011_ _.wn lor ~ WI
II ColI of 1Ibot. Do nollrWclo IIIIty pold 10 )'ClWM1f .
,
:It Mil...... 'I/Id IUJlIlIM
111 ClCMt ~ .
:It Add IInIlI :13 IIvaugIlIl1
III ~y AI ond 01 \'Ill
:14
38
.
.
3
eo.t 01 oodI.oId. Bubltlclllne 3a ,_Ilnt :It, Enllltho rolUl1 tltro ond on . I, lIn. 4 40
IntcrmlUon on Ycur V.hlcl.. Complete thll pert ONLY II you are cl.lmlng Clr or truck .xp.ns.a I
11n. 10 and II'e not required to nle Form 4562 lor this buslneas.
41 When deI)'OU pItoI yaurYlhlcll... awwtce fot buIIneIa purpaNl7 (month, dIy,"", ... ......../........./...... .
41 0I1he 101II_ 01..- ~ _ yout _ duMg 1m, on'orthe numbor 01 mIIII \'OIl UMd yout_lot:
. 8ulIIneIa ................................... .. convnutIng ................................ a OlMr ...................................
41 Do \'OIl (... youtlPOUMl limo _ """"'" .- for poroonoI UN? .
o Y..
o Y..
ON
ON
44 Wu yout _ ._ lor ... during oll~ howl?
451 Do \'OIl ...... I\'Idonce 10 IUppol1 yout -..uon?
b II.., ".. tho __ WIlli..?
8
Y..
Y..
N
tI
~ iilllW
Oth.r l!xpln.... Ust b,'aw buslne.. expenses nollncluded on lines 8-26 or line 30,
............................................:.........................................~t........................
.........................................,.................,..................LU~\\~~,..~~t~
..... ........................................ ................... .,.~J\(4~.....:t:\Q.,~,(tl,~fA.l:\.t.....
................................;........,..................,...,.....W..tO.k0...5~.........
'800
2.2.3.
I.I'l
~,-z
<J'"
......................................................................................................................
......................................................................................................................
.......................................................................................................................
......................................................................................................................
......................................................................................................................
41 Totol oth.r II n.... Enlor h.,. end on
",Un.27
48
:,~. 4- 2-2-
lJ"
114
........., Aedu,"Uon ,..,... ..-.
.w.~." 01 le'l"l, 'I Wl'1\c" IIIlt 101m '11111. L..
. '
l "
el.ollon To exp.nll C.rI., T.nglblo Prop.rty (Soollon 179) (Noto: If you have any 'Listed PrOperty,'
com I.,. P.rt V b.lotl au com lote Part I, .
1 M..,mum dOller IImlllllon (If en .nlllprlll lono bUllnlll, "0 Inallucllona,) . . . '. I 17 Soo
a TOlol call 01 IICl,on 17& prop.rty pllcld In lo...ico during Iho IllJI Vllr (all Inslrucllon.) .
3 Th,nhold COil 01 lac lion 179 prop."v baforo roducllon In Ilmitollon, , , . , . , .
4 A.ducllon In I,mlllllon, Sublllclllnl 3 Irom lin. 2, but do not onla, I... Ih.n .0. , , ,
· Dollar IImnlllon lOt lIB VII', SublllCI IInl 4 from linl 1, b~1 do nol Inlorlll. lIlan .0., (II
mlrrild IIlin II 1111., III Inllrucllonl., , , , , , " """"
1.1 OUCnpliOl1 of ptOPlf1Y (bl COil Ie, Eltcltd COIl
OU~6P,
... AnaCh Ihl. fonn to our ,alum.
OMS No 1l46.0ln
~@93-'
AlllChmtN
IIqUlIICI No 67
kI.nllf'tlng numb"
I 1-
2.1
~"I""I'N""
..."" ""..... ...... lJlt
N~II thOM Dn "1\,ItA 1...
... ... I. .,.1. In.lruction..
3
4
200 on.!L-
5
1 Llllld prOPI"V, Enlll Imount Irom linl 28, , , , , , . , , ,
· Tolll IllClld co. I of lacllon 17& propl"V, Add omounllln column (c), linea 8 ond 7 8
8 Tlnlllivl dlduclion, Enlll th. .m'"11 of lino 5 or lina 8 , , . , . , , . , , 9
10 CIII'/OV., 01 diullowld dlauclion Irom 1892 (III ,n.,rucliona), , . , , , , , 10
II Tuabll Incom. limnltion, Enl., Iha .mallar olluabll incomo or f,nl 5 (1IIIn.lrucl/ons) , I
II SlcI'on 17& uplnll d.ductlon, Add Ilnll & Ind 10, but do not onlor morolnan lina 11 12
13 COIr\,OVtI 01 d,"lIowld dlducllon 10 1994 Add lines 9 and 10,le,,',ne 12 ~ 13
NOlo: Po nol UII Part /I 01 Pan /11 Calow lor IlI'eel property (au/omobile., c.nain o/ha' v.hicles, c.//u/ar '.'.phOlles,
tertltln com lIt"., or ro Irt Ul,a 10' emlff.lnment. ,ecre.tion, or amu$lment). Instead. us. Part V lor listea fa en.
MACRS D.pr.olallon For AII"e Ploood In So",,'o. ONLV During Vour 11193 Tax Veor (Do Not Includo
LIII.d Pro .
1&11 Monln ana lei a.I'1 lOt O'PIKllhOl'l
rll' plletcl in (bt.lIU'll"'It'I'f"lment ~..
''''-IC. Llt\I -I" "'lttUCIIOllI
14 0.11.111 O. r.CIII'On B Ilam aDS ee. in'lruction. :
. 3. '1' fO In
b &, .Ir ro."
e 7. eI' lo.n
d 10, 11/ ro .n
. U. II' 10 In
t 20, 11/ ro ."
& Allldlnllllllnl.,
.
h Non,esidlnllll rill
---R!
1& AII.rn.llv. Oa r.cl.lion S .lIm ADS (II. inslruction. :
. CII.. hI. '
"1112. IIr I? r.,
e40...r 40 ra,
rbm.lI. Other D.preelation (Do Nollnclud. Llltod P.roporty)
18 aos Ind AOS d.duCllons fOt ....11 placad in ..",Ie. In I.. VII/' begiMin& 00101. 1993(SN Ins!ruclions)
17 Prop."v .ublecl to seclion 166(Q(1) Iloclian (lIa Instructiona), ,
18 ACAS .nd Olnll de /.clalion ..e ,nslruclion. , , , , , , . . , , , , , , , ,
~
..;, .
. \.;)
27,5
27,S
rs.
MM
MM
MM'
MM
SIL
S/L
SIL
S/L
S/L
SIL
S/L
18
7
18
19 I ()
rs,
MM
,n11".4 Summary
1& Lill.d proplnv, Enter amounllram hna 2" , , , . , , , , , , . . , . . . ,
20 TOtll, Add d.ducllon. on hno 12, linll 14 and 15 in column (g), and Hn.s18lhrough 18, Enler hilI
and on Ihl Ipproprlal. lines of VOU, IIIUlO (Psnne,snip. and 5 corporalions-se. InSlruclion.
21 Far .15111 shOWII above and placad 'n sa"',ca dUling Ihe curr.nl voar, enler
Ihe onion ollha bllis allliOulabl. 10 seCllcn 263A COSlS sea inslruclions 21
'0/ P.p.rwork R.ducl/on ACI NOlic., 'N p.ga 1 ollha ..palll. Inll/\Jcllon., e'l, No, 12i06N
311
,"'" 4562 ('Ill)
,..... '1611'"31
Ulted Property-Automobiles, Certeln Other Vehicles, Cellular Telephonel, Certain ComputulS, a
Property U..d for Entlrtslnment, Recreation, or A1nullment '
FOIlny Vlhlcld (01 whiCh you '" uJlng tn. Jllndlrd ml/..gl ",. or d.ducllng (..51 up.nu, compl.,. only 221,
22b, co/umnJ (.) Ihrough (c) o( S.cllon A, .1101 S.Cllon 8, Ind S,clion C illpplic.bl.,
Section A-Oeprecllltlon and Other Inform.llon (Clullon: S.8 instructions lor limitations lor automobiles.
. 221 00 ou hay, IVldente to IU on 1he boslnns/ln'iUlmenl use clalm.lS? VII No 22b II -VII. is he evidence WfI en?
,
1-' II
Ila I'i) IIu&lMU' 1d1 . II)
'rPt ., ptopMy filii 0.1. plKlct If\ ",."lImln' Coil 01 OllW BUl' 101' d.pttc..11Otl ,*0\'1'"
ven.c"IIIIII) """"" ".. bUI (bua'''....^'w..''''''''_lOCI
petC~lIo- UM 01\ ..--
23 Pro I ulld more than 50% In a ualilied businlll u., II' Instrucllons :
I !- oJ I U'.~ i:
, !'> 1'/'I"nte.c..,I... ~ " . IX
.
o
'"'
"'tlhOdJ
eonv......
\hI
Oec>>ecllhon
OtdUCIIQ"
1.1
IlICltd
MellOft 'fI
COI'
"
, l.'
Z. "
..0-
.('1.
24 Pro. uled 50'1/0 or I... In 1 uahliod bus In... UII ... InSlrUCI,on. :
'I/o
'I/o S L-
% !i/L-
Add Imounta in column (h), Enler Ihe lolal here .nd on lin. 19, page 1, 25
Add amounta In column I, Ent.r th. tOlal her. and on lina 7, a aI, , , , , .
a.oUon B-lnlormaUon Rogardlng U.. 01 V.hicl..-II you d.duCI up.nsu (or vehic/u:
o A1w'YJ comp'et. /hIss.cllon (or v.hic/es Ulld by 1 JO/. propri.,or, partner, or olhor "more Ih.n 5'10 own.r, " or ro,.,.d pmon,
. /1)'0. prOVld,o "'hlelfs'o )'0.' .mp'oym, Il/sl ,nSWlI Ih. omllons ill S'C/lon C 10 SIII'YO. mll"n .",plion 10 eompl,'mQ IhlS SIC/Ion (or Iholl "toellS
W M ~ M W M
V,tuel. 1 Vehcle " v.",,1.3 V.htClt" Vlh"" a v.""" .
25
25
1:.
25
27
Tol,1 b.slnmlinVIIlm.nl millS drN.n d.llng
th. y..r (00 NOT Incl.d. comm.ling m,les)
Tolal comm.ling millS drN.n durlno th. year
Tot.1 other parsonal (noncommulIngl
mllu dllv.n, , , , , , , , ,
Total mllu dnvon dUring th. yoar,
Add Unol 27 through 20, . . , ,
Voa
No
v..
No
Vu
No
v..
No
v..
No
v..
No
28
20
30
31 Wulh. v.hlcl. avallabl.lor personal
u.. during off.duly houri? ,'. ,
32 Wal the v.hlcll ulld prlmlrlly by a
mOre than 5~ owner or ralaled porson?
33 II anolhll' v.hlcl. availabl. lor pOllOnal
ull7 . , , , , . , , , , ,
Section C-OuuUons lor Employerl Who Provld. V.hlcl.. for UII by Th.lr Employ...
AnJwer Ihese queJllonJ 10 d,'.rmln' I( you m", .n exc.plion 10 camp"ling S.cllon B, Not.: S.cllon B musl alw~YJ
be compl".d lor v.hic/es used by sole ,.repri"a", partners. or other mor" 'han .5% owner. or rat. led persons.
V" - '"NO
34 Do you maintain a writt.n policy Ital.m,ntlhat prohib,ts all per.onal UII 01 vehicles, Including commuting,
by your omployaes? , . , . , , , ',' . , . , , , , . , . , . , , . , . , , .
35 Do you mllnlain a wrltt.n policy Ital.menl thlt prohiblll pUrlonl1 UII 01 vehicles, excopt commuting, by
your employees? (So.lnltrucUans lor vohlcles ulod by corporal. off,corl, direClorl, or 1'1/0 or more ownera,)
30 00 you lreal all UII 01 v.hlcl.. by .mploy"s as peraon~1 ~..? . . , . . , , . , . , , , , ,
37 00 you provldo more Ih.n liv. v.hlclos 10 your .mploy... and rlla,n th. Inlormalion rec.lv.d Irom your
.mploY..1 concerning the us. 01 Ih. vell,clos1, , , , , , , , , , , . , . , . . , , , ,
3B Do you m..llh. requirem.nts concerning qual,liod aulomolJlle oomonstralion UII (II' Instructlona)? , ,
Nollllf our .nswo, 10 34, 35, 36, 37 0139 IJ .y.s," au no.d nol com 10" S.clion 8 (01 Ih. covellO vehic'.s,
Amortization
'.1
DHenpIIOn (II COlli
fbl
Dill ImO'1IIIhol'l
beg.n.
1.::1
Amot1IIIDI.
1"I.;<unl
'01
CO<l.
ItcliOn
39 Amor1izatlon 01 cosls that be Ins durin our 1993 lax ear:
.
40 Amor1iza\i~n 01 calls thai bo an boloro 1993. "" , , . ,
41 Total. Enter he,. and on "Othot DeductIons" or "Other expensos" line 01 aur rulurn
312
40
41
/
- I~ ~
, II ~
~ .
~ 11-. -
9f
, '\>!
0
. ': :c; lj 11~
jj.. ~
.J. I~
..
.,
II J ...
>-
II ~ I~
:r II
ij '~ ..' Cl
~ 0
t-- ~ ~
t:(. I~
I I A
.1& Ie I
1-- '-' .D
i J I I
ISI I), I
,
0 ''j \'
I
~ .
IJi r4 'I
Ig 1;':I~1- ~-
1-- ~~ f
· jil g; g r,
8 .:t 1& R ~.
,
-
.s ~ ~ "
!Ij f-, <:
'":. ~ ~-
~ ....;;,
j
.'
r I <r0- o
,
l I~ ~ ~'J
,
'& ~
I l), r
f _C" ~ ~
1 ljl
~ ~ ~
.~ ~
f
Peg. 8
320
'"
---------
'l"AlUl:I~Ilot)
I "^ilt
J "lInH,~.)o6nI'.1M1I
r 8l'J:,~'*';t,'::'~1I
D Oo.c.uM4,'II\M"'IIt"
IlolowlloolJ\
IUUlIHCY ",nul: (tNck OnIr H A '"H." At...,
, C>>Il1V..,~"" llU..
....11_11I WIL 01100.0
0.......... ..,,_...""""_.._._I....MI
1ioiI... '
Of'lCW.uN
='olI~UI~
o
o
o
o
o
[[]
o
o
o
o
;?il! ~ '. I ::J::J. IJ H8IIOenlInOIVIOUlllnCOme lex Return .
' .' ! . I
//' I ~,@. 0 FkCII ,... fill BtglMlllg liil 'I
/ i ~ En~nG 'G~
..........CAR-RT SORT..CROZ '".......
171-46-01Z1 DE
GLENN E OERKOSH
Z08 W RAILROAO ST
NESQUEHONING PA I8Z40-1411
"'UPAlION:
I""l 6 J
1\, Jll
.....',
..IMIIf,........
.....
lloIYl,"111WIt NUlIllJl
I
Ill' RI~ "~llI\QOI1 "" il* h L, 111I PIOtI 11I'"
",-l1W-lV~, A\t. ~o
,., GROSS ClI"I'fHSAllOH, Vi.., 11III1I1, lip., 1lC, AIlItft f.llnl') W,I................".
lb, UHIlfI..IURSlO 1Illl.OI1 IUIIHESS MHSIS, _ PA l""ilIII{') UI....,..,..,.I
", HIT PA TWIll ClI""NIATIOH, _ lAIn 1M ... ,...,............,..............,.............................., "
J, TWlLlIHTlIlfST, f.... '"""'. PA _ A ..................................................................'.......... I
I, TWILl DlVIDENOS, ,.... ......... PA Sc/lIllulI I ....,......................................................................, S
~" PA PRO'IT 01\ ILOIS) 'RO.. A IUIINm, PftIlIISSION OR ,AIIll:
I",''''' ll\ICiII<l kiII<lllitl.) C Illdl" Sc/lI....I.) , ..........................................A.
i"""" .lIKiII<l PA kiII<lIlItI.) 1I<-1....,........................................................AI
ii"~ TWIll PA PROfIT OR HIT (LOSSI, TOUI Unll 1111I. 'I..............,...................................................., ..
S, PA IIAIH OR ILOSS) fRO.. THE WI, IXCHAHOI 0lI OiSPOSiTlOH OF PROPIRTV;
I~, ',om ........ PA kiII<lIIlt(" 0 1IId1" PA Sc/lI~I) 1l-1..............................,~
Rll>,''''' IIIKhI4 PA kiII<lulI(.) IIH................,............................................J.
~Ic, f.... 1l\IC1lI. _ PA"I, SOlI.,. PI,..... _.........................,......,Jc
~Id, AII0UHT 0' ALLOWAlLlIXCLUSIOH 'RO.. lINllO 0' PA,II...............................................................
II, HIT TWIll PA IIAIN OR NIT ILOSS). TOUI inII ~, II, Sic ............................................................, ~
I, NIT lWlLl PA INCOIII OR HIT (LOSII 'RO.. lIlHlI, ROIALTlIS, PATINTS AND COI'YIIJOlITI
,.... IIIKhI4 PA kIlIdIl.II(.) 11lld1" kIlIduIt(.) IIJH....................................................................., I
7, TRUST IHCO..I, f.... .l\KlIId PA kiII<lult J........................,..........,................................................ 7
I, llAIIIlIHB AND LOnlftV WIHHIHGS, AIlItft _It " ~ DlInccrnI "1101I)................................ I
I, "NHSYLVANIA TWILlIHCOIlI, Add lilt.,. IS'. II . 7 on. ., DO HOT IUITRACT L05515 .......... I
S,O, TAX LlAIllIlY. Ull OIl1NI...... UN, ,011 ......,..........,.........,..............,......,..,........,........ '0
11, TOTAL PA IHClI..1 TWS WlTHHILO, f.... II1IClIId fotm(.) W,I....,................................................,..,.. 11
PA UTIIlATI.Il TAll PAVIIINTS: '", ClIdIl ffQlll IHI RoWl. I
111, TOUI lHl _ TII hymonll , lie, 7.. hid wllll .Hl ldInolon'
Ell, TOTAL ISTlIlATlO PAVIIEHTI AND CIlfDIT IAlld ""'11, 111 11I1 11') ....,....................'......................, 11.
!,l, TOTAL CIlfOIT fOR TAllIS PAlO IV PA IIfSIOIHII TO OTHlft STATIS OR COUNTIIJIS
I f.... .1I.,1lI4 PA Sc/lIdlIlt(.) G; PA SciII<lull RK.' " OIIIIr -... DI 11I11<II _ IWa ....................,.... 'S
i14, TAX fORBIVlNlIS CLAlIIIO PA ICIIIOUU IP, COmjl"" PA ....dull., ....1/1I., W.......I..................,., 14
i 141, OIpo.llOlll. CIIinI<l OIl PA Sc/lIdult .,; '0. Cl&ImIIII" TOUIIJlolIUIIV 1I~1lI 11Im ... 'I .. 1/1I .,
Wotk.ilIIl; ,.., Cl&ImIIII" TOUIS.pllOl1_ """ IlIp IDlI/IIII W_I,
1I,lIlPLOV..EHT IHCINTlVI PAV..INTI CIIlOlT, ,.... _ PA kIlIduIt('l W....,..............................,...... 'I
11, TOIAL PAV..INTS ANO CIIlOIIlIA<l. .... \1, 11., 13, 14, Illd Ill..........,..............................".........., 11
,..... U.. You, C.",.. f..... W'I
...... 0II111cl Coda SCIlI UI
,....,011
135 rt:>Sc/lIA
Sc/lII
Al1acn I!A Roqultl.
_.
SCIlI C
Sc/lIf
Cltl SCIlI RK'I
Trua ~hltn WI.III"
'Ill. On Of "'~'
Aplll 11, III'
SCIlI 0
Sc/lIOol
PA'1I
.Ii
Cl)1iI01 M:u.a
*
SCIlII
SCIlI1
13.!>
, 2.. ..
n.
... InouUC1lon1 fll
ClUnln hlimlll. CI'~1
-:?"l..
Sign YOlIr Rtlurn
IItJ
D
o
I:~', ~~R~~~~::::~~~: :~,~~ '~~t~~,~,~,~~,~~.~.~~~~,~,~~..~~,~~,~~~,~~~..~,~~~~~, :: - _ CIlIck V,", IIIIh
111, Amoulll" UIlIl1 III De RElUHDEO ........................................................,..,................,.................. TIll TIIIIII Uou ,11. III
1111, AmounlDl UIlIIIII De CRIOIlIO III YOUR 1114 ISlIIlATI.Il TAX A'COUHT .................,................'........, II.
I 1~lk._I~
,Ie, Amounl" UIlIIIIlI De DONATED II 1/1I WILD IIfSOURCI CONSlRVATlOH fUHO............,..............,.........., .Ie
S,td. Amount 01 UM ,. to be DONATED 10 UII U.S. Dl't't.lPIC couumu 'A DIVISIOH............................,,,,..... MUST 1.,.aI LMlI'. till
.....fWAII... .1........'..................., ....... .................................... ..........."...............
t'1W 0&11 ."'",_...~.......-.....,..,..............
Sign.. )(
b.rl
.. )(
)(
.....
..... Mil .~I"
=--_. -. - -.-
1'01' S
'.
'A-49 Uf.! ~ ., "'''1
, 'W
ALLOWABLE BUSINESS EXPENSES
...... Ill. .....)'W WI Mf _I \ trM4I r.y,.. .....,.,.
Altadl 0 . 'p.,Olo U!.2to Iorm PA~OR 10, lOch ,,"pl.y",
_ Prlft' or . olll"'o",,ollon
-..
..
...
III f.QVfrM .1 . ....,_ .. Mlft~1 eM ....
...hQble .. ... ...
I~...,.. J b, _ "''''''''''' 004... ..PP.... b,
'c.., '11,.,10 II ,
'ART D. 'IO.UIIONAL UClNII pm, MALi;::;.d'I':~ A
Ill. ,..IIt,d UI . CM41t1M Ml .
....5erw'.-~.. E .'1 ·
- UO""'""" I. _ __ W..._
..
19P3
SCHEDULE UE.2
'A DIPARTMINT O. RfVfNUI
odo
..,. "'.
o.
'AIT A, UNION DUll ~ 004 ~
,
'AI' CI'IMAU TOOU AND IU"UU
A
I
C
I
D
1
ICHIOUU IP
PA DIPARTMINT 0' ReVINUI
TOTAL IXPfNIII O' 'Am A THkOUOH D. I!!:!:EMT ON LINI1~ 0' 'A-40R
I Speclul 'i'.:lX Provl.lon. Schedule
Ino NOT PILI IP A D"INDINT)
",Inlot .."'foI'MOflOft.
A I, Ate roo 0 4.,...,... _" cNIdf ...,........,....,..,..............,........ 0 YII ~o 4, A" roo 0 OIVd..'.....g dol...d .'0 .
2. Are,.., d.hftM II . .ptftdMI eft rwr "fiM', :,~I,1. J.l. ."..".... eVil N. cf.p."d.", " OM"''' I.. rtlVr'ft' ."............ C V,. tiN.
~. AN rw~""", .'InIl'IlI.hfI~'" ,..l~,ui I.).. ,."..... OV.. . It HmorMcl.I..........f1I11l........" C v.. f1lH.
H .....,... ''Y...... ....... 1 ., 2 ,,3 "r " :;.,") NOT 'ILl A SCHIDUlI n. 6. Art 0 .,dow/wh'..."....................... 0 Y.I boN.
ai, ToIOI [lU..bor 01 do,.,odoot child... I. 10..11,
UII bol_.1 d.poridont, you a.. onll,lod I. clOlm.'DO NOT INCLUDE YOURSEl.. IAddlll.o.ll.formollon ...y bo ...chod .. 0
..patato ,hool.1
DIPINDINT'S NAMI ADI RELATIONSHIP IOCIAlIICU~ITY NUM.n
S Ollll.r Chll
i
!
lb
Q
..'or ho.. .... a. 11.0 1... a' 'A-401 '.'al .umbo, 01 dopa.donl. V.u a.. o.tltlod 'a d.lm"".."""..
2. Total Other Incoma Ironl ano a 01 SP W.,llah"h
CIolmonl S Sp.... $
h
!I
t
iil
'D
!a~
n
"'IE
S!o
u
-
c
1. TOTAL TAXA.LIINCOMI '~OM UNI' 0' PaRM PA...O~....,.."....,..,........,,,..
2, NONTAXABl! INTlRUT. DIVID!NDS AND GAINS lW.r1"MtI MooU)
$, ALlMONYIYOUR SU'PORT CWorl"h",liIIo .1 .od 131....",......"".."..,
~. un INIURANCE AND INHERITANCE PROCflOS 1W0rllah",U.. Ul
~. GlrTl. AWARDS AND 'RIZES lWorIlah"'llo, 1.11...."..""..."......".....
6. NONRUID!NT INCOMf lWorIlahoo"lno 161.......".....",...."..",,,,,.....
7. ALL OTHeR INClUDABL! INCOMI lW.rIl,hotlU.1I .7 Ihrough .91....".
I. TOTAL INCOMI . L1NU 1 THROUGH 7 ABOVE
Ifn'tI Oolmool'. T.'.II...... In Columo A .od 00 U.. I4b ., .A.4D~I......
9, 'ENNSYLVANIA P!RSONAL INCOM! TAX I',om U.o ID ."o,m PA.4DRI
10, un TAXU PAID TO OTHeR STATU ~I.o 13, 'OIm PA,40RI..........,.."
II. SUBTRACT LINE 10 'ROM L1N! 9 AND ENTER DIPPlRENCI...."..",..
12, PeRC!NTAG! O' 'ORGIVENISS (S"loc.m. Tobl.,., doclmoloqul'o''''1
13, AMOUNT O' SPlCIAL TAX ,ORGIVENESS (M.llIpl, U.. II b, U.. 121
!nl., h.r. and on IIn. 1.. of 'A...Olt................................""................
r... ,
COLUMN A
CLAIMANT'S INCOME
OR JOINT PILING
1 113~ ~O
2
3
4
S
6
7
COLUMN I
BPOUSI'SINCOMI
8 \, ~'::;.
9 ;:12
10
It
12
13
.~\
/' ::.: ~-~~:...., lit PIM.nhlp.. Jolnl nntw", 110'1 mu'l tw. fonn 1oea.
............... _ 110 '" AII..h 10 'orm 1040 or 'orm 1041,
, ~oIplepI~lot~)~~,\ z: Dl!l\.k.l;.'\l,
A PrincipII bUlln... prolllllon,lncluolng ptoGUCI., lI.....ie. (II' pog. C'l)
\,) l"
o SUtln... name. II no UPlllt. ... nama, ltavl blank. D Implo.,., ID NolIN., '1IH),II In,
- Il I " ' 2.32.74(,5.<.5
. Bulln.lllddt... (1nc1ucUng lUll. Of roorn(!lo.).. . ..l...... ~'.~.....\J.!..................................,...........................
CI town 01 II offiCI 1111. IIt\d ZJp COdI \.. It \ """ '-
-ling molhO<l: 111 SCUll 121 0 _ 131 0 0thIr (opoclf\1'" .................................................,
1oI.1Ilod(1) UUd 10 Lowlt 0/ COIl 0thIr (.1IICI1 "'" Doll nollpply 01
- cloIIng lnv.nlOty. III 0 Coli 121 0 ., _I IS) 0 upllnlUonj (4) jI)l. eIleckad, II<Jp IInI HI V.. No
H Wu 1/1." lilY ching. In dtlatmlnlng qUIIlUIlII, eo.lI, ., vlklIlIonI IlIlwlII1 oponIng and cloIIng InvlIlloty? 1/ 'V..,'1I\ICh
,
o
uplanaUon I . . , , t fl. I I . . . I . . . . . , . I . . . . . . . . . I
DId )'OIl '1NlIItIIIIy pat1iclp.II' In 1M opltl\Jon 0/ IhIa bualnau cIwtng 18837 1/ 'No,' IN page C.2 I., Imll on 10.....
1/ .laI1odOt uVodlhl.1lUI1naat ngS chockhlt.. , , . , , . , , . , , , , ,
noom.
, ,"
, Orou ,_Ipl. ., IIl.L C'UUonl U lhI.1ncomo wu /fPOIIod '0 )'OIl on Fonn W.2 _1M 'SlIlutoty 0
omp/oj'H' bAIr on lila, /onn wu cMeJltd. _ _ C.2 _ _ """ . . . . . . . '"
'?
Rllumalnd _WAne'. It. . , .
8ubttactUne 2'rom Un. 1 . . . I . .. 0 ~
Coal 01 goodo IOIcl (Irom IInI 40 on pog. 2) 4 0
010.. pIOnL &.bl1lClun. 4 from 11n13 . S C><'
0thIr 11comt, lncIudlng Fodltlland .,.1. gll<lllna ., IualIax crodll ., "fund (IN pag. C,21 e )
Oro.. Incom.. AcId un.. a IIld a . , . , , . . , , , , . . , , , .. : .: 7 ['10
E. In..., CluUonl Do nol enler .. '" for bu,lness UII 0 ur ham. on IIn., 8-27, Inst.ad II. 1m. 30,
. AOyltllllng, . , . . . -r: " PonIIon onG pronl.1hIttng pIanI 1.
. Bad dtbla lrom IIlII ., 10 RanI., Iaaaa (IN pill' C-4~
....Ie.. (IN pog. c.3) ., . I VohicIoI,"""""*Y, nl oquipnoIlI .
10 Cat and \Nell up'"'' II '~~ ':~'7 a ~ b OUllt bu&lna.. ptopofly ,
(IH pog. D-3). . . 0 . '..:..;> ,,' II Ropalta and ml/nlonanc. .
" CommIaaIona and f.... . . 12 Ill.Wlo& toot_In Potl 10
11 o.pMiUon. . . t . . . u r.... and license.. . .
n Doproclallon onG _ '17g 24 Tray.l, mula, and .nlanalnmanl:
__tooIlncluGod " 't.2.."t: liD .T"vat",.....
In Pan UO (IH pogo Coa) .' a -' b MlIlllnlllll'
'4 EmpIoyN bIIlanl ptogrlllll Ianalnmlnl ,
(oUllt \/Ian on IInIU). , . 0 ~4b20~~
la Jnauranca (o\hlt \/Ian haallIll , \0 "'IoIl0n0
11 Inll/..t laM pagl C-4) .
I Mottglg. (paid 10 banka, ...,) , d IliAlItlc1Iin1 2........ IIna 24b
b 01har. . . . . . II UtWtl.. . . . . . .
17 LogII and protaaolonal U Wig.. (IOU )obi orodlQ . .
.......Icot. . . . . 27 O\hlt _" ~rom 11n14a on
,. Offlcau n.., , . a -I 'J- _21 . , , . .
U Tolllo.ponal. 1lI1.,1 _ I., buaInou UN 0/ honwo, Add IInu I UVO<lgh 27 In colurMa. ,'"
II TenlaUvI plOnl OOU). Subtract UnI 28 ftom UnI 7 . . . . . .'. . . . . . . .
00 Ea:pena.u '1)( tKMJnau UN 01 )'OUr homI.. Altach fonn 1828. . . . I . . . . . .
II N.I pIOn, Of Ooul. __ IInI all lrom Una zg,
o 1/. pront. anlal on Penn 1040, IIna '" ""0 ALSO otIloheduI. III, Uno 2 (llallllOty ampIoyooa,
_ page CoSj. Flduclat\aa, anlal otI Form 1041.11na 3.
. II. Iou, you MUST go on 10 IIno 32.
II II you haw . Iou, cIIICk 1M boIllIIaI d..ctIbaa yout Invutmanlln IhIa acUvtljl (_ pogl c.a),
. II )'OIl chacllad 321, ItlIIt 1M IoaI on Form '040, Uno '.. and ALSO on Ichadula Ie, Une 2
lIl1lU101y ampioy....... page c-5~ FIGo.:lltlal, IIlIa1 on Form lD41.1Ino 3-
. 1I)'OIl ChaCkad 31b, you MUST .nach form I,ee,
for P,poIWorlc R.duoUon All1 NoUe., III 'orm 1040 InoltucUOIIL
113
CII. No. l1S34P
Sro
1-
2.
cq
2.'2..
,it)
7
as
21
30
....
. '
_ I
}
}
31
3237
be))
321111 AIIlnmlmllll .. ~, 'lak,
32Il EI SonlIIn""Im.nl it nol
1\ rl.k.
8chtduJ. C l'onn 1040) 18U3
-
.
__ a ""'1~ lIa
rmm
Ca.l 01 Gaed. Sold (II. pig. 0.6)
~ ---. "'~cI.'lW,'~w..II.\l\W'\~~,~h ~lAiJqn ,
33
~ """"*- .... coo. aI "oma wllllllrlwn '01 ....- UN
II ColI aI_. Do... _ ......, paIlllo yowaoll "
III Ma_1IllI1UppiIN
al 0tIw _II
III AdcIIneIll3 II1nlugh al
.. "-'tory a'lIllI aI )'lit
~
aa
u
.'
1
40 eol' 0' oodo oold. IllbltlcllN 31 'rom IInI 38, Enlllllle ..Iub h"o Ind on "' lIno. 40
lntormallon on Your Vehicle. Complete this psrt ONLY II you are claiming car or truck expensas
IIn. 10 and ate not required to me Form 4562 lor this busln.ss,
., - dld ~ plece your \'IIlIcle kllll\'lce ,"'_ putpOIU? (man'h, doy, YOIll ~ ......../........./......
U 011111 1ol?i_ aI..... ~ dtoYI your IIOIlIcIo eluting 1m, on'" ,,,. number 0' miIU ~ Ulld your wIlIcll for.
. lUIInIu ................................... b ConvnutJng ................................
o 01"., ..................................
CJ VII CJ N
CJ VII CJ N
B VII B N
VII tI
'" Do )'OIl lot your l/lOUIo) iloIlO anollllt _I IVllIobIo lot ....- UN? .
44 Wu your WhIclo IVIlIIIllo lot u.. during on-duly houri?
..... Do )'OIl ..... ovtdonco \0 ouppot1 your doducUon?
b n "Vu,. II Ihl ~ Wllllon? .
ImD
OlherEllp.n.... Li.l below business expenses not Included on lines 8-26 or IIn. 30.
................................................................I..................~t........................
........,.................................", ,....,............,.......,.:....LU~~b....(~Q.td.b.P.~
,..................................................................~lli~~...........~!-::!.(4~rA.l1l.....
,.\,/\1. q
........................."...............,................,.,..,.....'..>.-.J"~6..'(J ~.........
......................................................................................................................
'800
"fl.'
Cl
2.2.?
(fi
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
..
',~ y. 2.2-
()
Total oth.r '1 n'lI. Enl., hit. and on
.1. Un. 27
.8
114
~""""I""""
"".I\&l~tr'IwI__c. IJl'J ... .... "" .J1.t.ln.lructlon.. .. Anach tN, fonn let our ,.turn.
NIII\flI .....n on '''.'n )../ " c. Co" . l. P
. ~ON1 c.:l._ )-VU~~ ,
l4.I'lNII Of 1CIIYllr lO Whe" &ni.IOtm ,...,.. I.
lU Vi: 'v.., 1.-
Brill EI.ctlon To Exp.nl.. CMluilIlT.nglbl. Prop.rly (S.cllon 178) (Nol.: If you have any "LI.I.d Prop.rty,.
compllll P.rt V b.'''ru.l'~" com 1.1. Po" I,
1 Maximum dollllllmillllon (II an ~mu'~rlll lonl bUllnl.., I~I Inllrucliona,) , , , . , 7 SOO
2 Tolal COil olllclion 178 properl\' pl,'""d In II/VICI during Ihl III VIII (I" lnallUCllona) ,
:s Thr..hold coal olllOlion 178 propun} blfotl tlducllon In Ilmillllon, , , , , , , , 200 O').!l.-
.. ROducllon In IImllallon, SublllCI hn. 3 I,om Ilnl 2, bUI do nol .nlllllll than .0.
5 Dolllr hmillllon /0' III VOIr, Sublr.CII,nl 4 Irom hnl I, bul do nol Inlllll..lhan .0., (II
marri.d fIIino IIPlr.lily, ... In.lruch~n'., . . . . . , ,
(I) OnCltQhOn 01 pto~n, lbl Cot! Icllltc1ld cOli
(Including Information on L1ated Property)
8
7 Lilled prop.rty. Enllr Imounl/rom lin. 26, , , , , , , , , ,
8 Tolal IllClld Call 01 aeclion 178 P'OPlrtV, Add Imounll in column (c), linll 6 Ind 7
o Tenlallve dlduclion, Enler Ih. emall.r 01 line 5 or lin. 8 , , , , , , , , . .
10 Carryov.r 0/ dlsallowad d.ducl,on Irom 1892(,," ,naltuclionl), , , , , , , ,
11 Tuabll incoml limllllion, Enlar Ine amallll of Iu.bl. ,ncom. or I,ne 5 (all Inswcllonl) ,
12 Seclion 178 upanae deduction, Add lin.a 8 and 10, bu. do not.nlll mor.lhan line 11
13 Car OVII of dosallowed deduellon 10 1994 Add lines Sand 10, leIS hne 12 . 3
Nole: Do nOI use Plrt /I 0' Plrt 11/ belu,v 101 /isfecl property (.utornob,J." c.,,"/n Otl>8l vehiel.., cl/lulllll/ephon."
cen"," com urers, or pro en used lor en'ertainmen" recreation, Of amusemen'). Ins'.a::1, us. Pa" V for Ii,'ed /Jrop'(fy.
MACRS Depr.clollon For A..ell Pllced In Servlc. ONLV During Vour 1883 Tax V.., (Do NOllnclud.
Lllt.d Pro I
C'ICIII~C'llOt\oI ~
14
. 3. ear '0 In
b 5, IIr 0 rt
C 7. ear 'Dirt . ~.
d 10. ear ro en ,
. 15. I&r '0 ert
I 20. ear ro en
g Realdlnl,"1 rlnlal 27 ,S fl. HM
r e 27,S rs, MM
h Nonreaidlnlial real MM'
(0 ert MM
15 Alternative De
. Cle.. hll
b 12. eer I? rs,
o 40. ear 40 fI, MM
. '.;>
S/L
S/L
SIL
S/L
I!);,.... II I Oth.r D.p,.cllllon (Do Nollnolud. Lllt.d ProP.nyl
15 OOS and ADS dlduclion.IOI .ISII. pllcld In IIIViel in lu YII.. blllMlng 011011 1993(IH InaINC1ionl) e
17 Proplrtv aubJecI to IIcllon 166(Q(I)II.clion (...lnllluol,on.) , 17
18 ACRS and other d. reclaUon soa instruclions. ...........,.. 18
tUiTil.".I Summary
SIL
SIL
S/L
,
I
I
I
I
j.
I
,
i
I
I
I..
i
19 Lilted property, Enler Imounl f,oln hn. 25, , , , , , , , . . , , , , , , . ,
aD Tol.f, Add d.duchon. on line t2, hnll 14 Ina 15 In column (g), Ind linea 181hrough 18, Enll( 11I11
and on Ihe approp'illl hnll 01 your IIlurn, (Pannl/lhip. end S CorPOllllons-.1I Inslruclions
21 For IlSels 1Il0wllebov. and pllcOll'n .e/V'ce dUllng thl currenl y'"r, eml/
Ihe on,on ollhe basi. Innbul'ble 10 see lion 263A cosls sellnSlruclions
for P.p.rworll R.duclion ACI Nolie., I.. pa9' 1 01 th. "PI'"I' InllNcllon., ell, NO, Ili06N
311
a
()
-----
, Ilvvr U~ UfDUCTln~ll-.iic-.T~~n.~ at:tN WIT......cl" ...... .._
,.... 'lUl'"II
~JP,rly-AUlomobllll, C.I1.ln Oth.r V.hlelll, C.llul.r T.I.phonll, C.rtaln Comput.r., .
' ProP'rly Und lor Ent'I1.lnm.nt, R.er..Uon, or Amullm.nt ' ,
For .ny v.h~ 101 which you 11'1 u.lng Ih. Itlneill'd mi/llll' ",. 01 d.duCIlnIl'.... "Pf#II', Compl.,. on1)l221,
22b. column. I Ihrou hIe/ 01 Sle/lon II, III 01 Secllon S, Ind Seclion C /lIP lielbl.,
S.ctlon A O.prwcl.tlon and Olher Informllion (Clutlon: Se. imlfUcliofls fOf JimU.Uons lor .uromobil.J,
' 221 00 DU "'.. IVldene.ID SU M Ih. bUllnlll/lnVlllmenl UII elllm.d? VOl N. 22b II 'v" . Islhl Ivid.neD WII" n?
('1 1101 ...~... IIlI I.' In III Chi
'roe of P'ODMy p.&I 0.11 DIICoId '" II'tWftlmn CoIl Of 0U\tI .....Iot ~"ho" ~ "'-lnodI DtcwIcllhOft
""""""!tltl MMC.e UN INI4 CtMM"4.""'...."mtl'l1 Pl'1Od ConWMIIQn Dtch.cIOl'l
P4fC~I' UM on
23 Pro I UI.d morelhln 50" In. uIlIfled bulln... UII "' lnllructlona :
. ,!=. ,
I r, " , u . t'(" .
I N.
1.1
Iltcltd
IIClto" '71
co,.
'.0...
')
~ .
,.... .
24 Pro I used 50" or '1.1 In I ulhfild bUlln... UJI II' Inllruclionl :
"
"
"
25 Add .mounllln column (h), Enle' lhe 10lel here Ind on line 19, peg. 1.
25 Add Imounllln column I, Enler Ihe 10lel he" end on line 7 a e 1 ,
S",Uon II-lnrorm.llon R.gardlng UII or Vlhlol..-II you d.duet "pin." 101 vehlel,,:
I i\lwlys complete this see lion lor veh"I.. used by I .01. proprielor, penner, or olhor 'mOl'llhen 5% own.r,' Of ",,,.d por.on.
I /ll'Du ProYlllld VlhiCII. to your ImploYIII, '''''InS...r Ih. qu.lI,on. In SIC/lOll C 10 '" " I'DU mill In IltIp/lon /0 eomplllmg Ihl.lIll'Dn tor IhOII ".,rlll
~ ~ ~ ~ ~ M
YIf\CIt , Yehdll Vlft<)t 3 Yehle" .. v.~.. , V'M" I
S/L -
25
,
C'
25
27 TOil/ bUllnlSsIInvnlllllnt millS dlrvtn dUllng
Ihl ytll(OD NOT Includl eDmmuhng miles)
28 TOIII commullng 'mllll dlivtn dUllng Ih. ym
29 Tolll olhar perlOn./ (noncommullng)
mill' driven. .... ....
:JO TOIII mllll dnv.n during lhe y.ar,
Add IInll 27 Ihrough 29. . , , ,
Vu
No
V..
No
Vu
No
Vu
No
Vu
No
V..
No
Wla th. vehlcla ,v'llabl. 101 pellonel
UII during oK.duly heuII?, " . ,
32 W.. lhe v.hlcl. UI'd primanly by e
mor.'han 6" ownar or rol.lld pellon?
33 II .nolher ..hlel. .va/llbl. lor pellOnal
UI.? , , , , . . , , , . ,
S.ellon C-CuuUon. lor Employarl Who Provld. V.hlel.. ror Uti by Th.lr Employ...
lIn.swar lhe., quesl/ons 10 delarm..e /I you m..t In IKClption to compl./lnll Sael/on S, Notll SlCllon S mull alway.
be cornpleled lor vehicles USld by .ole propri.,ors. perlners, or other more Ihan 5'16 owner. or relllod person..
V"
31
,
34 00 you m.lnleln I wril1.n pOlicy .llIlmenllhat prohlbils III parsonll ule 01 v.h,cles, Including commuting,
by your Imploy...? . '. . . . . . . . . . . . . . . . . . . . . . . . . . . , .
35 00 you m.lntaln . wrinen policy IllIemlnl Ih'l prohlbil. perlonal u.. 01 vehicles. eMeapl commuting. by
your .mploy.,,? (Sol Inllruelion. lor vlhlCles ulld by Corpo'"le oK,corl. dl/ICIO", or 1" or more ownerl,)
38 00 you !twellll Uti 01 vahlcles by Imploy.., II peroo~11 UII? . . . , , , , . . , . , . , .
37 00 you provide more Ihan hVI vehlel.. 10 you, emploYlO1 Ind IIIIIn Ihl Inlo,m.lion reeeived rrom your
ImploY.1I concarnlng Ih. UII ollhe V.hlclll?, , , . . , . . , , , , , . , . , . , , .
3a 00 you m..llhe requi"m.nll concerning quahlled lulomob,le demonSlrolion UII (I" Inllructlanl)? . ,
Nolll /I r In.wer 10 34, 35, 36, 37 or 38 IS 'Y.s.' ou nNd nol com leI. SlCtion S lor Iha covered vehlelos,
Amol1lzlUon
No
I.'
DNcnphon Of call'
11I1
0,1, 'moI1'lallOfl
bt;.,
,.1
Amortll,!)I,
amount
3g AmOr1luUon of COlli 1"11 be Ins durin our 1993 lax ear:
:-
~o Amonlzal,~n 01 COilS Ihal be an beloll 1993 , , , , , , , , , , . , ,
~1 Tolll, Enter he" .nd on 'Other Oeduchons' or "Olher Expense.' hn. 01 ou, rolurn
312
~o
~1
~
~,u IN5TflUCTIONI ,
EASISlDE
/( .'
',~
C""''ft:u .1'4l,..U....L 110\"
201 wEST RAILROAD
NESQUFHONING, PA.
lJJ V.
ST.
1112100
.'
:
"
(FII.lhlar,'urn wllh lilt Ineom. Tor Olllell On or boloro All,1I 15, 1994
(ITEM 101 SIl.11 bo P.ld In lull wllh rolurn
Any bol.nee 01 'IX
h
FINAL INDIVIDUAL EARNED INCOME TAX RETURN
FOR CALENDAR YEAR
ORPARTOFYEARBEaINNINO........ol!\~..l.t..J.~.'?1... ANDENOINO oce .11, I ~'n
.................................
0243 OERKOSH GL~NN E
HAUTO GA~AGf
liP 1
NESQUEHONI'lG PA
111240
171- 4b-0121
IOC NQ.IIlI,., IiIO ""-IAaI OOMIe' " frtI"NUl1
r.. II) ~ (. /, Ii
5(JL' QH &n~.;.. tl~{ Y./l-"A
. ,) . r
Jt"""'~I\"l'
".'1M Cl . CWl 'OWN~'"'
,1
Ill'\.U&I YMI...., WANAItf COMIIC'fIClMa.
FORMER ADDRES.q
DATE MOVED
III ENTER YOUR TOTAL WADES, SALARIES, BONUSES, COMMISSIONS AND OTHER COMPENSATIONS RECEIVED BEFORE PAYROLL
DEDUCTIONS FOR TAXES, DlJE5,INSURANCES, BONDS, AS REFLECTED ON AnACHED
EMPLOYER FORM wa'l"c. ""NT IMPLO,'ER5 NAME. LOCo\LAllDAI55.c:nv, ITATI'lIP
.
EARNINGS
S...................
LOCAL
TAX \\lTHHELD
S................
li~
!~;
Willi .... . .J' .
. . '. .. $ (';;1', ,.,., ".,,\
(2) EARNED NET INCOME FROM BUSINESS OR PRO/LISID", ETC. FROM FORM 1~0 SCHEDULE C OR F ...................... .. .,....._..MdJ
PI EARNED NET INCOME FROM PARTNERS' liPS FROM FORM lDlDSCHEDULE K'1 .............................., $,..................
141 OTHER EARNED INCOME $..................
(4-') ;~;~~;;~~;.:. $ (~3B 7 i:b) _
llil LESS UN REIMBURSED BUSINESS EXPENSES, IF ANV, AS REPORTED ON FEDERAL FORM 2108 ................................"......, ~'
IllI NET EARNINGS ITEM 4A LESS ITEM 5 S, 32.37. m , .,
, '\
r' -()-
to. '-,
$..............:..... $,................ .
$................... $............._.
~
A COllY Of All sew DUllS MUS 4''' ACHEO
(7) YOUR TAX (1 % OF LINE 6)
, AMOUNT PAID:
" ., (7Aj BY WITHHOLDING F,ROM YOUR WAGES ......................,..,..............,...................................., $..................,
(7BI BY PAVMENTS ON YDlJR ESTlMI. lr.!J TAX .........................................................................., $..................
(7C) TOTAL OF 7A AND 7B $
181 IF YOUR PAYMENTS lITEM 7Cl ARE L.4ROLI11HAN YOUR TAX (ITEM 7~ ENTER OVERPAYMENT HERE . $
CHECKOClIF VOUWANTTHIS OVERPAVME,ll 0 OR CREDITED TO YOUR 0
REFUNDED TO YOU ' ESTlIoIATED TAX
~ IF YOUR TAX (lTtM 7) IS L.4RGER THAN (IT.M 7C) ENTER BALANCE OF TAX DUE HERE ~ $ _ (~,
(QA) AFTER APRIL 15 INTEREST ANn /'':NALlY WILL BE CHARGED ON UNE. . $
(Till TOTAL PAYMENT OUE WITH THIS RETUR,j (UNE B PLUS UNE IlAl . $
I DECL.4RE, UNDER THE PfNALnES OF PEI\JURV, THAT THIS RETURN HAS BEEN PREPARED BY ME, AND TO THE BEST OF MV KNOWlEDGE
AND BEUEF, IS A TRUE, CORRECT, AND COMPLETE FORM,
~
I ~ COMPlETE iii,! I'OU.OMIjQJI' Pl\Ep,...:o ~y OiliER THAN TAXPAYER
"~. (l./
.. ~ c. 1
Q; OAU()lI"'l',.",.IOr.
ill:. I,. ,I f\i l"o,',{ .__ If\,...L.\... (." ,
~ " ~T\lRIOI'f'IIlI"oUlI"
C
DA'I
~"1UII0I"....,..,Ul
.......t.cc:wru...., 01 ""',""'"
;'1"1" ,
., ., I'"'
-..
r, :'./, ,;
1"1 " ',"
... I' ~ t' _ I'...c.,.
I
,
THIS FORM MUST BE FILED WHETHER YOUR TAX HAS BEEN WITHHELD OR NOT
- PROOF OF DEDUCTION MUST BE ATTACHED
--- --.----.--- - .--..--.---- -....--.-.-.- ... -- - -~ - _._- --.--.---------
A
-~\'\ E Dm.h...oo-h
PMc!p1l bUlIII.~. prol..,Ion, including ptOCluct et..Mc. (I" pag. C'l)
\ 1 ~',
Due'" nltnl. II no "P'~.I' V'..~ name, I..". b&&nk.
, l I.. 1 I 'I. . I (
8uaInt.. _... lIncIuclIng lull. CI room ,I ~
CI town Of II otnce III" and ZIP c .
AcoounUng rne&hod: 11) mealh (2) CJ AccN., (3) 0 Othet (lpeclfV) ~ ..................................................
M.IhOCl(I) uttd 10 Low" 0/ cot, 0_ (.1IIch 'nl Doel IIOlopply CI
Valu. cIotIng mtnloly: "I 0 Coli C2l 0 ClIlII/Il'1 (3) 0 tlljllanallonl ~) jCIj. cI1tcktll, IkJp lint HI VII No
Wu 111." 1Il~ ching. In Iltltnnlnlng qUlllUU.., COllt, CI vlluaUonl bel....n optni'lllllCl cIotIng Invtllloty'/ n -V..,'lIItch
uplanaUon. . . . I I . t . . . , . I It. . . . . . I . . . I , . . . . .
DId you ',",lwIIIIy pII\Jclpll.'1n "It opmUon 0/ IhIt bulinttt Outing 1m? " 'No,' _ paga C.2 lot IImll on 10....,
II \'OIIlllI1td CI wtd IhIt bulln,.. 0 1993 cI1tck ha", . . .
ncom.
C
.
,
Q
H
1
Cltota ,tcI!p1t ClIIlt., CluUon,lIlh1.1Ilcctna IOU _td 10 you on FOttn W., and "'" .SI.t/u1Oty 0
tmpJoj'H' bGir on /III' IOttn "II c:/ltCAtd, _ pa(JI C., and _ hart . . . . . . . ~
Rltumllnd &>>owancM . . . . I .
2
3
.
5> 0.0
o
co
I
I 84lIl1rlC11lna21ram.....l . . . , .
4 Cotl 0' goodt told (Inlm IIna .0 on pag. 2J
. Gra.. ptOftL 84lIl1nlcl1lnt . I,om lint 0 .
· 0Ihar Incomt. including FtdttlllllCl ._ guolIna Cllutllax crtdIl CI "fund (_ pago Q.2) " I
7 G'OIl Inoom.. Add IInIl a IIlClI , . , . . . . , . , . , . ~ ClO
Ell .n.... C.ullalll Do naf enlor /III en.., lor bualnos, u.. a au, horne on IIn.. 8-27. 'n,'ud ,ee line 30,
· AdvttlJtlng. . . . .. · 18 P......1IlCI prolUothItlng pII/lI II
I Bad debit from IIltt CI 20 RanI ClIout (_ page ~):
_" (tit pag. C.Ol ., I . v--. """*"'1, MIl oqu/pmInI.
10 Cat IIlCl INck upanall 0 1..1.3,~7 ~ bOlh" buIinttt propatty .
(... pig' Q.O). . . , 21 Ropllra IIlCl mIlnltlll/lC' .
ConvnIIIIoN ond IHI, " . 22 IIuppIioo I'lOC _In PIn IlQ
Dep&lUon. . I . , ," I 23 Tu.. and UcenIIa I . .
DopttclaUon IIlCI IOC1Ion 1711 24 Tra""~ ,",all, lIlClanlll1a1nmanl:
..- dtductlon (nollnclucltcl . _ 't.-2.. ~ . Travel. , . . , . . .
In Pill UO (... page C.3) . . -' I5D b MIIlt IIlCl "'.
I. Employ" btnonl ptOQrImt ..1\&IIvnon1 .
(Olhlr than an lint 18). .. . 0 fIIltt 20" cI
la InIuranca (_than haIlth). 15 ~ 2~=
II Inltrlle Iota page 0-4) .
· """'gig. fpaId 10 bInkI, tic,). I al d s..blract lint 240 fnlm ... 240
b OUlM. . . . . . 8b aa UUllUu . . . . . .
17 LogIlIllCl ptOftttlontl 28 WlglI (11II )obi crtdIQ , .
HlVIcII. f . . . I . 27 OthIrpPlf\lQ(fromllne4eon
II Olflca.. 11.I', I 't pagl2) . . . . ,
21 TolII 1IlpI/III' befetl __ lot buaInNt UII 0/ hamI. Add I/jlIII UVOIlQh 27 In cokImnI. . ~
II TontlU"" pro/\I 0aatI- IIlIbltoclIlna 21 llIllT1l1na 7 . . .
~ Exper\uI for bualntu UN 01 ~ home. AttactI Ponn 1128, I . . . . . . . . .
II N.I ptOftl 01 (10..), lklblnlclllna :10 !tom ..... 28.
· n I ptOn~ Ill'" on 'onn '040. tlnI II, IIlCl AUIO on IohacIuIa I" Un.. (11t1u1oly IlT1jlIoyMI,
III pago Coftl,l'IduclItltI, anltt on FClm 1011.11na 3,
. U . lou, \'OIl MUST go an 10 lint 32,
U U )'011 ha"" . ..... _ lhI bale IhIl a..- ~our Inv..lmonlln IhIt ICUvIIl' (_ pag. 0.5),
I ")'011 cI1tcktll 321, ttlItt "'" Iou on 'onn 1040, tlnI 12, IIlCl AUIO on _ol. IS. tlnI a
(lItMory .mpIoy..., _ page C.5). FId_" tnl" an FOttn 1041, Un. 0,
. U you chlCktd 32b,)'OII MUIT IltIch 'onn l1ae.
'0' P.p.rwOtll RaducUan Ac1 NoUo., tI. 'onn 1040 InllNoUOtII,
113
. .
~,
"
12
10
uo
2
.d
27
28
21
2.2.
ro
}
}
32.37
b()~
321 'lZS AIIlnv..lmlnlla II noli.
:I2b B'" SornIlnvlllm.nlll nol
.1 rtak.
Ctl.No,I1~P
8ehadul. C (fOlm 1040) ln3
_0,.,., 104q 1m
IiZiIDIII
Co.t of Oood. Sold (II' page C-5)
a3 Irwwlloly., bogInn/ng of)'lll, "clIflltllll ,"'"' 11I1 \'N#'I ciolinO in_ICIlY, 11\.." Iapilnllion
a3
1I4 "'""'- .... -' of lIImI_wn '01 ___ UN
II Call oIl1bot. Do noI hUlllIlIIy poJd 10 ~"
II MlIIIIIlII/ld IllPPlIN
17 Olhot 00111
.. Md ..... a3 IIvaugIt 37
II Irwwlloly II IllcI III )'III ,
.
114
"-
"
Coil 0' oodllOld. Slbltlcl line 3D from IInI :la, En'WIhI tIIUlt """ II1d on I I ani 4 40
Informallon on Your Vehicle. Complate thla part ONLY II you 811 claiming car or truck axpenaes (
Ilna 10 and ate not raqulrad to fila Form 4562 for this business.
41 When did ~ plIoI yow YIIllcIIIn II/VICI'OI buUltu puIJlOHI7 (monlh, diY, YIIIl ~ ........l........l..... .
41 0111II101II numbIr 01_ you dtoYt VOW _ during I D1l3, Itllwlhll1llll1bW 01 mIIu you IIIId yout vohIcIl 'or.
. IuIJnIN ................................... It Convnuung ................................
o Other
43 Do you 101 yow _I hoVl _\hit YIIllcII _rOl pnonoI....? .
D VII
..................................
C1N
44 Wu VOW YIhlclI Ivlllablllor "'"lbIng ""-duly /loin?
D VII
4SI
b
B
VII
VII
Do you hIYIlVldencIlo IU;lIlOfl VOW dlduclion?
II...,... II IhI ~I ,,"I\..? .
Oth.r .Expen.... USI belcw business e.xpenses not Included on lines 8-26 or line 30,
IiliIIl'J
.....................................................................................~t........................
..............................................,...............................Lu~~k...~1h.P.~
...................................................................~~~..~..:t:\~!J.(~~rA.}U.,...
...................................................,.........,.........'...>...).,&~6..,5D..(~.........
......................................................................................................................
'800
?? ...
,.._~
......................................~.....'fO......... .................... .......... ....... .........................
......................................................................................................................
I.....................................................................................................................
.........................~................. ............ ..... ............. .... ....... ..... .............. ...............
48 Talll oth.r II n.... Enl., h.r. .nd on I . 1. Unl 27
:~ y. 2.2-
4e
1101
--
C1N
B~
6'l
~r.
C5
I ,'II"'UUIIlIO IIlIurmllllon on Lilted Property)
~"IIWI'I"~
.....1'1II ~........ ex) .. .l." lei .,a.. In.tructlonl. . A.....ch (hi, form to ur felurn.
",,,,,,,) tnoW" on ",..." ):;:11) (",,, _ _ l. P
. ~~OKl C'I W~~,
II.l'.ne.. 01 'ell'l"'r ~ "'hen lhl 101m '-'II" t.
l U ~~ lv.-,'!l--
mau Election To Expen.. Cunulr\)Tenglble Property (S"cIIOn 178) (Nole: If you have any "Listed Prop,r:y,"
com 1", Par: V b,'ore 'Ou com I", Par: I,
Ma'''mum dolllr IImJlltion III an Inlorprile Ion. bU"in,"I, .ee inllrUClionl,) , , . , ,
To'ol COli of IK',on 178 proP'rly plac.d In """ce during 'h. lax y..r I..e lnalructlonlj .
Thrllnold COI' 01 IKllon 178 prop."V b.lo" "duclion In lImil.tlon, , , , . , , ,
RllCluetion in IImil'llon, Sublllc' lino 3 Irom lin. 2. bu' do nOI enter I... In.n .0.
0011.. limil.tion fOf lax v..r, Subtrlel lin. 4 from Iin. 1. bul do nOI .nler I...I/Ian .0., (II
marri.d fll,n .. ,,",il , II. Inltrucllonl" , , , , , " '",'."
t'l CtlUlQlfOI1 of PfO~'lr fbl COil {oJ (1Ic1tel c.ol'
lJWH3
A111C'vn.1\I
....ne. No 87
-."lno -..,
I ,_
z
1
2
3
4
6
a
500
7 Lillld prop.nV' Enler amount from "no 26. , . , , . . , , .
8 TOlal allclld COil of ItCI'on 178 p,opony. Add amoun.. in column (c). Iin.. 6 and 7
g TOnlaliy. deduclion, Enler Ine Imalier 01 IIn. 5 or lina B , , , , , . , . , .
10 Carryoy.. 01 di..llow.d doduCtion Irom 1892 (III Inll,uCtionl) , , , , , , , . 0
11 TaXlolo Incom. Iimitalion, En'er 'h. smaller of ,aXlbl. ,neom. or I,n. 5 (I" Inaltuctionl) .
12 Sacllon 178 ..p.n.. deduction, ADd "nil 8 .nd 10, bUI do nOlan'er mOrt lnan lin
13 C:II over of dlllllowed dlducllon to 199.& AcId lines 9 Ind 10, lell hn. 12 .. 3
NOlO: Do no/ uae Pin II 01 Pin 1/1 bl/olY 1001""d plOplfly (Iu/omobilea, cenlin o/llIr .Ihlc/la, c.llu/ar te/'Phon..,
cerTain com uter., or ro ert used lor IIntBn.mmsnt, recre.tion, or .musement). In'tNd. UII Part V lor listed ro art.
MACRS Depreclollon For Alleta PlacId In Slrvlcl ONLY During Your 11183 Tax V..r (Do Notlncludl
Llatld Pro I
M M..l'lln Ina lc:. 811'1 lOt a'plecllhon
,lit p;~'..:1 '" (bI.Ittntt""'''"tmenl WM
h'."". unl -1M IttlltUChO"1
14 Genital De reci.lion S Ilem 19~~~~t:!;.e inslructions :
. 3. ear '0 en ~' ~"~".:~.~~
b 5'Ylar property "~;:_::.'~~~~:~'~
c 7. ear '0 rt ~-'."~1~?~
. .~"~','
d 10. .ar '0 Irt :5: _' ~~~'\~,
I 15. II' '0 on ~::'~~~~
t 20. II' '0 .n ,.,'K~'
g Roaidantial"nlll
r 0
h Non'"lid"ntill ..al
ro 0
15 Allernlti.o 00 ..ciaUon S
I CII.. lifo
b 12. oa,
o 40. lar
e.J ClIlUl(llIOrl 0' Pfopt"~
.
0;. . ,
,
27,5 ra, MM
27,5 ra. MM
MM'
MM
I~ rl,
40 ra, MM
S/L
SIL
SIL
SIL
S/L
S/L
S/L
1'='..111"'''1 Othlr Dlprlolatlon (Do Notlncludl Llatld I;'ropertyl
16 aos.nd ADS dlducllonllOf 111111 ~1'COd ,n ""'Ic. in I.. v.m beginning 0.10..,&&3 (I..lnsll\lctionl) 5
17 P,oplny lubloc'lo "clion 160{.,II) .'oclion (slIlnslrucIIOnl) 7
18 ACRS and Olner dep,acilliDn (,uo In",ucUons . , , , , , , , " ..,., 18
r:N1\~ Summary
18 Lisl.d proplny, Enllr Imouna from lino 25, , . , , , , . . , , , , , . , . .
20 To"l, Add dodueliona on Iino 12, 'mil 14 and 15 in CDlulM Ig), and IinOl161hrougn 18, Enler herl
and on Ih. ap~roprial. Imll 01 vour tllum, (Pannmhipl and S corperllions-..o inllrucUons
21 For IISlls shown above and plaCid In seNicI dUflng lhe curronl y.ar. Inll'
Ihe crtlcn 0' the basil ."flbulatl. 10 secllon ~63A COSIs see inSll'\JCllOnl 2
far Plp.tWa", A.duGllon Aot HollGe. 1M PIli' 1 of In, "PI'II, InIINGUan.. CII. No. 12806N
311
()
~~
..,
,.... 41e111H31 . PI 02
UIlld Proplrty-Aulomoullll, Clnlln Other Vahlclll, Clllular Talaphonal, Cane In Computers,and
Proparty Uud for Enlen.lnmanl, Recraatlon, or Amullmlnl
FOIlny ~cJa (01 which you arl us/nglhl "lnef,1'd milllgl fill or eflductlng/ll" IIIPIIIII, campi", only 22"
22b, cOlumn. , Ihrou h (C) 01 S,c/,on A, ,11 01 S.cllon 8, .nef S,ction C 1/, lic,bl"
S.ctlon A-D'DrwclaUon .nd Oth.r Infarm.lIon tClullon: Se. instruction, for I,mil.llon' lOf .ulomobi'es.
'22. Do vou hlVl ....,dlnCllo su M Ihl bUllOlllllnYIIlmlnl UII clllmld? .1!.LO No Ub II .VII ."Ih. Ividlnc. Willi In?
"1 IIlI ...~." 1'1 /'1 ,~ 1.1 1101
'roe 01 P'0C*t11'tt1 0.11 .-.ctd ... .,."..I"'Ml Coli Of Oln.r ..~. lOt aerw"..11Ol\ "KO~ Ii4I1I'1Od/ Or.DtK'"1Otl
~. f~1 MMCI ".. bI~ tbul'nl'W""lmtnl",*, Conv.nIIOft 0Mwc1.,
"rUnl.ge u,o 01\
Pro, Ulld motll"'n SO" In I ulllllld bu,'n... UII "" In.lrucllono :
J .,.. ~
, 1:(' " ')
24 Pro, Ulld SO" or II" 'n I ulhllld bu"n,.. UII .eo In.lrucllon. :
"
"
"
Add Imounll In column (h), Enlar Ihl 10lal hare Ind on IIn, la, p'g, " , ,
Add Imounl, In column i. Enler Iha 10lal h,re Ind on IIna 7 a, 1 , , , , , ,
SleUon B-In'ormltlon Rlglrdlng U.. 0' Vlhlelll-ll you ef.duc' ...p.ns.. lor vehlc/."
· AIw'Y' comple,. '''I' '.cllon lor \I.hle/., used by I sol. proprietor. parfn.r. or other -mora llYn 5" own." . Of ,.,.t.d paraon.
o I/)'Ou prOVld,d ..hlClfs '10 yOUr .mpIOfflS, tirsl 'M.." Ih, qUII/'MS /II SIC"on C /0 SIIII YOU mill In ""PliO' 10 compll"ng 1M' "",on lot/hOlt ""'tIll,
W M ~ ~ W ffl
VIhCIt 1 Vthc.. , V.,.CIt :I Vthc.. II VlhC" I V.I\.CI. I
31 Wlllhl vlhlcl, IVI/I.bll for plraon.1
U.. during Off.duly ho~ra?, , , ,
32 Waa IhI IIIhlcl. ulld primarily by a
more Ihan 5" own.. 01 relal.d paraon?
33 la another v,hlel. IvaUabl, 101 pa"onal
u..? , , , , , , , , , , , .
$.ellon ~uIIUon. for Employ", Who Provld. V.hlclll 'or U.. by Thllr Employ...
An.wer Ihlse qu"tlon. 10 delermlno ,f you m,II In ..c,ptlon 10 completing Section 8, NOI.1 Section 8 mU'1 a/ways
be comp/,t.d lor IIIhicl" used by '01, proprle'ors, partn,,,, or other more Ihan 5% own,,, or related p,,,on.,
VII No
23
'!o
'r,
n
25
28
27
Tol,l bUllnllllinvlllmlnl mil,. driven dUllnO
Ih, YII/IOO NOllnclullI commulmo mllll)
Tolll commllllno mill, driven durlno Ih. mi
TOlal olher parlOnll (noncommullng)
tnill. driven. . . . . . . . .
TOlal mil.. dnven during Ih. y.ar,
Add Un.. 27 lhtough 2a. , , , .
28
IV
30
.....
No
VII
No
Voa
No
VII
No
VII
3<1 Do you mllnlaln I whll.n policy lIatomenllhe' prohlbll' III per.onal u.. 0' VOh'CIII, InclUding commullng,
by your employ...? .'. . . . . . '" . . . . . . . . . . . . . . . . . . . .
35 Do you mllnla'n a whllon pOlicy lIallmlnl Ihll prohlbll, porson.1 u.. 0' v.hiclll, "c'PI commuting, by
your Imploy,,,? (St,'nllruetlons lor vlhlclo, ulld by eo'porsll OffIC.rs, dlrtClors, or ,.. or more owner,,)
38 Do you lrell III UII 01 ..hlclll by Omploy,oall partonll'u..? , , , , , , , , . , , , , , ,
37 Do you provide more Ihan Ilv, Vlh'cl.. 10 your ,mpIOY.1I .nd rellln Ihe Informltlon roc.iv.d 'rom your
employe.. concerning Ihe use olltl' V,hlcl,,?, , , , , . , , . , , , , , , , , , , , ,
:Ie Do you mill Ih, requlremlnla Concerning quahf"d aulomoblle d,monllrlllon u.. (all Inllructiona)? , ,
Nol.: /I ur an.wer /0 34, 3S, 36. 37, or 38 IS 'Yes,' nlld nOl Com III' S,clion 8 lor Ih, COVllled v,hic/es.
Amort ZllIon
1.1
DtKftphon 01 COli.
IlIl
0." .tnQF1IUhCln
begin,
tll
Cod.
"CIon
lei
Amol1ll1bl,
_mount
30 AmoMallon of COsls Ihat b, Ins durin au' 1993 I.. ear:
40 Amon""lon 0' eOlls Ihal b, an ~lfOrt 1993 , , , , , , , , , ,
41 Total. En'.r her. and on .OUler Oeducllonl" or "Olh., hplna.." 11M. 0' Our ralurn
312
40
41
o.
1'1
_'-CltcII
Mcloo" "~I
co,.
'l.
1.
..",.
""'.
-
C.
28
No
VII
No
In
A,mo'1I111l0l'l10l
In.. V'.'
w
w
.
I.lb.1
UHth~
IRS'lb.l,
CthIrwtu,
p'-." print
Of tw.,
ESlldlnllal
.alD
ImPlrl"
Flllng Statu.
Olock only
on. box,
Exemption.
If mo.. than
6 dependents.
... lnlltl
In com.
Mlch
Copy 8 0'
your Fonna
W'2, W.2D, ..
10tl.R h.,..
If l'Oudid
nol III .
W.2. lei
INltuctlo"..
Encloso
but do nol
attach Iny
p.~nl
With )'Our
III\.I'n.
Adluslmants
to Incoma
Caution: 5..
insttuctio"1 . . , . . ...
rot Privlcy Act
and 'aperWoric
_ ___ R.ducllonAct NoI'...
.... - Hllnltructlon..
Jim Thor e PA 18229 V.. No
Do)W Wlnl $310 go 10 IhiI Mdl ,,','" ,,"'" ",','" """""'.'""""",,, ,.", "" X
.. If.' inlrehm don Ot.Uwent to ololhial\rld? ,..............................
1 S"'OIo
Z Marrlod filing jolnl ,.hm (.von II only on. had "-no)
I Marrlod filing IOpar.1o rtn, Enlo' tp....... SSN lbovo .. lulllllmo ha,. ,,","" ..
. X Htad 01 houoohold (WIth qUlIlf)1ng p./IOn), IIIht qUllif)1ng p'"", II . child but nol )'011 dep.nd.nl,
ent.rthlld\lld'aMrnehlr. ..................
QuIll n widow I' with de .nd.nt child If DUM dild" 19
YOUrMU. 1f)'O\W p.,.nl (Of' someone ,1M) can cl.im)'au I' . dep.nd.nt on hi, Of
ha, 10. ,.I..n, do nol chock boo 60, But be .... 10 chock Iht box on In 33b on PI 2,
b . DU" ............,......................,..,...........".....................
c D.p.nd.nt., (2) c.. (3) "" I" _, (4) 0..........
.... ..,.l'ldtnr. '"* '.""'1hiI
HarM Il.tMIIl ancI""f\WI\t . 1 UC\ll' fllI'l'lbtr ..
Matthew Glenn Oerkosh X Son
....~.I"l..m WI U. "....,- ""_1I1l11 rw....m.. otIryu
U.S. Individual In com. Tlx Relurn
For the Ir Jan 1 . Dee 31 1994 0( other taw If be innin
Yw In& '*"'
Glenn
".,.,.. '.a. .............. Nmt
.. LaIlMM
E Oerkosh
WI LtWnM'lt
MImI..... (nwMef _ "MQ.. rwtl.h.. '",0,.... ...lfl*lIdlenl.
-""
d If..-CfIild...''''."", ..klro.A......rnM..~.'.,.nlundll. ,".ll1""lNlIMftl, ..hef. ............
. Total nl.M1'\ber ol..em It.:!n' claimed............. ...,....,. ....... ..,.......... ,...
7 Wage., N~,i,," tip., .Ie. Attach Formes) W.2. "..........,.,.. """"" ,....., .......
.. TUlbl.InIo,..llncomo, Attach Schodul. B II ovo, $400....,....,..............",........
b Tu....mpllnl"..I, Don1 Includ. on IIn. Sa,.............." Ib
. Divld.nd Incomo, Attach Schodul. B if oyo, $400............,......,....,................,
10 r...bl. ,,""cIs, ...dill, 0' offsets 01 ...1. and Iocallncomo ..... """"""',,',,',,',"
11 Alimony received "10""" "'" "0 ,....". """ II ,..".. .""..". lOot ......" I." ,...
12 BUlln,,"lncomo Of ~o..), Attach Schadul. Cor C,EZ"""""""".""""""""""
" Capllol glln 0' ~o..), If r.quir.d, Attach Schadul. 0""""""""""""""""""",
14 OIhtr g.ln. Of (10....), Attach rorm 4797 .",.."""""""""""""""""""",
115. TolllllRAdiallibutionl ,."., .W Ib Tillable amounl ... ,.,..........
1'. Tot pensions & annuitiea ....lJ!.!] b Tauble amount................
17 Renlll ,.al ..lal., loyallies, Plrtn.ra.hipl, S corporations, trusts. etc. Attach Sch E ..........
1. Farm Income or (lou). Attach SchIdul. F ...............................",'.',...,......
1. Unemployment componsation."....,."...""..".,...".,.,."...".......". ,....,..'
20. Socill MCU'ity benefltl ., l!!!J Ita Talllble lmaU'\1 .....,...'....,.
21 OIht, Incomo, '_ _ _ __ _ _ _ _ _ _ _ _ _ _ _ ___ _ _ _ _ _ _ _ _ _ _ __ __ __
22 Add the amal.flls in lhe far ri hi column for lines 7 . 21. This Is UI' lolallncome ,........ ...
2,. Vo..IRA d.duc:lion ...................... .......... ........' 2'1
bSpouso'.IRAd.ductlon ......................,.............. 2310
24 Moving '.peOMS. Attach Form 3903 Dr 3903,F ............... 24
2S an.,hal'ol soU,erT'jlloymonll.. ..........,.................. 2S 972 ,
2& Sel',.mplo)'tld hallth In...lnc. deduction" , , , , , '" " """,. 2&
27 K..q, rollrll1lllll P"nond ..",omplored S[P doluchon . ......, ...., 2'
21 Penllly on ta,ly wllhdrawllo'aavino. ,..."".,..""" 21
2. Ahmon, p.tld. RKipienra SSN" 2'
30 Add hnes 231 thro h 29. These are or lolalad ustm.nl.
AGdrolu,SslO'ndcomo 11 '..wMt11M JOkll'IlkM22. UI.,.,.WlujIlIIM,,...'U_I. ./nI....J,!I.....,'-"',...,
.,11 t.,...,UQlJ".tM.1....,....,... 1...'{M"n-C11111CtflOrltlnl"lKlorJI ",..
DIll
'DIADIlZ III'....
,..,...w...... ...
J71 -46-0121
........ ..... ......-....
'r.,':.,:::!--
i.': ::' .::::r
......
}........"
'''Hb'"
....11II.. .".,
(5"" M...I "11'
rt....." &IlU.,,,...
IlomI ".""
12 .~,~.~....
I
I
'.11II.,...
.......11I..
......Ke..
M,..,....,....
De,.a4......
k.......,.,
..... ........
AllllIII'_MfI
...."...
.....1l1V1
.
,
II
~'...':;
I 363
I
10
11
12
13
14
15b
lib
l'
II
I'
2Gb
21
22
13 750,
IS 113
1.' '~':.
50
972
.. '1
14 141
Form 11140 (1994)
,n ,tUQ (1994)
t',..
,Comput.lion
/'
II )'OU wonl
!hit IRS to
fig..o)'OUr
tiM, ...
.,.ttuctlons.
ennllt.
Other
Taxe.
Payment.
Attach Forms
W'2.W,~
.nd 1099'11
on P.O- I.
R.fund or
Amount You
Owe
Sign
Here
Ko.p 0 copy
of this return
1ot)'OII 'OCOlds,
Paid
Preparer',
Use Only
nxAAIIJ 12114I'M
Glenn E Oerkosh " 171-46.0121
IZ NnounI~omlino31 ("",,,,.dg,oaalncomo) ..............................'......,....,.. n
130 Oc II: 0 you..... tr./.Idor, 0 Blind: 0 .pO.IO.... 651older, 0 Blindl;:
Add tho ~, 0' boxes d..cl<od .bo.. .nd onler tho Iotal he.. , , , , , ,,' , , '" ~ 13. ""
~ 11)'011 per.nl (ot IOtnODIlI .110) can ctaim)'Ollll . d.p.nd.nl, ck he.. ,," , , ,~l3b ~T!,
c 1t)OU at. married tihng ..p.r.tlly II\d )'Ow apOUM illmllD dlduc1ion1 r;:.;:
14~: )'OIl{.~-.:.::::.;~~~:':: =:':.'1: ~,':, he.."""""""}.. ~ I3c 1,~j;;
...." 11...........04 ""'wn bolo.. lot )'011 Wong 110..., ....11 yo. ckd H
01 Illy boa on llno U. 01 b, _ _Ions to find)'Oll _,d
)Illr. clod, 1I)'01l clwckld boa Uc,)'OUr .lIndard dodi.ction 10 ,ero,
o Slnglo - $3,800 'liNd 0' houIOhold - ",BOO . Morriod filong jolnlly
ot OUIlifloing _w(or) - $6,350 0 Manild filing IOplIIl.,y _ $3,175
J5 Slblroct llno 34 ~om lino 32, ......... ....,..,..' ..,.................., ....",..,........ .
14 II In 3210 W,B50 01 loa, mllIt/ply $2,450 by tho Iota I no, a. ...mpllons ctaimod
on In 6e, IIln 32 is owr $83,850, "I the Ntructiona rot the amo~t to Intar .,............. II
P TIllllbI.lncomo, Slbl1oc1ln 36 .om In 35, II In 36 10 mot. thon In 35, .nler ,0. """""". P
II T.x. QlIck lI.om ~OO Tox T.blo, ~o Tox Rata Schod""" . 0 Copital Gain T.x
Wot1<Ihotl, Of, "Oform8615,Arnou-1I.omFormC.!!.8814 ..,~o II
.. Mllllonsl ta..., Oc II .om,..",.o Form 4970 ~U Form 4972"".."."",.,..", !t
40 Add linll 38 .nd 39 .... ,..................,......, ............................ ,...... ~ 40
41 OId,I for child .nd d.p ca.. IXp. Attach Form 2441 , 41
42 Oldil lot the olderly or tho diubl.d, Attach Sch R , , , 42
43 Fot.lgn tax cr.dil, Attach Form 1116 ........................, 43
44 Olhor cr.dita, QlIck it .om '8 Fo,m 3BOO bo
Form BJ96 cO Form 8801 .. FOIm (splC) 44
45 Addlinos4111Yough44........................ ........................................ 45
41 Slbtract line 45"om linl 40. If line 45 is morl than linl 40 Inler .0. ............... ....... ..
47 Stll..mploymonllox, Attach Schedul. SE ............ .................................. 47
41 AII.moti.. mlnillUT1 tax, Attach FOIm6251 ...., ......, ........,..'"".." ............... 48
41 Rocroplln ta..., Oc II ~om .0 Fo'm 4255 ~D fOlIO 8611 cO Fo,m 8828 41
10 SS.......odicll...."'\4>incomenol'_ltdloemplojw,AI1.xhf"mllll ........................., 10
11 TI. on qUllirted r.tir.ment pl'nll Including 1RAa. It rlquired,l" Frm 5329 . ,................ '1
12 AdYlnce ..med Incomo ...drt p';<nonta ~om Form W.2..,...., , ...... , ....' , ............, 12
IS Add.., 46. II. Thbb Iotlll.. ....,..............................,...................., ~ IS
14 fodorli income... withheld. II "'1 b I,om f,,,,(.) IIl'l!, ell .. .... ... 14
.5 1994 ..lImaled tax p';<nonll .nd 'molllt .ppli.d
~om 1993"1.," ..........................................,
II Eom.d Incomo 'redlt, II "q.o.d, .11 Sch Ele
Nontll(lble limed In.;-ome: lmounl ...
and typo . "
17 Amount p.1d with FOlm 4868 (elllenlion requolt) , . ........, . .. 57
18 Ell"" aoctal Ncurit,), .nd RRT A t.1Il withheld . . . . . , . . . . . . , . . .. l5B
II Other P';<nonll, Cletk II Irom "eO Fo,m 2439
~o Form4136 ......................................... II
60 Add Ins 54 . 59. Tho.... ere oUf'tatll I mInis........ ........."....."...."........,. 60
11 lllinelDb""'."""'..5l.""'~"""'lllloml"'lO. ThIJbilloJ/l1OUllI/llllOn'P.ld ................, ~ 11
12 AmolXl' or linl 61 )'au Mnl R.rund.d to You .... ,.. .....................,.",.."....... 12
15 Amt 0' In 61 ~u wanl AppUad 10 Vo.,ll" Exl Tn........ ~I" I
14 "In 63 II molO thon In 60, OllbI1.ct In 60 ~om In 53, Thb b tho Amo.nl Va. aw..
For dlLlllI on how to PlY, Including ., to wrill on )'OUf' pml, III ,"ltNehoM. .........,., N
" EII/malad I.. .nan, AI..lncluda on lin. 64 ..,...,.......,. 65 9. "'.i".,',".'. f:.
':i.h
~,~:~.:
(l"n~
l\~n;
'i/J.j,;:;':~
J~:l;
~~4~
600. JX~X
;\\];',:
.~~~\:
4~':};,
1 539 ,i.'t
....,..",
~j:5~'~
't,.:::,
,'i't>,
~;~;~:;}
Unde, ptnalll.. 01 ,"jlllt, I _Ill. ""'II hi" .~ M litWtn and ,uCll'llPln~" Wl~ and iIa'-Nn~, and '- '" IM\I " my.,.... .,..
........ twr I" ""', WIld, MIl c~. D'~"'IIIon" 1l"'l~1f (0IIIf J\an LlI,fII~I) II uloid.,.. IlIln1otm1t111'l "Ilftlch '"ll~. till In, ........
Y.,,&lQnItwr.
Dolo
YM.u"",1lon
self em 10 ed
.,.,..',.u.lIOft
.
,,.,..', '9\&IWI. JI'. fWI' IIWln, BOTH tnIlW "W'.
D.~
.
PI''lIl'''1
M' .
D.~
a..ckl
......."""
1'11"''''' ~ hUlIlt,He.
hm',1\In'lIt
COf""'"
_."",Io~
Md_H,
.
...
lIP ....
14 141
5 600
4 900
6
44
544
544
1 943
2 487
2 139
357.
.:;1'"
'1.2210. Underpayment of
fI':" Estimated Tax by Individuals, Estates and Trusts
,0....-1" fit T,.~ . 5.. UplrltllnltNCtlonl.
,-................ · A".ch 10 form lD4Q.fonn 1D4QA,fonn lD4QHR,orfonn 1041,
r fWM(~ tho.n on....,.~ U"'''II' NlIlMtt
Glenn E Oerkosh 171-46-0121
Holllln 11IO.I1 CAS", wu do nol n..d 10 nil fOtm 2210 Th.IRS WI/I ~nou.. W1Y ponolty you 0"" /JfId IIndyoU 0 bill Fill FOtm2210only If....
or -. box"", POll I epp/y 10 you, If you do nol n..d 10 nil FOtm 2210, you 1M moyu..II 10 /lQ<J.. your ponolty, En'., lIIumounllom Wlo
ZOor line J6 OIl 111. ".""!/y I",. olyour ..'urn, bul do nol o/l.Ch Form 2210.
IPJirt I~~ R...anl '0' Filing - " II, b, ot c bllow II'pli.. to you, you m,y bllbll to lower or "imlna'" Y"" p"""IIy, Ilut you
mutt ClIlclc 1111 box.. II1lt II'p1y IlI1d ~II form 22tO WiIl1 YO'" "'" "ILm, " Id bllow II'plll' to you, ClII'" 1I1,'llox IlI1d lill
form 22tO WIlilY"" "'" "un,
llll8Ho,1141011G
1994
06
lC11lclc WIllchl"" box.. opply (II IlOIlO epply, "" 1111 Noll lboYI):
10 You ,"quo'll wily.... In _ cKcun,tanc.., 1111 IRS Will wII.. III ot pllt 01 1111 pltlllly, S.. Wily", 0' Plnally In 1111 Ino~_,
O You uu 1111 IMUllllod Incomlln,tlllmlnt mllhod, " yo"'lncoml VOIlld CUing 1111 Y"', 1111, mlll10d mlY "c1Jc1 1111 om"",' 0' one
b or motl requlrld InstoJlmlnls, S.. ~II InoUucUons,
O You hid Ildttlllncoml lax Wllnhlld ~om wag.. and you ~Iat It a. paid 101 ..Umalad lax pl.Iposa. WIlan II was Idually wllnh.ld
c Ino"'ad 01 In lquo! om...,ls on 111. paym.nt ciJa da'". Su 1111 Instrucuons lot lina 22,
You requlrad ......... paymlnt ~lna 13 bllow) I. basld on Y"" 1993 tax and you f11ld ot arl filing a Joint ,aUn lot alll1er 1993 ot I~
d bul nol boll1 1.,1,
IIi..itiiill Requlrod Annual Amount
ZEnte, YO'" 1994 lax anor crldill .. ...................... , ...... , .. .., ..,.... ........' , ,............, ........, Z
100000r ""'..""..."""""""",.."""""".""""""""",.""""""""""",.""""""" 1
4Add 11n.. 2end3 .........., ........" ........,.." ....'"", ........", ..,..........", ....' ...., ........', 4
5Eamldlncomlcrldil............,............,................................, 5 I 539
ICrldil 101 Ildorallax plld OIl lulll """"""""""""""""""""""'" 6
7Add linlI5 end 6 .,....,"""""',..,",..,'"".""""""""""""""""""""""".."""", 7
IClnlntylar lax, Subhct lina 7 ~om linl 4....,.... ......,...., ....,....".... ..,....,...... ......, ........' 8
'WUply Ilna 8 by 90% (,90) .., ......................"" ....,......,........ ...., 9 853.
10Wllnholdlng lax", Do nol Includl any ..Um,tld lax paymlnll on 1I111linl """"""""""""""""."" 10
11 Sub~acllinl 10 from linI 8, 1111.. 111..... $500, Ilop horl; do not compl',1 0' fiI. 1I1111orm. You do not OWl
1111 plnally """,..,...,""""'"""""""""""""""""..".""."."""".."""""""", 11
44
I 943,
2 487
,~l~
I 539
948
o
948
UEn'or 1111 lax aho"," on ~O... 1993 lax roun (110% 01 lI1al amounlll 1111 adjUllld grO..lncoml aho"," on
tn., '.un II more than S I51M)OO, or It marri.d riling "paralely for 1994, more VlIYl $75.000).
Caution: Se. NUUC'/OflS .,. ..,........... ................ ,..",. ....,.... ...................... "0" .....0. 12
15Roqul,odlnnull p"ym,nLEn'or 111'""'111., olllnl 9 ot Ilnl 12 ,..,....""" ........................"..,.... 13
Hotl: II/in. 10 is .qual to or mot. lI1an ,'". 13. "op hit.; you do not 0"" 111. pene/Iy, Do nol nl. Fotm 2210 unle.. you Checkld
box Id Ibov.,
!'Part oj;:j Short Method (Clullon: R.od 'h. inlr,uclion, '0 ....,you can u..II1. shotl mOlhod. llyou ch.ck.d box Ib ot c In
ParI I s.\ this t and 0'0 POI' I\(
14Enlor 1111 amounl, II any, from 11n. 10 Ibov. ..................,..............,.., 14i~1
15Ent., lI1alollll amolXlt, I' any, 0' ,.Umat.d lax paym.nts yOU madl""."""",. 15
1&Add linlI14ar1d 15........,............, .............. ...., .........."", ............'.. ......' , .......... 16
649.
649.
17TolI' undlF1>lymlnl 10UII,. Sub~act IIno 16 from linl 13, "zoro 0' II", ItOP hor.; yoU do nol OWl
1111 plnally, 00 nol 101. form 2210 lXlII" yoU ch.ckld box ld Ibov. """"""""""".""""""""", 17
18WUply Ilnl 17 by ,05725.............. ..............", ...." ...... '....", ............"" ......, , .......... 18
11"11 1111 omDunI on 11n. 17 WI' paid on 0' Ill., 4/15195, Inlor ,0,.
"II 1111 amolXlt on IIn. 17 was pald botoro 4115195, makl 1111 tollowlng compullIlion to I,"d 111. amount
to anlor on 1'"1 19,
AmolXl' on NYmbor 0' days paid
linl 17 . boloro 4/15195
x
,00025.........................., 19
ZOPlnllly, Sub~act lin. 19 ~om IInl 18, Enter thl rosull hor. and
on form 1040, hne 65; Form 1040A, line 33; FDfm 1000NR, ..
I,nl 66' ot form 1041 I,nl 26.........., ..,.. ..............,..,....,.......... ......,.... ..,.. ....,........ 20
0181 For Paperwork R.ductlon Act Notlc.,.", Instruction..
Form Z210 (I~)
rtlIZW12 lltl2lM
171-46-0121
t PI' 2
Soctlon A - Figure Your Undorplymont
(I)
4/1!1194
PI mont Duo Olio.
(b) (e)
6/1!1194 9Il!1194
(eI)
1/15/95
11 Required In.tallm.nta.1I box Ib ~Ii... ent.r Ih.
M101.11tJ from Scn.dWI AI. 11M 26.- OV1erwtM. enter "4
Olllne 13, Fonn 2210, In.ach...IuM.................., 21
22Eotimal.d till plld and till wUhh.ld, FOI eoluM IN
onIYl.!l1O .nl.. II. om...,t from 111I.22 on IIIlt 26, II
line ia II .qull to 01 mOl. 11M II". 21 101 all p.~.nt
periods, atop her.: you do not owe Ihl plnat,>" Do not
m. Fonn 2210 ...... you ch.ckod I box In Pili '"",," 22
Compl.to llnoo 23 thrO<q\ 29 01 ono ...1uM b.r...
going to II. nllll ...1Lmri.
2!EnIlf........~ HMI. ',omliMliol proviou,colUlllll, "",."" "" 2!
24Add 11ne022 and 2J ...................... .............. 24
25Add lI1lOunU 01\ linII 27 Md 2801111I p'IViou. column .. .. .. .. .. .., 25
HSublrlet lin. 25 from line 24, 11"'0 011.... .nl.r ,0..
F 01 colllM (.) only, .nl.. II. omol6\l from lin. 22 """ 26
'ZIlr lIle BmDlI\t on line 2611 Zlro, aubtTac:llin. 24 from
Iin.25,O".........nl...O, ............................ 'r1
162
162
162
O.
!lJ~;'.'~.!..b,'..
$'(:'f I"",,;r\;
,it!'~~;.~'Pj'
. It', -~,~,":\,.......{ft.'t,
~m.~~.t'--'*':i'~~ll~d.
o
00
!}. ,', ;;"--~~" ,
0,
162.
600,
324,
114
114
o.
O.
162,
276
JWh~lift,;~i!~'~};;.
2BUndtrpaym.nL It line 211.lqu.1 to or morelhlln lin.
26, IUbtlacllin. 26 from line 21. Then go to Ilno 23 of
n.xl collIM, OIh.twI.., go 10 line 29 .... .... ...... , ... 28
29O'11rp.""onL II line.26 I. llIOl1lh1n Ii.. 21, IUbU,,1 lin.21,.om
lin'K Thtft 10 hn. 23 ot nut column ...........,............ 2t 114.
Soctlon B - Flguro tho Ponllty (Complet. lin.. 30 thrO<q\ 35 01 one colllM b.rOlo going to II. nexl eok.mn,)
April 16. 1994 - June 30. 1994 ~".L 4/15/94 6/15/94
R.t. Period 1 lloyo' lloyo
See Penalty St.t
162.
162.
49.
!ONumber of daYI 'rom the dale Shown above IIn8 30 to
the dall tn. DITlount on hn. 28 was paid or 6/30/94,
whlchlver Is IDlher ,.................. ,.....,........., 30
31 lkIderpa)'l!1enl N""ber 01
davs on line 30
on liR. 28 x 365 x ,07 . 31 $ $
July1, 1994 - Soptomber30, 1994 r:-,: 6130/94 6/30/94
R.t. P.riod 2 ""', ""',
52Number 01 day. lrom ". dot. shown abovo Ilno 32 10
tho dot. "0 amount on IIno 28 was paid or 9/30194,
Votllchover Is oarlior "."" , """ , " , , , '" , , , " , , , ,,' " 52
Number 01
53 lkIderpo)'l!1.nt dav. on IIna 32
on 111I0 28 x 365 x ,08. 53 $
Octobor 1, 1994 - April 15.1995 ",,' ,9130/94
Ral. P.riod 3 ll.r"
$
$
'. ~~,'-~1~,.!t~-~Sti'<~t
""'j41~"Pili1it
~.':~\'~rt~~}tht
9130/[,4
""',
9130/94
""',
1115195
""",
54tbnber at days 'rom th. dale shO'M'l abovI Ilnl 34 to
tn. date thl Arno".,1 on line 28 was paId or 4/15195,
",,"Ichlver II'AI'lilr .... ... ................. .... ........ at
55 lkId.rpa)'l!1.nt
on hne 2B )C
N.mber ot
dev! on Une 34
365 x ,09. 55$
$
$
$
116P.nllly, Add .11". omol6\ls on lin.. 31, 33,,,and 35 In all...l.."n.,
Entar the 10101 h.,o and on Form 1040 IIn.",,' Form 1040A, line
33' Form I040NR line 66' 0' Form 1041, hne 26 ,........................,....,......,..,
· 116 $
9.
Fa2DJlt 12J1SIM
Plrtl
Int.reet
In com.
fiR
. ...
8:l<l ',....
-..."
"Mmenl hM
Lt":=......
-:::
r:-....,,~
..-..
hlbM.
P.rtll
Dlvld.nd
Incom.
~:II
.r...
OPI.o.v,
.~,,,..
aaWrnenI tom
z.."';t:l'I:
Inn.. MInI"
~:J:'=
~.
=-.."'.
Plrtlll
Foreign
Account.
Ind
Tru.t.
PI 2
v..._...lNt\fo.....
171-46-0121
Schedule B - Interest .nd Dividend Income
08
Notl: If had 0\1'81 $4(X) in taxlbld Jnt.teJI i1com.
musl also C MId PM' III.
1 Li,1 nalll. 01 p.ye" " OIly Int""II, tom I 101I"'Iinanc.d monglgo one! thl buy.r UIOd
the property u . ptt&onal ,.Ildene., M' th. 6Ntruc:tlona and hit thl. Antarl.1 tw.t. AIIO
Ihow lilt' buylr"lOClal MC\I'IIy runb., IInd Ida.U....... to............, to............". ..
Amount
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
~~~jDt~~~tjnto~2)j~~~2~v::::::::::::::::::::::
2 Add thl II11DlWlls on line 1..........................................,........................ 2
I Excludebl.lnt."st on s..,.' EE U,S. liVingS bonds I.....d lnor 1989 ~om form 88IS,
IIna 14, YoumuI' lnocl1 form 88IS 10 Form 1040............,......,..,....,...."""......, I
4 Subtract lina3 trom Iina2. Enter the result her. and on Form 1040 line Sa .................... .
NOI.: 11 had 0"'" II'J oss diVidends and/or othlf distflbullMS on stock must also c '-'a PMt 1/1,
S list nom. 01 plYlr. Includ. gross d,vld.nds ondIor oth.r dlsbilluUons on Itock h..., Any Amount
copilol glin dllU,buUons ond nonwebll dllblbuUons WIll b. doductld on linll , one! 8 ,,"',' ~
I 363.00
I 363 00
I 363 00
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
S
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
---------------------------------------------
, Addthlll11DlWllsonlinlS ',.."..................,....""..............,..............",.. ,
7 Cllpllol g.1n dI.blbuUDna, Enter h... ond on ScI1lclJll 0- "',"'" 7
8 Nonlwll~ dil~ibulion. (S. inI~ucl... lor fDlm 1040, lillll) ,',',' , , , " , " " 8
8 Add Ilnel' ond 8" ........, ......,........,..,.. ......:...."........ ...., ....,..,.... ...... .
10 Sullb.ctllne 9 tom line 6, Ent.r th....ull h....nd on form 1040, lina 9 ..,................ ~ 10
-If you do not need Scht:dule D to 18PDft any other gains or Iou.s. .nter your c~'tat QIIIn
d;.U'DuIIOl1J on Form 1040. 111I. 13. ~II. 'CGD' on III. dolled 111I. next 10 IlIle 13,
"you h.d OVlr $400 01 Inll,est or dlvldlnds 01 hid . lorllgn .ccounl or W.'I I grontor 01, or . Uonsll'or to, .
I...lgn trust, you must compl.t. bols pllrt,
,
..,.o..:'i
If,~~'
Yn No
111 At OIly Um. cUing 1994, did you have on Int.'.'1 in or I Ilgnlll.r. or oth.r .utho,ily ov.r I finonci.1
DccCUllln I 'orelgn COlSllry, such as D bank DecoUll, EfICUIl~eI accounl, or other llI'UIl\Cial ICCO\.f'lt?
SIIlnslrUcUonl for ..c.pUonl ond Illlng "'l"lr.mlnts ,.., form TO f 90,22.1 "','"""".""".,."""",, X
bU'yes,'enterthenamloltht.lo,eigncoLl1try .. -------. ----. -----------------. T.'.' :\:'.'
""', "ft.
12 Were you the grantor 0', or ~ w,1.s.'eror to, III lorelgn l1u:.1 th..1 ,~u1l5Ied dUl'Ing 1994 v.tlelher or nol you hav, ~. ~\ ,
any beneflclallnlerest In II? l!.'\les,' YOU may have 10 Illd Fr.Hn 3520, 3520.A or 926.,.".........,...,......., X
fOlPapo,..,or1< Roductlon Act Nollce, '"" fu,m 1040 Inlll\lcllonl. Schlaul. B (Form 1040) 1994
'DIA04OI 10!19M
0181
.
Jdul. C
. 11140)
r .
i .. P.rtnenhIP"jolnt vlntur.., .1" mU.1 m. F.... 1065.
.e.:::.';;;'::'.:"I~ .. AI1i'h t. Fonn 1040 01 FOI11I 0.11. .. S..lnlltu'~on. I.r S,hodul. C(Fonn 1040~
' HImItf"",,.,..
~ Glenn E oerkosh
A "-..........-,........_,,,_
Weldin
...... '*"t. ,,"'..,............ '*""'. ..... ....
Hauto Weldin 2 -27465 5
r: ~':''=-::::n:;:.:J. .. .!l!Lt~Q.x_.!n.._________ ________ _____________________.
' " Hauto PA 18240
F """,,,ling m.flod: (1)IID Cuh (2)0 A,CNIl (SlO Oflar (","'1)0) .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Q =~~'~~1ory. (1)00 C.lt (2)0 ~::''''I (1)0 ~~:lh (4)0 ~1::.':~'IJ.:H) VII No
H ~f;'.~pta't1t~ ~~t'on ~~~~ ,~~~~,~~', ~,".~: ,0;, ~~~~~,~ ,~~~~,~ ~~~~ ,~,~',~~ ~~~.~:,.".,',.,""""
OId)'OU 'm.tarlllly partlclpal.' In fl. .paraUon ., fill butlntll I16lng 1994111 'No,' H. In&tnJc~ona lor 1lml1ltiDN on I...... )C
" ltarted OI.C: .d thll bu,lnl'l Ol.I'Jn 1994, chock her......,............,...,.., ..,. .......... ......... '" ...... ......,
Inc.m.
Profit or Loss From Business
(Sol. Proprl.lo.-hlp)
"'Ho.'MI~
1.994
09
IecW ....ri~ lI.....C.1Mj
171-46-0121
B a.w___..
1
1 GrOll ""'pll or HII', CauUon: If lIIi. Incom. was "potl.d '0 YOU.OII FOIm W.2111d III.
'SlIlutory .""lDyII' """ on lIIallblm... ch.cI<.d. ...11I. "'~ucll""lIId ChIC' h.l. "".",." "'lJ 1
2 R.Unt Ind 1l10WWlC..""".., ........"......",...", ........ ........"'...."",....,,, ...... ........ 2
I SLb~lCt UI1I2 ~om 1111I1 """."""""", "" ",., ",',',' '",.""""", "',' " ",." "",'" ",.", I
4 COlt 01 good".,d (~om Un. 4D onp.g. 2) ......,....,.. ........,.... ,..,............ .............. ......' 4
I aro..pront, SLbhct 1111I4 ~om 11n. 3"""""""", """"""""""""""""""" """""'" I
· Oll1arlncom., including I.darailnd 11.,. g...Un. Dr ru.'1Ix cr.clJl or rofl.nd.. ..,...... ..... ... .... ........, ,
7 aro..lncom., Add 11n.1 5 1Ild6"""".",.".".""" ,,"',' "," ",' .""" .""."""".",."",.. 7
Ex .n.... Enter III emits lor bUllou, use of OUl home onIon Ijne 30.
· Adv.r1Jllng ..,................, 8 2 500, 18 P.".lonlllldprol",lhlllngplllll........,
· S.d d.bll ~om III.. ZO R.nt or I....:
Otllrvlcll.................... It IVlhicl.l,machinlf)'.andeqlltpmtnl.............
10 ClIlIldtruduxp."... ........ 10 2 383. bOll1arbulln.llprOp.rty .................
11 Commllllons Ind ,... ........, 11 498, 21 R.p.'rs IlIld m.lnl.nllllC. .. .. .. .. . .. .. .. ,
12 O.pl.tion......,..,........:.., 12 22 S~pll.. (nollnclud.d In PII1I11) ........
25 rlX.'lnd U.."...".""""""",.",
'1 OeprlcleUon and I.ctlon 24 TrevII, mllll, end .nt.rt.IMl.nl:'c'...
179 ,xpens. deduction
(not InClU<l.d InPIIt III) ......., IS 6 898. .r..v.,.................................. 24.
14 Employ.. b.n,',t p,ofllll' b M."I IlIld
(oll1.r flllIl on lin. 19 ........, 14 .nl.rlalrvn.nt .. .... .. ..
15 klIUlI/l,"(.lIorlhMlhullll) .."...., 15 3 803, C["lfSOll.lli..2Ib
16 Int.resl: ;.,~,. IlIbjeclllJllmltlllilJns ....".
aMortl'QlCP'idlobonk~.~) ......., 160 dSLb~lClhn.24cllomlln.24b....,...... 24d
bOll1or ......................... 1Gb 2S Util,ti.. ................................. 25
17 LtO.hnd pI,'all...I........ ......, 17 26 W.g.Q'....mplol'l11.nl cr.dlts) ........ 26
18 OII"..x .n51 ................ 18 600, Z1 01"" tnltl Iromhnel6.. 2 .......... Z1
28 T.t.laxp.n... b"Dt. exp.ns.. for bU'", . " "". 01 home, Add hna. 8 1I1,0ugh 27 In collmnl """",,'., ~ 28
21 T.nlltiv. ptom 0011), SUb~lClllna 2S 110.. l,n.7 ................ ......;,.. ...... ........ ..,.............., 29
SO Exp.ns..,ot bUlln.1I U5I olyoLr homo ' 11"", ro... 8829 ...... .............. .......... ...... ............ SO
51 N.I ptolll OIOO"~ SLb~1C1 lin. 3D ~om,..o 29,
· II. ptom, .nler on Fo... 1040,lIn.12, ..,~ .100 on Sch.dul. SF:, IIn. 2 ,.lai>Jlory }
.mployo.., ... InlI"UcU....), Flllu'lOrll unl.r Gn Form 1G41, IIn. 3 """"""""""""""
· II "011, you mUlt go on to lina 32.. .................................... ,..,.... .......... _
SZ II you h.v. "011, c:h.ck 111. box fI., de. ,,,".. ,.ULr Invaltmanlln II1l1lCt'Vll)o,
· It you Checked 321, enter Chi 1011 on fu.-m 1040, IInl12 and .110 on Sch.dul. SE, Un. 2 (statutory }
employee" 'OIlnltrucbons). Fiducll/'IU, t.:nler on Form 1b41, I.n. 3 '"'' ............................
· It you Ch.ck.d 321>, you mUI' ."aell fOlIO 6198 '"..",.",'.,... """"".""""""".."."
D181 F.r P'p.IWOrl< R.ducUonAct Noll.., III fo... 1040 Inolrucllonl.
'DiZD112 10121"..
100
3 000
2 100
8 026
4 074
54 074.
,''--c' .~".'
1~
o
:'~J)\~
1 978
2 366,
17 498.
40 324.
13 750.
51
13 750.
NII'VOlImanI iI
SZ.O ."isl.
Som,'nvlllmonl
SZbO II ..,., lilt
S'hallYl. C (fDtm 1040) 1994
--'-
>--
, .dul. SE
'l"' 1040)
. .
_'.....T....... )
. ~Rewnwe""'"
..... ~ WI'" ..........,...t~ (M""" on'''"' 10&0)
lenn E Oerkosh
Who MUll FlI. Sch.dul. SE
Self.Employment rlX
atr.8....I.. .0014
· '"Inlltucllonl 10' 'chldull 'E (Form 1040~
. Atllch 10 Fo"" 1040.
1,994
17
Soclll J'C\I'IIv runblr 01 plrlon
W1111111l..mp[oym.nllncom.. 171.46.0121
You mual ftle ScI1lc1J1. SE I~
· SVou hid nol.arn[nQ~ tom 1I11'"mplo)'l11anl tom oll1lr 111," cI1..ch .mploy.. Incoml ~1nI4 0' Short ScI1.c1JI. SE 01 .... 4c 0' Long
chi....,. SE) 0' ~ 01 mOIl, ...
· You hid c:lucl1.mploYOI Incom. 01 $IOS,2S 01 m...., Incom. tom ..""COO ~ porlormld .. . mlnlal., 01 . momblr 0' . rlllglOUl
OIdot II not cI1..cI1 omployo. Incoml,
Nolll EVIIIIf you hI... /011 or .1tnIt1/ emounl 0' inc",,", tom .."..""laym.nl, II tIlIy bo 10 YOU' bonIn/lo nil SdIIduIl SE Itld Ill.
""',, 'opl_, mothod' In""" /I oILong Schldull SE,
Exc.pUonlUyou- only 1III,.mplo}fl\onl.lCom. WIll tom ."nlnoa .. . mlnlller, m.mbor 0' . rollgloua order, or Clvlltion 9cl.nco
","ctilloner, And you 1,1.d Form 4J611tld IIc,'v.d IRS IIlprov.' nol to b. w.d on 111011 .arningl, do nol ",. Sch.o..t. SE. Inol.ld,
"'Ill 'Exlmpl-form 4361' on Form 1040, line 47,
M.y I u.. Short Schedule SE or MUST I u.. Long Schedule SE'
Old ou IIc.lv. wlgn or IIpaln 19947
No
v"
Arl ~ . minister, member of . rellgloul orde, , Dr
ChriaUII'1 SCI.nee practitioner who ,eclivld IRS bpproyal
not to bl taxed on .amlng. from thesl IDIXCU, but YOLJ
oW. ,,1f'lm 10 ent tax on other earnings?
No
V.I
Wu tn. total of ycMI wages and tips Il.tljlct to IOclll
IeCUtlfy or railload raliremenl tax pl~'_ yoLW net laming.
trom ..It.employment motl thlll1 $60,6001
No
No
h. ~ using on. 0' 111. optional mlll10ds 10 llgurl yo..
nolumlngs?
Old you reclivl tipllUbject 10 IOclal &easily or Medlcar,
w 11101 ~ did nol /lport 10 you- .mployer?
Old you roc.l.. cI1..ch .mploy.. Incoml /lport.d on
form W'2 0' $IOS,2S or m....7
No
You m.y UII Short Sch.dul. 5E below
You must UII Lono Sch.dul. SE
Section A - Short Sch.dule SE, C.ullon, ReId lbo... '0.11 /' you <In UII Short Schldulo SE.
1 N.llarm "'0111 or VOSl) tom ScI1.ClJI. F, 111\. 36, and lorm pllr1nershlps, ScI1'ClJI. K.l (F...m 1065),
Iln.l51 .........."....,........,..,.............."..,..........,..,....,..........""......,.......... 1
2 N.I prolll or OOSl) tom SchIClJI. C, line 31; Sch.dul. C,EZ. 11n. 3; and Schodul. ",1 (Form 1065),
line 15. (other than 181mino). Minlst~rl and ,"omb.rl Of religioUl OfCSerl M' lnIb'ucliona for amCK.l\ts
to r.port on 0111 line. S.. lnitructlons for oUter 1I'lC0000e to report ,....,...."...,..",.,....,.."....."..... 2
, Comblno IIn.. lltld 2 ..""..,.."......,'...."...."..,.. ....,..""..".." ......"",....',......,..,
4 N.lnmlng. 'nlm IIU.employm.n\. Mulliply I,n. 3 by 92,35110 (,9235), U I'SlII1'" $400, do nollllo
II1ls 1C/10dul.; you do nol ow. 1OII,omploylll.nIIIX..""",..,.."" ........,...... .................."".. 4
, S.U..mploymlnllu. U 111. emoLllI on IIn. 4 I.:
. $00,600 or I..., multiply Ilno 4 by 15,3% (,153), Enler 1110 rOSlll1 hlro and on form 104O,lIno47.
. Moro Ill", $60,60<2, multiply I,n. 4 by 2,91. (,0::'9), ThIn, Idd $7,514.40 10 Ill. rlSllI\. Enter 111.
10111 hero ond on '0"" 1040, IIn. 47.
,
J
5
, Oeducllon tor one.h.U of IIU.employm.nt I.', Mulllply line 5 by 50% (,5),
Enler 1110 /lSIlII hero end on Form 1040 IIn<1S ............,..,............,.., 6
DI81 For P'PlrwOr1< R.ducllon Act Nollce, a.. Fo,OI 1040 InalrucUons.
972,
Schedule SE (f...m 1040)1994
"""1101 1011.....
13 750
13 750
12 698.
VII
I 943.
Earned Income Credit
(Qualifying Child In'onnatlon)
. AIIach to ronn 1040A OIlll4O.
~"'.I''''''''.
19.94
43
.... T-.y
"*"'-'................
~ w-n M '"'"'
Glenn E Derkosh
B.lore You B.gln".
· m_ II. .....1lonI1n II. 1040A 0( 1040 Inolruc:tiona III ... " ~ con loko 1111 cr.lllL
. "~con Ilk. II. cr.lll~ ftllln '" "","""lit In II. 1040A 0I11l4O InolN:tiona to ftlJU" you' cr.diL
But II ~ wonl II. IRS to ftlJU" 1\ I., )OU, ... II. 1040A 011040 InolN:tiona.
ThIn, compl.te II1d .ltoch ScI1Ic1JI. EIC onI)' II ~ Ii..... . quollf)ing dllld,
............Ie&~M.......,
171-46-0121
Inlonn.Uon About Your Qualifying Chlld or Chlldren
II ~ h..... mOl. '"n \WO qulll/)'lng dlll...n, ~ onI)' hive III lI.t \WO to got 111. maximun cr.diL
CllutJon'''YOU don1 "" ...,1 1111 /ina tII.lopply, "Will /Ill. u,
/ongoIlo ptoc... your ilIum 11II1 1IIlI. your 111.Jnd,
(.) ChIld 1
(II) ChIld 2
1 Child'. nom.
(llr.t.lnitill.II1dI..lnom.)........,.........................., Matthew Glenn Derkosh
2 Chlld'ly.ll'olblrll1....,..,..............,....,....,..........,
1t "
1t
I II dllld woo bom 1>o,...1t75 ItId -
. woo . .tudonl undong. 24 .t 111. .nd 0'1994, Chock
thl 'V.I' box. or........ to.,..,.,............................,.
bw.. ~.nnon.ntiy ItId tolllly dlllbl.d, dlock 111.
'VII box ....,.. .........., ...... ......;, ..........",.. ....,..
YII
YII
YII
YOI
4 II dllld wu bom 1>o,...,tN, .nllr 111. dlilcr. IOcl.1
..CU'llynunbor ............,'....'....'..""".. ..............
I Child'. rol.tionshlp to ~ ('0( uompio, IOn,
Wondcl1lld. .Ic)........,........, ........",....,,'.. ......,.., Son
5 l'Unber 0' manll1l dllld IIv.d will1 ~ In 111. U,S.
In 1994 ,.......,..,..,....,.............. ...."...., ".."..,,, 12
month.
month..
~V. ..I.~.\f Do ~ WIlI1II11. .amod Incom. crod,t I,ldod I' YOU' lIko,hom. PlY In 19951 To... "you ","Illy, gll Fonn W.' ~om)'OU'
r: omployor 0( by coiling 111. IRS .t 1,800.TAX,FORM (1.800,8<9,3676),
,. '.penrortc ReductJon Act NOUCI,... Form 1040A or 1040 Inll.nN:tlonL
SChodul. EIC (FO(m 1040A 0( 1040)1994
fDA1401 10I20IM
..
1 01" T......L
__1Wl
~l) It-.n In Nun
Glenn E Oerkosh
.........~ IiIllftcft........,....
Sch C Weldin.!
..'0."" El.ctlon to Expene. C.rtaln T .'lulble Property (Seclion 179)
1N011llll'OU h... wlY llst.d PrOPO,/Y, 0 '0 101. PMI V />oillt. 101. PwI/
1 Mamun dollll Ilmllollon, (II III onlerprl.. zone busIN.., ... InIINc~ono,) """""""""""".""", 1
2 T.... COlt 01 uctlon 17i proplrl)/ pl.ud In uNleolUlng 1111 lax YI" ..................,..............,.... 2
I Tlvolh.,d ....t., ..e~on 17i pr.p'rly />01"'" 'oc1Je~on In Ilmlla~on......"",......""..........,....".., I
4 RoQJcllon In Ilmlll~on, SW~1C111no Sfrom IIno 2, II Zlr. '" II", Inllr ,0. .................................. 4
I ~1I:~IZ1'Ia:: ~~~: ~~~~I ~~~, ~,~, ~'~~, ,I:,I!,~~~~ ,~,I~~: ~.~l~,', ~':. (II,~,~~~~~,':I~........"", 8
. OIICfI tion of 0 e COlt c Elect.d COlt
Depreciation and Amortization
{lndudlnlllnfonnltlon on Uet.d Proper1y)
I Atllch lNo form ,. YOUl ..Iurn.
_....11110172
1994
67
.....f)U.IIl......
171-46-0121
1
500
200 000
.
_, "~", ;.",.t
<~.:-.
,,~:~...~i:){~:~ ~...~~t.'5'}
i.,:.:";. :"',;;..~:~!;. ;:,~J.':~,-i ,~. ,
7 Llllod properly, Enter """",tfrom linl 26 '0"""""" 0""""""""""""", 7
. Totaloleelod COil 01 ..e~on 179proplrly, Add omo....1I1n eollnln (c), IIIlOI 6 end 7, 0' """""",,'.', '0" .
. Tlnllti'lll decIJc~on. Enlor ll10 omlller 01 lino 5 '" lino 8......" ......'..,.... ..., ....." ........' .......... .
10 ClIT)'Ilvor 01 dlullowed docIJc~on from 1993 ........................................................'.....' 10
11 T bobll Ineomo IImllltion, Enllr ll1e omall.r 0' lalcobll Incoml (nolle.. 1l1." u,o) '" IIno 5 , , , , , , , , . , , , , , , , , , 11
12 Sletion 179 "PI"" decIJc~on. Add linol 9 end 10, but do not onll, m"," ll1an IIno 11 ............,........, 12
U CII vo, 01 di,"lIowod doc1Je~on 10 1995, Add lino. 9 and 10 ,"..tIllO 12 ......,.... U < ,".., ,...
NolII 00 nol UII Pori II '" PWI /1/ />Ilow IoI/"tod ploper/y (.ulomobi/es, '0"'111 o/ho, vohir'"I. ../"''''' lolophonol, u,loin ''''''''''0'', 01
ploporly u..cI 101 onllf/lllMllnl. '''''''IOIl. 01 omulomonl). I""..d. UII PII' V for I"'"d ploplf/y,
IiiilI:3 MACRS D.preclatlon for Allels Placed In Sorvlce Only During Your 1994 Till V..r
o N.Iln<lud. L1llod p,o 0
(I) (b) ...........
a..lIcetionof~ ,..,""'Id
"WNlCe
:;~1l.; 'jJ:,~\,,,#..A:, '~k.,
tfh'
,.. 3. ear o.
b5. ear 0 e
c 7. ear o.
d 10- ear ro I
. 15. at' ro I
'20.,81' oe
II Rllldential ren/lll ........
properly ................'
h Nontllldenbll rial ......,
proporly .."............'
Ie) B................. (d)
(t.,iWntMlww..tmenl u" Aecowef)' '**'
.....n.IlUc.".
Section A - Gen.ral D. recllllon 5 .I.m GDS
(g) 000""''''
.......
MM
MM
MM
MM
S.ellon B - AU.matlve D. rlclaUon 5 al.m ADS
27.5
27,5
39
rs
rs
rs
S/L
S/L
S/L
S/L
S/L
S/L
S/L
1SoCllulll. ................
bl2, 0" ....,............,
c~. '81' ......,...,.......
12 rs
,40 rs
MM
IiifIlI::J Other Deprecletlon (Do N.tlneludo L111.d Prop.rty)
" GDS and ADS deductions lot allels placed in aervicl '" tax yewl beglming bafore 1994 ..........,....... '6
17 Properly IlJIlJICIIo I.e~on 168(Q(I) o'oet,on """"""""""".""""""""""""", 0""""" 17
18 ACRS and othor do loellt'on........,.., .... ,............ "......,,,,..,..,,..,..,.. ....,...... 18
"'-ifW::J Summery
11 Llltod proporly, Entor omo....1 ~om IIno 25 ,....,.... .............. ........' ......,.... .................., 11 1 ISO
ZO Tol.I, Add deduction. on IIno 12, IIn.. 14 or,c 15 In column (g~ and lin.. 16th,ough 19, Enlor horo
IItld on fu, lJI;PfCJptlblo IlfIo:; 01 yw 1&",:.Ir" r"IiII1,cf:.lII&J:' bill " '/"'~rAlJ~~/) .' U:O' l/ '.f!IJ'.'J',!...!) 20 !_.._.......""fJo...,~~,~.~.~.
748
21 For assell U\O'M'l above and placed in St!r~ll l!iJflng the ct.l'renl year, enter
Ihlt portion Dr Ine basil attllbulBble to Sl'etl"l :''103A costs.."" , , ",."",...
0181 For P'p.lWor1< R.duetlon ACI Notice, ...In,INellonl,
fOlllll12 12.06094
21
'';)
.,.....
. ",~,,;,,' "~.:') . ..
: ;_~:~_ ,t;';ir,' J/i....' "
Form 4562 (1994)
d'if .
,
"
, .i5a (f!l94\ Glenn E Oerkosh 171-46-0121 P_Z
. '.. . .1(..of Ultld Propertd; - Automobll... Certal!, OtherYlhlclll, Cellular Telephon... Certlln Computl,..
:" .
Ind Property led for Entlrtllnmlnt, Recrullon, or Amullment '
. . FOIII1.Y vohle" lilt lttIldI ~ w. u./nf1th. .tandald mlll.r. ",. ., dlduc/ing "... _'. COtfVl"" onlt 22JJ 22b
.0olilMl (.) th,ough (.) 0 S'C/IOII A. .11 of S"/IOII 8, and .c/lOll C If _,,.abl., ' ,
Section A - D'DreclaUon and Oth.r In'ormatlon 'Caution: s..1n5r,uctions lot 1""11"10111 for .utomobIMS. l
22.00-..............._......."""'""""'.......,............,,""""'" ,IXI VH I I H.I22b H'V..'u lIw..id_..illon' !Xl VH I I No
. (.) (b) (c) (d) (.) (I) (g) (h) (I)
T...~"", o."'11~ ........, .... . ~..~., ~ ........ D.- ..:b.1ien .":'ll.
--
..- ... ... ..... ~..''''*'l -... --... __I
......" -
ZJ Prnn.rtu used mort thin 50~ in. l'lL.titlld bulln... uu:
1185 .hr-.I.. 01101/11 100,0'
. Z4 P,on.... ....d 50% ot I... In . aua"'oed bu.in... us.,
war. t.ud 07/0111 50,0 21 000, I' SOD, 5,0 5L/HV . ,150, ~i' ~"'j,\?;
.'A;'<,:ijl~;-:'.
~.J1"~":
25 Add omOUllllln e.l"",n (11), Enl., th. total he" and on "no 19, page I ..........................,.. ,I 25 I 150, " ,11
~~:r ,",:;~;t
. '. .....,"
21 Add om."'llIln .ol"",n i>>: Enl., th. I.'al he,. and on IIn. 7, Dao. I ...... ..........,........ .........., ........ ....,121
. SKIIDn B -Inl.rm.llon On U.. Df V.hlcl.e - "you d.ducl'xpIfIJ..1Ilt VOhlc/."
. ,.,.,.,.. cetI'lpM........... fw'lMlc...... ~... ,,.,ntlol, ,..... lit... 'mati itIM ''Il ."..".......'-11,.,..,.
. tr...,,,.,... \t'ItlidM .. ~......., ""'1 tMMf hi......,. kt ...., c.. ... II)'CIU meel tit ..,.,lion to~.,. .. MClion ,.,...~.
(.) (b) (c) (d) (.) (I)
'Z1 T.W bu.I..../lnvostm.,1 mil.. driven during V.hlcl. I Vehlele 2 V.hlcl. S V.hlcl. 4 Vehlele 5 V.hlcl. 6
1Iw)Uf (Do IIOllnelud. commuling mil..)""""", 8 450 14 150,
. 21 T.W commuling ml'" d,m during 1Iw)Uf " , '" '"
21 T.ta1 .th., p.'1DI'I01 (noncommuUng)
mll.e alvon........,................" ,....
III T.ta1 mil.. alv.n c1Jrlng th. y...., Add
11na127 lIvoug, 29 ............,..........., 8 450. 14 150.
VOl Ho V.I Ho YH H. V'I Ho VH N. V.. H.
. S1 W.. tha vahld. availabl. 101 personal UII
c1Jrong .n,OJ1)/ nw.' ..':.................. X X
3Z Was the vehicle used ~rlmlVilY b~ I more
than 5% owner Of' rlla Id perlon . . . . . . . . . . X X
J3 II anoth., v.hlcla Ivallabl. lot
;,-.rs.nal us.1 ""',',',',',""""""',', X X
S.ctJ.n C - Qu..U.nIIDr Empl.y." Wh. PrDvld. V.hlel..l.r UI. by Th.l, EmpIDY'"
. An5....r th." qu.sllons 'D d,'"m/n. if you m.,'an ....pll.n I. .ompl.llng S.cllon 8, H.lo: S.cIIOII 8 musl.lways be .omplolld lilt
..hlc/.. uS.d by SOl. proprl.'ors, p111n'fI, or othe, mOle than 5" o"""s or """.d p"sons,
VH H.
54 O. you maintain a \oflllan p.licy 11I1.m.nlthal prDhIbI15 all p"sonl' use 01 vehicles, Including eommullng, by
you' empl.y.es? """""""" , " , , , '" ,",' , , " '" , ", , ,,', , , , "'" """" , , , "'" '" "" , ,','," , """""""" ,
. " 00 you maintain I written POll'la statement that ~Ohlblts perlonal use of vehicles, except commuting, by)'Ol.l'
employeel? (SlIIlnatruclions or vehIcles used y corporate Onlcera, dIrectors, or 1'" or more owl'lo,..) .. 0 0 0000.000.. 0" 0 .
aG 00 you treat all UIe of vehicle. by employe.. as perianal use? ".. I.,' 0" 0 0 0"" 0 0.0.... 0 0 0'" 0 0..000. 0..00.....'., 0.00..
1/1 00 you provide more than fl.... v.hicles 10 YO\X employeea and r.tain th. information r"elved from yoll employe..
concernmg the us. of the vehIcle.? ... 0.0.. ... . .. . . .. 0 . o. . . 0 0.... . ...... ........ . o. 0..0... .. 0 . .... . . . . .. . 000..0........ .
!II O. you m..lth. r.qulr.ments conc.rning qualtfl.d IUtomobll. d.mD"'traU.n us.7 """"""""""""""""""'" E
H.to: If your ans...."o 34,35.36, 37, 0138 is 'Y.., , you n.ed nol.ompl.,. S.cIlOll 8 fat Ih. eovo"d vohlel.., ."" 1,f'r'..,1
. ;:,1 AmortlzlUon
(.) (b) (c) (d) (.) (I)
o..cn,l;on of call o.M'~"" """"",.bIo -- AtMtV._ ...........
....... ..-., ....... ...... ..........
...........
39 Amortiution of costs thet benlns durillM \lour 1994 tal( year: IT "'''1
I I
I I
. 40 Amortization of costs that beaan before 1994 ............... .. ...... ......140
...... ...................... .....
41 Total. Enler here and on 'Other Oeducbons' or 'Oltler Expenses' hne of YOLl' return.. . . . . . ...... ........ ..,141
flXlDI12 ,........
"
I
. . /. Comrnonw.allh 01 Pannlylvanl. -....
. j4 RlSldent Indlvldulllncome Tax Return. ,
__ 0 FI""'V....FU" e.glmlng 1994 · I . 1--'" OceupaUonl ,
.- End"n 11195 '~~ S x_ ,..aca.,..
. yew....... ..."-...... .,...... hdll....~ ......... 15~1 f ~mo loved
It'ren d ,.. .......bfr) J ......,......~trn.n
M .......,....._.... .....,-...
171-46-0121 T __"'._
Lool_ '...HMw,InI.... .,.. .....'. , ~......,.....
Derk05h Glenn E 0..........
--- ~~dtncy SltlulI (Ch.cI< only II. ptr1'yo... IflldtnQ
289 W. 10th Street , C::l;t.,'f... .... .. ,.
~..... orac- I.. l1fI eo. _oIAdd,." L.bol~Uon
Jim Thorne PA 18229 --Ff DwcU....lIf~ .,::::r.t1....-.w
willi III ~. MINI""'", I'IIlt:::',
U Chtd< he.. II Ihl. I. a cIwlngo .11d<Wu ,_ .,.....'-.- -....
loll y..... ..WIn.
____........_JI,....) . ,......... IOC-'~
Jill Thorne Area 13S00 IAOt ,
.
. 11 Gr...eomp.nsaUon ........,...................... 101 PlwIult)OU,..",,1 ....tI,..".w.a."",_
i 1 b u...lmt"nod employe buslno.. oxpo",o. , , , , , , , , , , lbl _I dIlU., cadt """~~~"'-
1 c NIl Pomaylvonil "'lblo componsaUon ......,..,..,..",..........",.... Ie "',..~.IA...._
c 2 Toxlbl.lnto,..' """""""""".'"""""",.""",.""""""" 2 I 363, "',..~.).,"'-
.0
c' 3 Toxlbla'llvldands "",'.'"""""""""""""""""",.""""" 3 "",,~~c""_
~o 4 Nlllncoma or ~o..) from tIla oparaUon of a bu.lna.., pt'ofa,,'on or form '" 4 13 750. "'...~.)A(.I,_
c. S NIl gain or ~ou) from tIla solo, axchongo or llilpo.IUon Dr ""ono"" ".."" 5 No...~~,...._
.~ SI Am...,1 of .xcluslon from Ilno 20 of PA ScholkJlo Anach III """~"'C'''_
:2 PA.19 (00 nollncludoln IIno 5Ibovo),........,...., 51 required doa..m.ntl No,..~~o",,_
II . NlIIncom. or ~o..) from ronts, royoIUo., patonts Ind cOPl'l'lghts '" " """ S No............{...O,'I,,_
.
i 7 E.tata Ind lrusllncomo ....,.."......................................,..' 7 "',..~...It..,_
. Gembllng Ind 10Uory wImIngo.......................,..............",.... 8 Ho."'~(l)I...._
. I T.hIPATIllIIt IlIClm', 1T,lJllinu I. ~ 3. 4. ~ 0 IIId. - O...U.duct I~...'" .., . 15 113 ,....IchelIUe(~J".._
I 10 TllCLI.bljjiVt.\uiij;;j;;llno 9 bV2,B%1.0281 ,.. ....,.,....' ......,....",.... 10 423,
11 Total Ponnsytvonio incomo ..... WIlnhold....;..,......... , , , ...... ........ 11
12 E.Umllocl P.ym.nll and CtocUt.
12. er.llit from 1993 Pomsyt....a ,aUn """"""." 120 Thl' IIUn must b.
, tiled on 01' betor.
0 12b 1994lnstallmont paymonts,....,......"..,........, 12b April 17, 1995
II 12c Paymant wltIll994l1que.t 'or axlo",lon " """"" 12e
! 12d Total plymonts Ind crodlts"""""""."""""""""""""""", 12d
13 TllC IDIlllv'_1 ,_ PIM,ylvanl. Schodul. SP
& lh O.pandants clalmod from IIno I, Pori III 01 S.. InsIrucUons
c Pamaytvonll Schadulo SP ......................... lh forllporting
r a.Umllod We
13b ElIglbl~ Incomo from Ilno 3, Pari IV of crodlt and
P.ma vanlo Sch.dulo SP """"",.'"".""", l3b clolmlng ...
13c Federal Adjusted GroD Income from line 2. Part III fOlglv.n.u
of Pomaytvonlo Schodulo SP""""""""",.", l3e
1301 Tox Forgivono.. ~om IIno B, Pari IV of Pom.ylvonla Schedulo SP , ,,',"',' 1301 No..,.........(.)II' "'_
14 Total cradil tor ..... plld to 01l10r 01.10' Dr c...,bl..""""" , ,'," , , , , '" 14 No...~...o...._
15 Emplo}ln1lnt "Inb"'. payments crULII....,..,...,...,...,.".. ,..,........ 15 """~,,,w""_
1. Tol.1 Plum.ntllnd Crodlt. 1T0Iall,n.. II. 12d, 13d, 14 and 151' ...,......, 1.
Ii 17 TllC DUt S.. 1n.Iruc~ons tor poying yo", tax ciJ., If 10..1I1an $1.00, no p.ymont 1.lIquirod .."....,.... 17 I 423.
18 Ouorplym.nl,....""""....",..".." .............. ......' ......,'.... 18 I I Doublt Olocl Vou, MlIII
C' 110 Amollll olllna 18 to bo R.fund.d ,...... ..........,.., ......"......", ....',,'....,.... ....,......... III
.2 lib Amollll of Ilna 1810 ba Credlt.d to YOLl' 1995 E.Umotod Tox ACCDll1I.........."............,..,......, lib
o' lie Amollll of IIno 18 to bo Donatod 10 .,0 Wild Ro.....ca Con.orvoUon FlIId """""""""".""""" llc
.r 19d AmD\.X1t of line 1810 be Donated to the U.S. OIvrnl'lJe Commlhte PIMsvlvanla Division.............,.... lid
L/nIMr ,.natkl 01 P'?"Yo I"''''' 1'\111 1\I....UIT\ltIM M nYn, nUkng KCDmfanrnll ~ anct ,tal4menll, anct ID '" MIl 01 m1~ Ind MIot'II.. M,
CGtNCIInlI com,le",
'feu...."'. 0.14 a.gAI"" 01,,,,.,.,, .......I\an ""''''. ........., AI nkt 01 lIIhIch "'p,.,.,.,he4l11t....~
SI "-X X
h.~. apcllM" ~VI (I' Ning ~a,. BOlM fn.j,1 ~.-wen if onIr one hid W'I'WIM)
-X
P,.p.ltt. T.~phent No.
Dolo
PA1A0401 OW9JiS
(
/
/'
L. ~I'l. A Comm_..II"oIP......~onIa
. ~ Profit (or Loss) from Business or Profession
. . _ (Sol. Proprf.tor.hlp)
. . I !ti4 Attach to Form PA-lOR, PA..4ONR, PA,6S or PA-41
,.". "'''''''' _1IwM'l.".... PA.Qt, PA<4afi, "Jr.4'. 1'''-41. .........,.......,,.,,....
Derkosh Glenn E 171.46-0121
AMlln buslneu actiVity .. . lVocU:t OIIIMet" W d t nil
BBUSino..NamI. Hauto Weldtn. .. ,__,"-
DEIu&ino.. _... (runIler ond .h.Q llR I ~l!.x JZ.l
CI" SItItend ZIPC.do . Hauto p,,-iii40 -------------------- !]-274S~H
!Malllod(l) ....d to YIlut d.aIng In_tory:
(1) 00 Coal C2) 0 L._.r coal or m_1
,
Ichadul.C
'ADUNmCHilltlll-a
''''''''''tlng mlthod: (1) 00 Cull
C2) 0 A.CNOl
fflO
fflO
Other ~t .11", .ttach 'Iljlllnlbon)
c
Othor (","cl~ .
YII
No
OW.. ,,,ft 0Irf chongo In doltnnlnlng quanbb.., COlli or YIlutbON be.....on oponing ond cI<lalng Invonloty? ""","'" ,.,'.. le..
ft "'",' Ittach Ixplanation. IIIIi "" ...._
~~~:~"~;:~~~,~.~~~,~\~,i:;:,h~~,~;.:,: :;:;,;;;,' :;;.::: ',";,~~..;::;.',;;:;:, ~:~:\;;~;:;'" :;:;;;,:;.:~;.;;:,': '.:" . ,\" i.,
1 G Is' ,.1 65 100 '.....'1;;1"...,'..., .'. ''AI,''
. (011 "CIIP or sau..........,. .............. ...,....................,..... . ;'\';'r~~~ii;!:;;~-;')' \.,"l,;...., ~~
IIR lb" . 000 .f~.::,~l1.;,.t!itI.V;-'!:_.:_ ~-r..-~:;;~t.l
.unaendaJlowanc:.........................................................:l1 .3. {.~~ ,." 'A,.. " "<'. .' .,'
cBtione..(IltlIr..lIlnt Ibfromlin.l.) ..............,...................................................., 1_ 62 100
ZC..I.' goodllOld lIldIor _.bona (Sch.dull C.I, lint S) '......,....,............,.."..,................, Z 8 026
IGr...pr.nl (lltllrOCl lint 2 from llna I.)....................,......",..,....,....,......,........ ,........., I "4074
40th" Incoml (Ittach Ichldulllln.ludo Inltr..1 from "_0<.I11s ro.llvabll, bulinl.. "'"eking lICCO<.I1It ond
011" buIinua lICCO<.I111, Also Incluclo aaJ.. .t operoUonti....II, S.. InItrucbon bookllll ,',""""""',,', 4
sr.,allncom. (add IIna.3 and 4) ..............................................................,....,....... ! 54 074.
, .::J:\";.~~~:.'~:.~',t..tl;,:!., ,_,':..7~ '-~;2;...::~:,,:{:::,,:i~':>,! ,~~~t.:.,--{<} 'J,~ >"H'~:'i;' '. -:~.: ,'~:;~,'.,r,.:'; . '.' ::~~ ;X.t?~:j;~.:~/~(: !J:~, ..',!:~-: .~',:J~ ;
'Adv.",.lng .............................., 2500, 31.W.g............... .i'I~:,.j,.\.;'~J;i~
7AmortiZation ) .,'~,~i/:t't~"tlf:"M\(
. .."""""""""""""" 3111 Empl.y.r 1"..nUva ~ .~Jr~".,;;!',;,~ffJ!f.
aBad dabls from aa'.. or ..rvl... .......... P.ym.nl Cnd" ....
IBn chargl.........,..,............,.... 51c B.lone. (dlra.t lint 31b from
10Carend lruc:k'lljllnaa. ..............,.... 2 383. lint3la) ,..,....................,..,....,
llCommlulona ,............................ 498
lZ0.pllbon ""."""'."""""""....,,
UOapr.dlbon (11ljl1oln In Sch.dull c.2) ","
140ua. ond P<bllcabona ."""""""", ,.,
15~~~l,~~~~ ,~,~~,,,::,,~ ~,~~~, ~~""'"
lIFrel\1l1 (nollnclucled on Schadul. C.l) , , , , ,
1711lSU'one."""""""""""""""" ,
lalnle,a.' on bulinl.. Incllbllclnl.. """".
llLlllr4'yend .llanlng ""'" "',' "",',"
2llL.gal end pr."u1onti aarvt... "" , ,.'" , .
ZlOttl.1 "'4'PIII' ....,,'.. ...... ......, ......
22P.nalon ond pr.m''''''lng pions
"" .mpl.y........................."...,'
Z5P..ltgl ...., ....""".........., ....',..
2.4Renl on bualnl" pr.plrty"",""""""
Z5Repalra , "",' ."" '. "" , , "'" """" "
2&Supplll. (nollncluclld on S"'"dul" C,I) ...
27T.... """""""""".""""""",
ZlT","phOl1l ..""......, ..........., ......,
2fTro",,1 and .nltrltm1lnl................., 1 978,
lIOUIIIIU.. ......................,............ 2 366,
UTolal deductlonlladd amolM"lts In colLnlns ror Ijne~ 6 thrOunh32s\...........,........,..".........."....... 53
6 898
S2 Other 'Iljllnaa. (1pI.1~:
I Too Is
II j~t~ti=~~mt========:
c .tI~tdJ.D&_5~epJj~l_____.
d -'.Q'ltJ~~t ~~,-vj ~ltS_ __ __,
6 978
I 800
7 120
I 600
600,
.
I
g ------------------.
h
I
I
k
I
3 803,
1 800.
m
n
o
o
p ------------------,
q
r
I
40 324
S4NII pr.fIt (0' I...) (ll.Cllroclllnl ~ ~.m,lIn. 5), E','cr 101.' h." ond on 111 appr.prlat.lln..f y.... Form PA-4OR,
PA..4ONR 'PA.65 or PA.41. U . net (IOU1 Is shoVtf'l, tinter the lWT1oll'ltln brackets on VOI.J" return .,."....',....."..,
13 750.
PAW>>II 12131....
S"'"dull C (1994)
Glenn E
171-46-01210
/
I
ScII.liJl. C (1994) , P
.z
~(;'.l ~-[ ',....'.". , j!~"~ i'.'~"'" .,..'~,., .. ~.,. ~~, ,
." .. _. .'> . .. -'.
lln""nlOl)lII b.gimng of y.ar (II dJHer.nl Hom 1..1 y....'. clollng IIw.nIOl)l, Iltach 'lljllanation) ,,' , , , , ,,"" , " 1 0
Zo P..cII...................., ............................................, ....,"J z;1 F1:~,
bCo.t.fllom.WiIl1cl'I""lorpatoonaJUIl ..............................,......,1 Zbl t:Il.:
c 811....... (uhct line a. Hom llna 20) ,",","'" """""""""""""""""""""""""""'" Zc
ICo.t of iIl>ot (do not Inc:Iude ulery plld to )'011..,9..""""""""""""""""".."..",."",..,.... I
4Melarlal. and 1l4'P1I1l ..................."...........,................."....,,............................ 4 9,526
10th., co... (.1lar:I11d1.0JI.) ..."....................................................!..................... I
.Add llna. 1, 2c, I, 4 and S .................................................................................. . 9,526
71n_1OI)/11 and.' yaar"""""""."""""",.."""..,."""""""""""""""".",..""", 7 1,500,
'Co.t of ..d. IOld "~it,~~' ,(~tr'CI ,'in. .' H~ IIn.6t~,~'~~, h~r~ ~ ~ P~', Ii~~ 2 , , "';' '.. ' ',: ~... . 8 026.
. c. ~ In-',.,.,.- (!,", l.,""-j. ,>~y,~...,..'''-..'..t.,.... .,f,..,; '~';d" ....\;..,.. ,~,',.,.... _...., ,,,.,,',, >,..-.I'.:,...d.- . lO.-. 'C)., ;~'i.;. ~'j..;~ ~,.'-J,':.;iJ"rhtll
OllQ'lption ., prop.rty Oal. C..t Of O.pr.ciation Melhod 01 LU. Depr.clltion 'Of
a11.wed Of allowlbl. cOtnpllting Of
acqulr.d oll1er bul. In prlOf y.ara depr.clation roll Ihlly....
(.) (b) (c) (eI) (.) (I) (g)
tTola/ _tional Clr.t'y.ar d.",.cl"lon (d. n.1 includ. In lI.m. below) !!::j!
20ther d.pr.cl.ti.n: "".,' .1 '~"llI'!'!~*'I';""" ....,.-.;-'....: "'."" "'l. . ,
BuIlding. ....................
FLmlu. and "xv.. ........
Tranaporlation .quipm.nt ....
Machinery & 01111< .quipm.nl
Other (oplcJIy)_ _ _ _ _ _ _
----------------
----------------
----------------
----------------
----------------
----------------
----------------
----------------
----------------
----------------
1T0tala ...................................... ........................................ I
40.pr.cl.Uon cl.lm.d In ScI1.dul. C,I"""""""""""""""""""""""""""""""""""" 4
~Ianc. (ub-acllin. 4 Hom lin. 3), Enler her. ~d,",n ~.rll~:,'in~ 13.::...: ,..",'....,......""",.. ....... S
eau.. <<.;-.:t -:I!"vr.ense1nfo.', ,-~,-.,:..-,'<,..;~{~;_,- -':h>:: ',. .::h,. '.l::,:r-~
U you incu' any 01 111. 'xpanHo d.scrib.d bel.w, .nler 111. am....' 01111. alljl.nH and d'lQ'ib. Ih. kinds ., co... incu'r.d end
111. busino.. Pl-fP...,
Ex nln
Amount
AEnterlalMl.nl facility (boal. (I&Ort. ranch. lte)
8 LIWlg accommodatioN (IJlC.pt employ.. on buslneu)
Vacatlona 'or YOLnelr, )'OW employ,. or tt1l1r families.
s
s
PAWlI12 IZAlIM
Sclladul. C (1994)
.'
. '
. ~'A~DIS' (9.;4)
. .
.ch.dul. [)
Derkobh, Gtenn E
SII. or Exch.ng. 01 Property
171'~6.D12~
Enter In.xchang.. or other al'~.lo,itlont o' rty,lncludlng r..1 or
. Kind 01 ptop.rty and d..alpUon b MonthlO.ylY.... . Gro.. &Ill..
(Exompl.: 100 11I1..... 01 'l' Companj) (put d.,. IOld ptlell...
abOVI dOtted line ..plNe 01 &all
R dati Icqulred
b.low don.d hn.)
I whether tanglbll or In
dCo.'",
odlusltd bul.
IbI..
. GlIin '" Qo..)
(c I... d)
2 SLCltotal""""""".""""""."""""."""""""""""",.."""""."",.."""""".""."
I G.1n from inll.llmont..I.. from PA Sch.dul. 0.1 V.l68 ".."" ....",..,'..',.....",..""....'....",..
~ Taxabl. ,.tun 0' CIll'tal dII~IbuUona.
Enlor Iotal dl.~lbution ",' S I... ad usl.d b..ls "" S
5 Net aln ",10" from IBI. 016,1.71 0 a altachPASch.dul.D,71 V,I7 ..............................
, Net .In from th. oal. 0'. orlOl1.1 r.ald.ne. .nacl1 PA Sch.dul. PA.IO .. .. .. , .. , .. .. .. , . .. .. .. .. .. .. ...... .. ..
7 Nel ollin (", 10IB), Add colum . and .nl.r Iotal h.r., II. net ollin " 11I10"", .nl.r on hn. ~ 0' PA-IllA ot line 6
01 PA-4OR. If. net ou lslhown enter the amall'll In brackefS, ..... ............................................
PA Sch.dul. SP Work.h"t
Thll worksheet musl bl filed witn VOlI' PA Schedule SP. Complete this WOl1\shell before preparing you' Schedl.Jte SP.
Uldor 111. Clalm.nl Column, .nl.r YOlM taxabl. lneom. and nonlaxabl. incom., Uld.r 111. Spou.. Column, .nlor you' ._'. taxabl.
Incom. and nontaxabl. 1ncIll'n., UICl.r 111. Joint Column, .nt.r 111. total 0' each IIn., " mam.d, you musl compl.'. th. S_ Column
.v.n" ',lino ..p....I.ly ot .v.n" ~lM IllOUS. dOli not qualify lor tax ''''o'v.n..., II m...ri.d and "ling. Joint Claim '''' Tax F"'gi.......
in you must compl.le 111. JolnlColum,
CI.lm.nl
S_
Joint
Iltp 1 Toxobl.lncom.
1 Enler 111. .""l,"t from page I 0' you' PA tax r.ll.m ",. ,I 1
(Line 9 0' PA-4OR ot 11n. S 01 PA-IllA),
lS.1l3.r;-
11
Sltp Z Nonloubl.lncom.
Z Cun paym.nts you r.c.'v. '''' you' support. '" " "" , " Z
I Nontaxabl. Inlerllt, divid.nds and na. go,ns ,." , , "". " I
~ Alimony,....,......................"'."'.."......." 4
5 LIl.lnsl.ronca proceeds and Inh.ritanc.s """".""", 5
, Gills, awardaand ptlz.. ................................ 6
7 Income eamed or received aa I l'\OIYesld.mt 0' PA. . ,. .. . 7
. Nontaxabl.mllilll'ylncom. ......................,...... 8
. lIain u:ludod on PA Sd.tu~ PA,I~ ago SSIIld..er .loclion ........ .
10 Nonlwb~ od....lionalldlolMshlp~ 1.II'WIllips and slipond. ........ 10
11 Olhlr nonlwb~ in<onll !!ll1.lnod und" 'Dol"mlnln; \\lJo1her You
Pr..idod All.aIIl Dna Hall'f Your Own Support' .................. 11
12 Total nontaxabl.incoma, Add lin.. 211110ugh II """'" 12
Sl.p I ElIglblllfy Income
11 Add fino I IIldl", 12. Enlllhlt.lIldonjOlllPA WIIWIn ........../11
(line 130 0' PA-4OR ot ''"'' 90 01 PA-IllA).
Z Z
3 I
4 4
5 5
6 ,
7 7
. .
. .
10 10
11 11
12 12
15,1l3.113 /11
You mu.t compl.'e St.pe 112 and Iln Old., 10 fII. PA Schedul. SP,
P~l OIA>>Jt$
.
. ,11M FR!
.. l'U TO INmlJCT1Otj1
JIH IlfViIllIIlDl
~.
JIM THORPE EARNED INCOME TAX OFFICE
14Q WEST TENTH STREET JIM THORPE, PA Ism
(117)32103081
, ,\'
/
-
J ,
fiNAL INDIVIDUAL EARNED INCOME TAX RETURN
,tW1NDAII YW'
) '.'J1-99'+'
PUASI PILI THII RITURN BY APRIL litH IVIN " NO TAX .1 OUI OR I' IT HAl ALl. BEEN WITHHELD,
, \ ~ '
NAMe ~O ~~~'.' ' ' 1_.... IlCUlIlTVNo. I
'-, '. \"1\."'1".0\"2...\
~U!)>~ '<.. 1:>.:"lI..lI...!>'"
'l..'l:.o.. 1..>>, ,o~~.
j,l'" ""\Vro\\V>2 \ ~"{)o, ,~-z..1.q
"
" .
lUll
..
OUIIITY
'"
.~
"
-'
.Y'OUWO'I'ID
..-0 THI
......
COWI.ITI
THI FOW)W.
INCI,
I'lIIIlNT AOOIIIII-<HCl.UDllTIIIlT 0II11OAll
'j,:. "0/'" ..
'" '
..
."".
,"""
TO
101I1110 AOOIIISI-IN(;WDlITlUlT 011 OOAD
. ,I. '
~"q"
'"
1)a.'\"\
,,;. "
,I
'"'-
"'INTEIlI'\.OYEO'S NAME. LOCAL ACORESS. CITY. ST ATE.ZlP IUSE OTHER SIDE 'OR 1l0RE THAN. EMPLOYERS,I
AI. ...
lNO ftOUNOWGI
L W1tiiHiW
IIID IIIOUNDlHQI
. ,
I
I
I
I
I
I
I
I
A COpy OF FORM W.2 FOR EACH EMPLOYER MUST DE ATTACHED '" :'
1 TOTAl. GROSS EAIININGS All USTED AIl0VE NO ROUNDING
LESS: A11ow.bl. nOrH.lmburMd .mp~.. butln... ._pen...
2 YOU MUST ATTACH COPY OF PA STA" 'ORM UE.l OR UE.2 AND 'ooM 2101, IF APPLlCASLf
I DEDUCT: W.gttlncJudtd GoYe on which Non Rllld.n, City T.. h.. betn paid '&II worUhtlU
. TAlCAILI W.2 EARNINGS 150...... U.... 2 .nd 2lrom Un. 11
I OTHER TAXABLE lARNfD INCOME. Anach fOfm 10il
INT'RflIT NnT TAVAAll
I TOTAl. TAlWILf EAIINED INCOME !Add 1101'. .nd II NO ROUNDING
7 NET LOSSIS '
(11II acw.. " +
.....~ ""'''''''''1'' a h"'~II&~n
. 'UITOTAl. ISubUlC1 line 7 from Ilne'I" "N,h.n IIro. Inler IIro
....................1
2
~
.....................
.....................
.....................
+ ,.,.'........lkkl.Q
7
.....................
'=:.~:: ~~~Q
+ h.,.,...cau.'1
+ ..... '.......IkJl,. l.tI
.....................
\ '3,'S'O
n,'1Sb
'. ,10 TOTAl. TAlWILf INCOME AND NET PRDFlTI!Add Unt,l.nd II NO ROUNDING
11 TOTAL lARN1D INCOME TAK DfJI
Muhlplv 11M 10 by 1% {.OU
12 ClIIDlTII tDO NOT INCUJDI PHlLADWllIA CITY TAlC AI A CIWlIT,IIUIlI TO UNI J.I
C.I E.rned InconM Ta.. wilhh-'d u IIlted.boYt .
"."; CbJPrtmllntlonDedar.tlonofEltlmllldT.. I ',' TOTAL
. ,nd 1.1' V.I"I ovetDa'i"Rlnt If crldltld " ... CREDITS 12
UllfyourCRIDfTI (line 121." ~rger thin you~ TAX DUai IIln. 111. an\eflnflY....V...INTJ ................ .... .13
CHECK HIRE "YOUWANTTHIS~J.YMlNTRElUNDEDTOYOU 0 OIICR1DITEDTO NEXTVEAII'S ESnMATEDTAlC 0
fHO REFUNDS OR CREOfTI fOR AMOUNTS UNDER 11.00.1
,." rour TAX DUE lllne 1111. llra,r thin your CRED6TS 111M 121. Inllrlfl aw. MTAX DU~ ........... ........ .1.
" AlT'ERAPfUL 11.PENALTVANDINTERESTWSUleCHAAQEDONUNE '4 IV." per monlh Ind .Ich month Ih.r"",,1 ........ ....... .... .1.
II TOTAl. PAYMENT DUE WITH THIS RETUoN . Add IIn.. ,. ond " IPAVIoIENTI UNDEo ",00 ARE NOT REGUIRED,I , ............,....,.11
..............,;;....10
II ,,,>,, '0
, ~..,. ~
\'3'1,50
ll!
!l!
i:
~
~
iC
M.k. ChICk P'V.bl. 10: JIM THORPE AREA &CIIDOL DISTRICT
GAD IIGNATUIII O' TA.'UAYlA
~.GQMf'UTI n-. .",..-....- f.b.uaun.v 01HD.1\UM T.&..O,j)'th<;.1
rw.nClfN'ItNoTlOfil ......'COWIIHfOf,...''''''A
IGUtNlllClf....'AAlA
-..
.'
I
I
,A'.40R Uf4, 4..... . (toM)
" _~O
". ,.
Allowable BusIness Expenses
Ellp.flI.. fO( lOIllch ~ 11" nollllrnlKslld by you< emploYI(,
41tach . IIp,,,.', UE.210 Form PA-4OR fO( IIch employer,
PI",I 0( . Illlnlorm.tion,
1994
Schedule 'UE.2
.' """"..........,'.".PAoQt
Derk h Glenn E
I....... HMw
I,..,.,..,..,.,.....
....0-......____
1___
on Du.. (Nom. IIIld 1m0000Q
..,........................, 4
Plrt B: Work Cloth.. and Unltorm. Qf llqult.d II I condltion of .mploymlllt rod nol
suitable tot IVI da usa . .,...... ..... ............ ............. .
Plrt C: Small Tool. and Suppll.. (R.quIt.d by)llU omploymllltlllld nol ~1I.d by
em 10 Ir "..... ..... ... ...... .... ............ ...........,. C
Plrt D: Prol.. onal Clnll Fe.., MalprlctJclln.urlnCl end rldlllly Bond P,.. um.
· It.du I condition of em 10 en ..................., 0
Towr _01P1ft14th hD.. onUnolbolPA..oR ....................,............,............
Schedule A 'nle,...1
II Inter..t incom,'. over $400, compl.t. Ihl. IIchll1Jl., Includ. Inler..t ~om f.erlO/laJ I<cOU1I1, IUCI1 II liVIng. 1<....,11, credit ""ON,
livings and loans IUDelaliON, c.rtd,cales 01 deposita, Ilc 6n Part I. In Part I, report the ;"18(1lt UlcDm. you r,clly, u . pmlr or
Ihlflholder. ".ddi~onaIIpIC.11 ne.ded, attad1l1pw.tllh.,ta.
Part I
Hlme of thl PlY"
Amount
1 36
NesouehonlnK Sa.lnKS
1 S~total........,..................................................................................,......
Part II
2 1n1l".1 ~om p.melllllpa ~om P.lYlSylYIlIlII Schll1Jl.. RK.! """"""""..""""""""""."",., 2
, Inlerlll from F'omaylYlllllI S COIpollbons ~om P.maylYlllllI Schll1Jl.. RK'I """"""""""""""'" ,
4 ToW Inll,..t Incoml. Add 11n.. 1,2 and 3, Enter h.1I ,,"d on linl2 0' you- PA-4OR......................,.. 4
1 363
1 363
Schedule B DIvIdend.
If dividend income II over $400, complete thlllchedule, All dividend Income llla.able In tn. year r.celved Of' credited. In Par1I, r.port tn.
SOlIC. of tne dividendi you receive dncUy. In Part II, report Ine CSlvldencls thaI you rlCIlVIr U a par1ner Of' shareholder. II addl~onaIIpIC.11
needed, Ittadlaeparlll lIleets.
Part I
Ham. or the Plyer
Amount
1 Slblolll" ....".." ........"" ....,.... ..,.. ..........'".." ...."".. "",..", ....,..,....,..,..,.."
Part II
2 Ol~d.ndl from plll1nlrllllp. ~om Perv1lylvanll ~'hll1Jl.. RK.I ,'......,........'"" ....,..,............" 2
, O"ld.nd. from Po,.".y1vanlo S cO/porlbora, ~o'" Pomaylvanll Sd1.dul.. FJ(.I ............................ ,
4 ToW Dlvld.nd Incom.. Add lin.. 1,2 an43, Enl.. herl and on ,... 3 oly... PA-40R "',' """,' ", .""" 4
PAiIIUGI 1I~11M
_ ....... _w_.
- '-... ,
11040 u:&:'i;'divid:;;;;';-::T':::Retu;" ~ ~@Sa
For the V'NI' JM. 1~. 31. tagS. Of olhel W YMI' begMllg
tn. MIne Ind nuaI La.t MIlle
,-
Label
e:'1Ne1lon.
""_11,)
u.. lhe IRa
.......
OIhtIwiH,
pIoaoo ptlnl
OIIypo,
Pn.ld.nlla'
EI..II011 Campaign
II,
Filing StatuI
l8oo_",)
Chock only
one boll,
Exemptlonl
l800 page 12,)
n mort lhon ol>l
dtptlldtnll,
III pig. 13,
Inoome
Al1toh
Copy 8 ofrour
'otmt W.2,
W.2Q, and
1..R hi..,
n\'OUdkl nll
IlII . W.2, III
plgo 14,
Enclo.., blIt do
not attach. your
pI)'ITItnl and
pI)'Illtnl
vouchll, SIt
plllI33,
AdJustmenl.
to Income
rup~!
.
IRIIJM~..........~...__
,'~5,,,,,,,,,
. 18 OM~ No. "UOCJ7..
Yow _.....my....-
-'I 114/A OIa.L
-'._--
I I
'or prtv.OV Act and
P....rwork Reduollon
Aol Noll.., ... p.g. 7.
v.. No No~ ~ -v...
.... ftOf "*'01 )'OW
1M 01 N4ICI row
/OlIN,
L
A
.
a
L
H
.
ft
.
.12,
Ie, of MI..
1M... .. .. I
III" ...l-
:
Ie, of,..,
Wi........
n"
. 1110"". III L
. OJ.., U.nll
III '" II
'''''''It
u,onu.. (u.
"" 14) ---'
Do"...,1o ....
.......n......_
d "lllur Cl\lkI dldn' IIit wI1II jOu bul b ClIImld II lOUr dlPlnd.nl undor. pro-1NI.g",/TIII\t chlcllllll ~ 0 ::~~~II::"
. Totll number of .:.em tlonl claimed "
b
o Dtplndtnlll
I1lfl111namo
. . . . .
ptnGinlllCK
ll(ijnf't nlllT\bet.lf bom
.,
PI ,,,
/IIIlJOnIIUp1o
"""'"
M4illU
.
Lull\lml
,.
I..
7 WIgII, IIlaIIaa, 1Ipa, .tc, AIlIoh FomI(.) w.a
~
J...
. I I . . I . I
II
b
.
10
11
'I
13
'4
,..
,..
'7
II
II
lOa
II
Z2
lI3a
b
14
II
lie
27
II
18
~
31
7....... Inll..., I.-nt (III pog. 1&), AIlIoh llohtdult B n 0.1f 1400 ,
TIll.....",IInI_t(... pag. I e), DON'T Indudt on lint.. Ib
Dlvldtnd Incomt, AIlIoh &ohtdult B " 0... 1400 , . . . . , .
TIllIblt ..fIlndt, _III, 01 01tH1I 01 aliI. ond 1ocaI1ncom.lulI (... pig. Ie) ,
Allmon)' *I1....-d . I , , . . I . I I , . . . I ..
Bualnllllncomt or (IOU). Attach Schedule 0 or C.El I I . I . I It'
CaIlIlal ;.In Of ~OII), n roqulrtcl, .n.e11 &ohtdulo D (... pig. 18) , , . . .
01"" galna 01 (1otItI), AllIeII'ann 47G7. , 8' . , . . , , . ".
TollllRA dlalllbu1lon., I..1!!..J b T'''bl'lIIlOUIll (lit pogo Ie)
TolII Plnalona .nd annultJlI I..1!!..J b Tutblt IIIlOUIlI (lit pogo Ie)
Rlnlal rMI IItl". ravllli"., pII1nttIhlpl, 8 corporation., Wltl. .Ic, Attach SChedule E
Film IncomI Of' (JoII). Attach SChedu" F . ............
UntmpIo)'mlf1I comptn..tlon (... plllI In , I . " , . , , . , . , .
Social NCUItty bentflll IllOt I l-...J b TIIIllIt tmClIIll (lit _Ie)
01110# Incom., LIII typo and amounl..... pig. Ie ....,...,....................,......
Addth. amountaln Ih. tar n ht column 'or 11n.. 71hrou h 21. Thill. r total Income ..
Your IRA dtducllon (.1. pig. I gl , , . , 23<1
Ilpouat'. IRA dlduCllon (... pig. I g), , , 23b
Moving upona.., Anoch Form 31103 Of 31103.F a4
en..hatf of Hlf..mplo Iment tax. . . . . 25
SeH'''''ployed fl.IUn Ir..uranc. deductlon (a.. pI". 2t) a8
Keogh 6 ""'8mploy.d SEP pion., n SEP, chICk. 0 27
PIt1IIty on IIIly wllhd"NII 01 1I.lngl, . . , .. 21
oIIImony paJd, Roclpltnl'a ~"N ~ " 18
Add IIn.. 23. Ihrou h 2g. Th...." our 10111 Id u.lmtnl. , . , , , , , .
&ubUa~ IIn. 30 Itom IIn. :'~. Thl.,. jOur .ilu.11d lrou Incom., 111m tIIan $2&.&73 .nd. child IIv.d
wnh ou IlIIlh" 1,230 II . child oldn' II" Wllh au. III '!amld Incom. elldll' on I . 27 ~
ClL No, mua
.
o
2
1.11./0 00
31
---
I....
Compu-
tation
.
tj'-
"\'OIl wanl
lhIlRS 10
flgUtl \'0<1'
We,_
pago :14,
Credits
ISH page
24,)
Other
Taxes
(-peg.
25,1
Payment.
Atlteh
Fonn. W~2,
W-2G, and
1099.R on
thl'...."
III
aa
eo
81
Refund Dr 12
AmDunt 13
YDU Owe 84
10
Sign
Here
Keep I eopy
or thl, relum
'Of' your
record,.
Paid
Pre parer's
Use Only
Chock It. Cl YOU':I" 0( ok;;:.Cl.e;~; Cl ep;...~ ~u'oo'or~, b'lIlj~,
Add lhI_ 01 bo,," chocIltd .".,.. and II1tat lhIlotII hero, , . ..;u.
b "your pIIOf1I(or _ ....1 con cloIm \'0<1 .. I dOpo"do"l, ChodI herl , . I3b
o "\'0<1.... mimld NIng IOpIIlIIlIy and your _ _u doclUCllonl 0(
\'0<1110 I dUll'ltotUllllon, _ _ 23 and _ herl, , . . . . .. _ Cl
I-od doclucllono from _uiI A, line 25, 011 )
;w Enl.. IlMdonl doducUon aIlown boIow to( your tiling IlIluI, IIuI \I \'0<1 _kid
~ an~ 1,,01 on line 33a or b. go to pagl 23 to l'ind your .tandard deducuon.
or II you ChodIId box :l3o, your llIIldlld __ II .ItO,
your. 0 8100100-$3,1100 0 MIITiod ltJlng joInlly 0( QuJlfytng wldow(~,560
o HNd 01 ~,760 0 Mantod NIng 1OpIIlI1lty-t3,275
Subtrlcth34tromUnt32 . . . . . . . . . . . . . . . . . " sa
\I line 32 10 taa,025 ot ...., multJpIy 12,1500 by lhIlo", ....- 01 oumpllonl cIoImod on
line ... \I \lno 32 II """ t88,025, _lhIWOIkIhMI on pogo 23 ror lhI xmounllo 111111. ill
T....... Inoomo. SllIl~os;c \lno 3a from line 35, \I \lno 3a 10 moro Ihan line :14, 111111 0(1.. .
Tax. cnOCk " from .MTIll TobIl, b Cl Till Rail Sc:hIduIoo, 0 ClClp/tl/ GoIn T.. WllIk'
1hMt, ot d Cl Form 1015 1_ pogo 24), Amounl from Fonn(III014 . . I
Add_....., Chick " from . Cl Form 4&70 b Cl Form 4&72 ..
Add linII 3a and 3&
CtI<jIt lor chlld ano dependonl corl IllponNO, _ Form 2441
Ctldil fot lIIIlldlrty 0( lIII dlublod, AllIeh SchoduiI R . .
Foro/gn ... CtIdIL Altoch Form 1118 " , , . . , ,
Olhtt Ctldltt f- plgl 26), Chock "from . 0 Form 3800
b 0 Form 5388 .0 Form 11I01 dO Form (~_ ....
45 Add 1Jne141 thlough 44 . . . . . . . . . . . . . .
48 Subtracllinl 45 I,om linII40, " 1101 45 10 motl than Une .0, .nl., 0(1. ,
47 SI""""ploymonlllll, AllIeh 8cI1odulo 8E. . . , , , .
... AttImaUv. minimum taJe. Attach Fonn 8251 . . . . .. ....
48 RocopllnllllH, Chock" from . Cl Fonn 4265 bCl Form 8811 00 Form B8l!B
10 llocIII-..my and UIdJextOllll on up Incomo nol tlpoIIod \0 emploYII, Altadl Fann 4137
BI Tax on qUll11IId tll~1f11II11 pIoN, including lRAa, \I loqulrld, It1IcI1 Form 532& .
112 _1110O _ Incomo crldn paymonta from Fonn W.2 ,
13 HouHllold emplolmonlllll.., At1IcI1 _uil H. . . .
64 Add Iln.. 48 throu h 63. Thla Ia our total tax . . . . .
10 rldlllllnCllmt!lx wlUlh~d,1I any II from Formll) 1098, thICk. cl
10 1 &95 ':ItlmItall tIJl paymonlllnllll'llOWlt Ippllod '""" 1 &94 I'Itllm .
11 .__ _I\. _ Sc:hoduil EIC" you"'''' IllUI!lfYYlg
ChIld, Non__Incomo: _ .1 1 1
and \ypo . ................................................... B7
Amounl poId with Form 48&8 lutonolon roquIII) , , .. 58
EaClllooclollocur1!y end RRTA... wlthhlld (110 PO&" 321 B&
Othtt poymonll. CIlOCll "tram 10 rorm 243& b cl Form 4138 eo
Add 11n.. 65 thleu h 60, Tho...... OUI lolxl I nix , . , , . . ~
n.... BIll morl thin .... 54, I<JC>troc1lln154I'om 1101 Bl, ThilIlIho I/!IOUIlI you OVERPoIJD. . .
Amount of Ilno 52 you want RII'UNDED TO YOU, , , . , , , . , , .
Amount 011111I B2 IOU Wlnt Al't'l.110 TO YOUR 11M flnMATlO TAX . 114
\I Uno 04 II morllnlO line B1, oubttlClllno B1 from linII 04, Thlo II lhe AMOUNTYDU OWl.
For d.talll on how 10 pay and UN 'ann 104Q..V, P.yment Voucher. IN page 33 . ....
ea Ellimated tax nul see I . 33 . Alao Include on lin. 85 sa
Undet penaltln of perlWV. I dtcilfl Ihlll have lumIned hi "'lm and ac;compan~ng ICtlIduIeI and ltal..,.,&I. lI'ld'lo thI bnt 0' my kno..lotdg. MCf
beIlef, they It. tAle, CCllTICI..&t'ld complthl OtcIatltlon of~. (othlllt\ln lupIY*1- bINd on IIIlnlom'l.luon of which pl'epIIW hIIln)l ~
.... Your IignIIUI"I 0.1 Y lton
, , r
~ Spouse'. ~r\lIUf'. II .I,:unt filum, BOTH mUlt lign.
~
ill
:17
~
38
010
41
42
43
....
.
~
41
42
43
,.
. .
..
P_I~
tigMlure ,
Fm', name lot VOUf1 ~
\I ,,".omplo)'lCl) ond
,dd'e"
0.11
CIlec:' II
...t....pIoyod 0
EIN
liP COde
(!) PMled CIfIIKJ'dId IMIW
o. 00
-
48
48
47
48
48
BO
B
52
-0
-
-
"
"'_I IOCIol IICur\lyno.
I I
I
'UI ~""",oo...,.........
P.rt ,
In'.r..,
'noom.
IBM
pog.. 15
. IIld B.q
Noll/ n )'OU
lICIivId . Fonn
llJOi.lNT, Fonn
lll1li-OIO,,,,
lUb.tltut.
'IIt""'lIIt from
. broll...g. finn,
lilt IhI tlnn'.
/IImI .. IhI
poy., IIld .nt...
IhI tolll Int.,lIt
Ihown on IhIt
lonn,
P.rt II
Dlvld.nd
'noom.
(SH
pogll 15
IIld B.l,)
Noll/It )'OU
1ICI1'1d . Fonn
10llS.0IV...
IlIblUM.
"""",.nt from
. brok.reg.
firm, Iillth.
ftrm', n&mI U
IhI P'Y" IIld
IIIt...1hI tolll
dlvld.ndl
Ihown on tIlIt
form,
P.rt III
Fo,.'gn
Accoun"
.nd
Trulll
Schedule B-Interest and DIvIdend income
CIA. No, 114a.oo74 , I'tgo 2
v"'_IIClIlItIl'_
ILlL.IOI~'
Attaclvnwlt
Boq_ No, 08
Note: If htd OVIf 1400 In wabJ. Int'I'II' Incom. mUlt allO com .t. Part III.
1 U~I noml 01 Ply.r. It any Int....1 I. lram I 1I11.,.financld mortg.g. Ind Ih.
buy.. ulld tho prop.rty II . polIonll '1IId.nea, II' p.g. a'l Ind 11.llhl.
Inl~11 firel, Alia, Ihow thll bljllllr'o IOCI.I IOCUrlty numb.. and .dd.... ~
..N,tSlbl,l,(.bQ.O,\ ng,......;xJ"V. i.og$..,:T...J,..~~O....,...,.......,..
. 'i.l'" .,',':: ..... .'1\\.:..'...;..... 'Ii...... 'l::"'If'~' ','...........'.."........'...'..'.
..1lIC),v.c.r......1.....Ol.M:\ v......... \':\M~:J....lTQ, .....................,............
Amount
............................................................................................
............................................................................................
............................................................................................
............................................................................................
1
............................................................................................
............................................................................................
............................................................................................
............................................................................................
............................................................................................
............................................................................................
............................................................................................
2 Add the amounts on line 1 . . . . . . . . . . . . . . . . . .
3 Excludable Inlereal on aeries EE U,S, aavlngs bonds laaued efler 1989 from Form
8815, IIn. 14. You MUST attach Form 8815 10 Form 1040 , , , . , ,. 3
4 Subtract line 3 from line 2, Enler Ihe re.ull here and on Form 1040 line 8a ~ 4
Not.: If )IOU Md ove, $.100 In Dross dividends and/or olha, di.tributlons on .tock u mu.t also com MI. PMt III.
Amount
2
o
II UII nama 01 payur, Includa groaa dlvldand. and/or other dlalrlbullonl on Ilock
ha.., Ally capllal galn dlllrlbullona and nonlaxabl. dl.lrlbuijon. will be dlduCl1d
on IIn.. 7 and 8 ~ .....................................................................
............................................................................................
............................................................................................
.............................................................................................
............................................................................................
............................................................................................
............................................................................................
II
............................................................................................
............................................................................................
............................................................................................
............................................................................................
............................................................................................
............................................................................................
............................................................................................
o Add Ih. omounl. on line 5 . . . . , , . . , .
7 Copllll glln dl.lrlbutlonl, Entor h.re and on Schedul. O' .
B Nonl&lllbl. dlllrlbuliona, (SH th. 1nI1. I... Form 1040, 1101 9,) B
8 Addllnea7and8. ....... ...... ......
10 Subll'lc1l1n. 9 lrom IIn. B, Enter th. reaull here and on Form 1040, IIn. 9 , ~
'If you do nor noed Schedu/. D 10 report any other g.lnl 01 /0...., 1M 'M
In"lIIetlon. lor Form 1040, line 13 on I e 16,
It you had oVlr $400 01 Inlorlll or dlvldandl or had. lorelgn accounl or w.... . granlor 01, ... 11IIn11.ror
10, . foreign lrult, you mUll campllle Ihll part, .
. . . . . .
111 Al any 11m. during 1995, did you h.ve an Inlereslln or a .Ignatura or olher aUlhorlty over. flnanclal
account In a lor.lgn counlry, .uch aa a bank accounl, IIcurllles Iccounl, or olher finlncl.1
lecount? Sea po". D.2 lor IXcepllonl Ind filing requlremenll lor Form TO F 90,22,1 , , . ,
b It 'VIS,' .nler Ih. r,d.ne 01 the 10..lgn eounlry ~ ,......................,.........,.........,...........
12 Were you Ihe 9r.,.lor 01, or Irensleror to, I lorelgn IrusllhlllXllled during 1995, wh.ther or not
au ha,e an bdr.of,clalInlareatIn II? II'Ves." au ma heve 10 file Form 3520 3520.A, or 928 ,
'.r P.porwartc R.ductlon Act Noijeo, ,,, Form 1040 InltrueUon., @ ....,....__ Schedul. B (Form 1040)1895
'u,I.00wwrvn..~Othot: ,.... __'14
(SH
plg. B-2,)
. "'<to
~@9fi~." ,
At1KI\mItlI "
_No,2!-
V"", _ --"'Y"""'"
i i
Schedule A-ItemIzed Deduction.
(Schedull 8 lion back)
. Anach to ponn 1040. . 11M In.ttucUcna ler Schedulu A Ind II porm 1040 ,
SCHEDULES MB
(Form. 1040) .
~DflheTI~_
..AItnM ~ kW>I ,....,
Name(lllhoWn on form 1040
, CouUon: 00 nor /ncIudo oxponlll telmbullld 01 poid by ell1ol1,
Modlcal and dlntoloxpon..1 (I" pi 0 A-l). . . .
Ent.r amount Irom Form lGlO, line 32, 2
Mu~lp'y IInl 2 abovo by 7,5% (,075), , , . , , .
Subtllct IIno 3 from IIno 1, If IIno 3 II morl thon IIno I Inler -O-
Il
I
7
Madlcal
and 1
Dent81 2
Expen... 3
4
Tax.. You II
P.ld II
(SH 7
paO" ".1.) 8
II
Intel'llat 10
You Paid 11
(SM
page M.)
Nolo:
"'roonlll 12
1n'"UIII
not
deductlbl.. 13
14
Gilt. to 111
Charily
" you mad.. 111
gift and gel I
bontflt tor ~, 17
... pag. A.3, 18
, CIsuIl1Y Ind
Theil Lo.... 111
I Job ElpenSII 20
,
y Ind MOIl
I Other'
u Mlscellaneoul
Olducllons
Statl and local Income taxe. . . . . . I' . . .
Rial IItatl tax.. (I" paoo A-2) , . . , . , , .
Peraanal property talCI.. . . . . . . . . . .
Other taxal, Ult type and amount ~ ....................
Add ',i;'iii's' iiVO';"1i 's.:..',...:.':.'.:........'.....".......
Homa mongage Inlertlllnd polnll reponed to you on Form 1098
HcmlmortgaQ4lnterutnct rapcrtodteycucn Fenn 1098," paid
to thl perIOtl ~om whom you bought till hcrnI. III pago 1..3
I11d &hew thaI perIOtl'l naml, identifying no" and addtlll ~
................................................................
................................................................
................................................................
P~lnt. not reporlod to you on Form '098, SOl pooo A-3
for epeelal rules. . . . . . . . . . . . . .
'nvlltmont Inlerllt, If required, ottech Form 4952, (S..
page A.3.) . . . . . . . . . . . . . . .
Add IIn.. 10 throu h 13, , , , , , , , , , ,
Gml by caah or choCk, If you midi any Olh ot $250 or
mOrl.aeepagIA.3 . . . . . . . . . . . .
Other than by caah or ChiCk, II any glh 01 $250 or more,
... pago "-3,11 over $500, you MUST attach Form 8283
Conyov", from prior Ylar . , . . . . . .
Add IIn.. 15 throu h 17, , ,', , , , , ,
Casu.' or thlh lOll el . Attach Form 4884. See
Unrelmburaod employ.. oxpon..a-job travol, union
dUll, Job oducollon, ole, If required, you MUST attach
Farm 2108 or 2108-12, (Seo page A-5,) ~ ..............
................................................................
................................................................
21 Tax preparetlon f..~ . . . . . . . . . . , ,
22 Othor oxponseo-ln'.ltmont, oalo dopos~ bOx, olc, Ult
typo and amounl ~.........................................
R
A
V,
(SM
paoo A.5 ter
I.pen... 10
dlduct her.,)
................................................................
Add IIn.. 20 through 22 . , , , . . . , . . ,
Enter amounllrom Forn, lGlO, line 32, 24
Mulllply IIno 24 alJ"va by 2% (,02) . , . ,', ., 25
SubtTaclllne 25 II~m IIno 23, It IIno 25 II more than IIno 23 enter -0-
Olher-trom 1111 cn pogo A-5, Ult typa and amount ~ ..............................
23
24
211
26
Olhlr 27
Mlscallaneoul
Oaductlons
Total
Itamlzed
Deductlona
51
HI
I<tl
ell
'01'
raci
................................................................................................
28 II Form 1040, line 32, aver $"4,700 (over $57,350 It morrlod filing ..perotoly)?
NO, Your doduclion II not IImlled, Add the amounllln tho ter righl column }
ror IInll 4 lI110ugh 27, Also, .nter en Fenn 1040, lino 34, tho lerger of . ~
this amount or yeur Itandard deduction,
YES, Yaur deducl",n ma bo Iimiled, See a e A-5 tor tho omount to onter,
Fer Plparwe'" Reduction Act NoUel, I.. Ferm 1040 InlttucUon.. Ca.. No, \1330](
Pal
Pre
Ull
Schedul. A (Form 1040) '"5
-
. -._... .~.."
BU'ln... .aar.lIl.nCJudlng 'u.l. room no.) ..
ell. lo\\n or 00'1 o"ic.. 'Ill'. and ZIP cod.
Afccunl,rg "'tlncc: IIIlS.Cnn lal 0 Accrull 1310 Olnor l'poo"O ~ ...............,.................................,
M'lnoo,11 ...110 10 Low.r of COil Olhl1 (11I.cn _ Dotl nOI IPply Itt
value clollng nv.nlory: t1J ~ Call (2) 0 or mark.1 (3) ~ l.planl110m If) ....,j Chtckld. IklP line HI
W.. 1h'l, ."~ cnang' In U.l,rmlnlng qu,nhh.l. COlli, Of valuallonl Dtlwttn Dptnlng Ina ClOlmg Inv.nlory' If .VII'- an.cn
'Jlplanallon. . . . . . . . . . . . . . . . , . , . , " ..,.....
01Cl you -mater.ally Plr1iClp'la" In th. optrlhon of tnll bUlln..1 during 1eSS' If "No." I.. gig. C.2 for limit on 10'''',
II you 11'1'1'0 or aCQulrea Ih'l bU'ln,.. dunn 1995. Check nil', . . , , . . , . , ., .."
Income
GrOll ItC'lPtJ or lalli, Clution: ",,,/.lncom, WI' "POITI<1 to you on Form W.2 ana tn. ~Stltu'Oty
'1f1I.:IO)'HH bO.r on ,,,., form was Ch,Ck,d, IN P'Q' C.2 tnl1 ClllCk Il,,, ..
Rltuml Ina 11Iowanc.. . , . , , .
Subtracl hn. 2 from IIn. 1 . . , . ,
Call of gooa. laId Itrom lin. 40 on pag. 2)
Ora.. profit Subtract lin. 4 'rom hnt 3 ,
Oln., Incomt. Includ,ng Fldtral ana Itall gllollna or futl lax C"dl1 or "tund (II' pag, C.21
Grall Incom.. Add Imll 5 .nd 6 , . , ,. """",
Ex .n.... Enter ex enses lor bUSiness use of our home ani on line 30,
. .L 0
A
c
I
,
Q
H
I
J
2
3
4
.
.
7
.
I
Adv,n,slng , . . . . .
Baa a.DII 'rom ..111 or
"NIC" IIH Pig. C.3) , .
10 Car ana 1ruck ,.plns..
(," Pig. C.31, , ,
Commllslonland 'HI. . .
Depl.tlon, . , , , . .
Dtpttclll10n InQ IIctlon 179
..o,n.. CtoLocl10n (not IntluOtd
,n PIrlIlIlI'" Dig. C.31 , ,
14 EmpIO)'" Den"lt programs
10lner In.'' on hn, 19). . .
Inluranel lotnlr tnl" h.llth) .
Intltlll;
a Monglg. 10110 10 DankS, lie.) .
b Otntl. . . . . .
17 L.g'l ana prol'"lonal
.I""'CII. . , .
O"ICI '.Olnll. .
11
la
13
IS
II
II
21
al
30
31
I
18 P.nllon and plofll'lnarmg PLanI
20 R.nt cr 11111 1..1 plgl C.4):
. V.hlCln. macMlI)'. ItIa tQUlprnenl .
b Olhlr bUllna.. proP'ny .
21 R.paira and mll"t.n,nc. ,
22 SuppheJ (not InCluClIO In Pan Ilij
23 Tues and he.n.... . ,
24 Traval, meall, ano .nten.,nm,nl:
. Travel, . , . . , , .
b Meals Ind dn.
t'"31nm.nl .
. Enler 5011 cl
~nl 24b IUCjlel
10 ~ml1lllcn, 1_
1M' cagl C'~I '
d SuDtrlCI MI 24c "om hn, 24b
I 25 Uhhh.. . . . . , .
26 Wig.. (1'11 .mOloym,nl crldllsl ,
'27. Olhtr,xpenlllllromhn. 460n
plgl21"",
10
11
12
13
E "~iOl)
I :
I
J;04~
I I
14
15
~
1'"
1Sb
17
15
I
'00
Totlll.lp'"I.. btlor. ..ptnlll for bUlinflu ull of nom.. Add linll 8 Ihrough 27 In COlumnl,
T."IIII\" eroM 11011'. Subtracllin. 28 from hn. 7
EllQ'nllllor DUII""' UII 01 your hom.. Alllen form 8828, , . , . , . , .
Ntt profit or (10111. Subtraclllnt 30 from lint 29,
. If. prollt. .mer on Porm 1040,lIne 12. tnd ALSO on ICh.d,'I. I., Un. 2 (It.luIOty tmployltS,
I" Pig I C,SI. EII.I.. and lrultl, .nler on Form 1041, lin. 3,
. If. lOll. you MUST go on 101m. 32.
If you "Iv, . Ion. ChiCk tn. box U'I.I d.scrlbes your invlltmenlln Ihll IChvlly lit. page C'SI.
· II you Cr'l'CKla 321, Inler 1he 1011 on Form 1040. IIn. 12. .nd ALSO on Sch.dul. 5E, IIn. 2
Illall,,:lc:'", '-C10/tlS, II' page C.S), Eltahtl ana Irusts. .nllr on Form 1041. lin. 3
. II \O~ :"':"'1 32b. ,ou MUST IlIlIcn Form e108,
3a
For Paget"Norll P"aucuon Act NOhe., '" Form 10<40 Inltructlons.
:J~ ',G ..'~
------------
0' I
a
3
.
.
I
7
~
:lOa
:lOb
21
22
a3
~
241
24<1
2S I
21
~
a7
28 I
28
30
}
}
31
01,1'" lJ,ti-Oau
~@95
VII No
x
~
0,
00
'135'. 0
II
~3
0/)
o
00
'~~~o, Ol)
32.0 Alllnvlltm.nl i. 11 "lk,
32b LJ Sam. '"Veltmlln, II nol
.1 rIsk
SCnlcul1 C (Fcrm 104011l9S
111-4~-OIa.1 '.2
33
:14 Pure".... I,.. COlt clllem. withdrawn lat gtrlOntl un :14
~s COil =1 liDO', ~o nDllnClud. .Ilary PliO to "'0,",1"11 :15
~s 1.111""11 Md IUpphll . 31
~7 Oln" COil' ~
31 ""'0 ,nto 33 Ihrough 37 31
38 Inv.ntory at end ot ~..r 38
-0,-
00, Oll
00. 00
Co., of oodl lold. Sublractli". 39 'rom lint 36. Ent., thl "lull ner. and on CI . t. Iln,. 40 000, 00
Information on Your Vehicle, Complete this part ONLY If you are claiming car or true expenses on
line 10 and are not required to file Form 4562 tor this bUSiness, See the Instrucllons for line 13 on pege
0-3 to find out If you must file,
., Wh,n aid )'ou pll" your "thicl. in lervlC' for bUIJn'" PUrpD.II? (month. dl)', )/"'1" ......../.........L.... .
.2 0' In, 10111 numb., at mil.. you drove your v,nlCl, dUn"; HISS. .nler tn. numb" of mIl.. 'fou Ulld your v'hlcle for:
. BUlln'.1 ................................... b Commuting ................................ Q OIP1" .....................................
43 00 )Iou lor YOLlr ,pouSt' hlVI anOlhlr v'hiell IVlllabl1 for perlonal u"?
, CJ V.. CJ No
, CJ V.. CJ No
. CJ V.. CJ No
, CJ V.. CJ No
44 W.. your vehicle l"'lil_bl' 'or UII during oN.duty hour.?
441 00 you na"'l Ivid,nel to IYPpOI1 your GIGuctlon1
b If "Ves." ilthe IVldence wnnln? . . . . .
(Plt';il'4 Other Expenses. Ust below business expenses notlncluuea on lines 8-26 or line 30,
,..W"ld inj",..,$,U.p,p.\,i.e.S."...... ',.....,..",..,........,......"".""..,..,.."...."......,
8. oc)
......................................................................................................................
.......................................u.............................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
......................................................................................................................
.........................,............................................................................................
......................................................................................................................
"IS Tolal other IIplnlll. Enler n,r, anrt en CICI 1 Iln, 27
~4 B. OCl
e ....''It..''f9C~',....o.,
-
--
'~"'(It _____
--
00
~.:./ ~~, .
jt.'.'!~~II\: ~. f1'Il'I'I/!r!~n'T>' '",,~.'~' -'"11"'" ''''Lt':PlIr.' ~IP."1"rnJmJrlrn~' ....,', 'nll_ .
f'~UUL.t::I:I ..,~ ~~~~~~I""~I~~.:l~~;.J,.:,.:.ll:dfl1da "COrnu .u'eDn;':'~ 'It.,, ..H '1.1i J~ ~~..~1~' 11:~:.I: ,UM~ '.11MO'W11~
. lfo~:'i~~;~!'f~) g~ii)/l;;,~i;:;:ilIIQUilllfY,IHg 'ohlld 1r1'ohtliltl6n) 1~tl,\I:!Mt~~~~ i,~\'Ii:~@95 ':\"~r~
' ~lII""t~.."I\ ~l'~:' \,~,.pi; ""i l''':,Ii,Attabh IbFbtm i04GA afllU(l, ".I~rV,;' ,,<'1/" i,i.'\'I" ~1~~1 .i',' J~J:!
" "-nil",""", ....',' ~ .~ ' '.~,,-. ':. ..,:1"...... nltrucUbnabttbac ,"'.'I'l; " .'" . ," ........~ .,~ ,.t" lWdNd. d"".l.
l Ntmo(~....""..,,,,,,,, G ttn'n E. ,'De.r'kMI) ,,., ""'i4i.:iOt5'i
I ""',"M,tl;~,!j;f . . ~~/.,{;,l :""r.:;il~~II".'\;'fl{\"',1:,lti1I1f ~^I'rii':"';l,::.~,.t;;l\~ +,ti.':, il:.'\:-~~l-i'" ;1~~in,V"W"!!iI'.
be cll1lroll bilgln '~.. ;'\'\~I"'~I""\1 \ i;;'lr,"t~'I' ":1 f:ll',' ;."",', "!',,~,...:!, I;'~" ,'.tlS'I",:"""':'('r,:.,"~:t:"~ t.';, , ;(\ "(,.'r,11"
Yr';,): i: \~ if N,~~'lrl~;;\J~,f'ltlAW;d.J"6t th~~tjiiiHJ4~~lh~r~~l"~;~~~~1 ~~, 1t:""~'~~~f~ll~kl~~;iJn1
.~";",, /.: i,', ;(.' ,lei '1Il'~' 'YllOitlll(,:~~8 ,lhld bliltllr!!:~~\'''\:'i':' l:t\\-i;~~',: ~J', :~f~,~.if~:/ ~ ~l'l,t,.J :~?~.\('tl\ii~ s:: if;: ,,',',', M'.~
l', " "'"":"11 ypU'l!"lllko'tfnl'll1'lItIllihl/.ln tho WIlr'kllllf6 ''illl /la08'~~ 10004r tlt\liitill :l!8lfb4 'll K~urii youl clildltl
;....: ;'~! : ,: ;:~ ~I\t" Y~il..~~,~ll~,..!~~ 1,1r.~~U~llt:fll!:Y~~("i1I111~U~'.4~'I'~~'br ~~~"'~"lt ,:. .l;Nj:;"t,~:",~:~~!){.;
Tl1ell, yoU'frillll C'briiPlbld 'lI~~fliHil6HlIcHlidulll ~l5tlhlY.1'YbUildV' Ii ~U41!IYlri~ bhlleJ IS8d'~~~II'i~"bllckli:~;!) ti~ ,:.
, ,,' ..... :~ l~'..~ . '. . I of to' l (.', 'I'.~' ;: II~.~ 'i:.al' ,;..J ';A,.: ': ',l,.. '.j,- .....'r '., lfi". ....,J:.. ''; ,I ~ .' t~" ;\",' . r:~..: )I....;~ ",', '.,., ~J\:,
, ,
.
InfonnaUon About Your QualiMlIlI Child or Children. '.. : , '
. '. "', ~"'.'.' I,"',', . t '. I .
" you have mora than two qUail lying children, you only have \0 III1 two 10 gellhe II14Xlrrium credit.
. \' ,
-
"""'=
"""'=
~
==
~"""'=
~=
~
=
~
===:!
=
"""'=
ImII
,: J1lI~.lIOIWbfll~6lIU61ni~'A.1 NIiU~.;. '~cIiM~~"'~',IJ4r.-Ila~lfulM';~~uli.llcI:il4llilj'iMllA'lilili41ll'n1ia
' " ." ,','," .... " ". " II' I . '. .;", '. , ' "," > '" , '" .' ....., ~ .' .' " '
i'btJD40.lf!!!!!.t_~ri'.~I.,~..t!'''''i'''IL..I.'''''-L.:''.r.~_~ 1.,~lJr..J.l.""- ~........to .'T'Jl.....,...."d.:d.\ ._.J;". ' "'.' ,\.
.i,
.
,.
, ..
I ''t' ~~UI ~ ~~
__Ill
....
---
'"
.
~'It-.'...."')
.. ~.h"c.
mm'UIII\O""" on '.Ivm
Depreciation and AmortIzation
(Including Intormut/on on LIlted Propurty)
~@95'
............,
-. No. 87
kttntlP)1"t numbtr
1- I.-Olal
ava any .Ustad Propeny, .
517 500
aMI No 11<100112
... Ie. II .,.,. Inltrucllonl. ... Attach thl. form 10 our ,.tum,
l"" 1) I BI,I"",,, 01 ICI,-w.'W')a.....n tI,n, IOtm ~'i~II'ld '
nt:, lr 4S ~c. . I WQ. In
Elecllon To Expenle C.rtlln Tanglbla Prop arty (Slcllon 178) (Notl: 1/ you
com lete Part V belore au com lete Pan I,
1 MaJumum dollar hmltatlon. If an en1erpflllt zon, bUllne... II. Plge 1 or thl Instruction. .
2 Total coal or aecllon 179 property placad In aeIVlca dUrIng Iha tax vear, S.. paga 2 at tha
inltructlons . . . . . . . . . . . . , . . . . . . , . . . . . . .
3 Thrllnold coat 01 aaction 178 propanv bafora raducllon ,n limit allan , , , , , , , ,
4 Aaaucllon In limllal,on, Subtractlina 3 from Iina 2, II lara or lass, anlar .0. , , , , ,
e DOllar hmilallon for lax vaar, Sub!/Oclllna 4 from line " IIlero or la.., anter .0., II mamad
tilin ae aralll , a.. pa a 2 of tha ,natruct,ona
III 0.""011011 or Ptop..,nr
200 0 0
lei COil
lei EllClta COal
.
7 WallO proparty, Enter amount trom I,na 27, , , " "" 7
8 Total e/aclld coal 01 aacllon 179 propeny. Add emounts in column (cI, lines 6 Ino 7 8
8 Tantallva deducllon, Enlar tha smbller 01 lina 5 or line 6 , , , , , , , , , , II
10 Cartyover at d,..IIowad deducllon from 1994, S.. psga 2 of lhalnatrucllona, , , . " 10
11 Taxablalncoma limit. lion, Enlar tha smJllar oftiUab/a Incoma (notlaas lhan lerol Of Ilna 5 (118 InllruCliO/lS) 11
12 Section 179 expenaa deduction, Add I,,,es 9 and 10, bul do not anter more lhan lina 11 12
13 over of disallowed deduction 10 1~96. Add I,nea 9 and 10, lasalina 12 ~ 13
NOla: Do not Ult Pen /I or Parr 11/ below (or IIsltd proparTy (,ulomoblltJ, carr'In olher vahic/n, ca/lular It/.phones,
c.rtain cOml'ut'fI, Of prop. us.d (or f:ntenoJinm,nt. reCreation. or amusement). Instead, use PI" V lor listed pro ,
MACRS Dlpreclallon For Auatl Pllcld In S.rvlc. ONLY During Your 1885 Tax Vlar (Do Notlnolud.
Wiled Property,)
14
101 C"""CO'OClIl 0/_
lOa
b
o
d
a
f
D
27,5 rs,
27,5 n.
39 rs,
MM SIL
MM SIL
MM SIL
MM SIL
",ol.lIan S lI.m ADS 5.. a a 4 01 '"a Inslructlons,
,.. Clasallla SIL
b 12. aar 12 rs, SIL
o 40. aar 40 rs, MM SIL
Other De reclal/on Do 1/01 Include Wiled Pro . Sse a e 4 of tha instructions,
17 GOS and ADS dilductlona tot Wits pl.Cdd In IINlealn tax \'811I1 beginning balOtl 1995 , 17 .J;. q 7j). 00_
18 Proparty aubjacllo aactlon 1S8IQ(I) .I.~tlon, , , , 18
111 ACAS and other depraclallon, , . , , , , , , , g
~ Summary ISae paga 4 of l/le Instructions.
20 Waled property, Enter amount from I,n. 28, , . , , , , , . , , , '. ,
21 Total. Add deductlona on IIna 12, IIn.~ 1~ and 181n column (g), and linea 17lhrough 20, Enter here
and on tha approprisla IInll of vour lol.rn, Panna'1hlpa and S corporations-saa Instructlona ,
22 For ullta .hown abova snd placed Ir, sar;lcI during tha currant Vllr, anlar
tha onion of Iha bull an"bUltbl.to LOClion 283A COltl . , , , ,
Far Plp.FWO", R.ductlon Act NoUe., II. ~"O' 1 at th, IIplral. In.tructlon..
h
20
21
22
e.l. ~o 12i06N
r... 4562 IIIISI
-
-
P.go:l .
Wlt.d Proplrty-AUlomolJlluo, C.rtaln Other V.hlclll, C.llultr T.I.phonll, C.rtlln Comput."" and
./' Prop.rty Ulld lor Ent.rtainment, R.crtatlon, or Amullm.nt
~, Not.: For .ny v.nlel. lor wni,'. you .re using Ih. IIInaara mllllg. fit. or atc1ueting /1111 ..p.nll, eom~,.t. on~
23a, 23b, cOlumns I.) Ih,ou (I Ie) 01 Stelion A, .11 01 SlCtlon S, .na Stellon C il.o /iClb/t,
Slella" A-D. reel.tlon Ind Olh., Inform.tion Ciulla": 5,. ,..5 01 'he ""tructlons lor /ImitatIons lOf automobiles.
23. 00 Ou ".1\1. h'ldentt!:1 SilO ortln, t1uslnes"lnveSlmenr use clalmea? V.. No 23b If .VII," illh. .\lldenc. wrln,n? VII 0
1'1 i 101 O.,~,. Idl . I.' III 1.1 ilIl III
Type 01 ptODftfy 11'1' I Cllt: .eta ." IItntllft-"1 COil Of olntf 811. 'Ot C1'P'fCl&llOn Aeco..-.ry Melf\odl o.p,.lIl101'l IItc1IC1
YlhlC)f. 'It'll I "'\,ce wi. DIIlI t tDutll\l.II"'''''.lmenl PthOCI ConvtrlllQn dlcM:l~ Helot 171
. pelC.nt.;. , UN onl I COil
24 P, en USld mar. IMn 50'16 ,n a ual.f,od bUSiness uSlISee a . 5 of Ihe In.lrucllon., :
1 00 \
I
I
25 Pro en USld 50'16 0' 1'5I,n 0 u.lit,.d businos. use fS.. a 0 5 of IhO inslructlons, :
SO '16 3 000. 0 ,0
OK
~; I
Add amounls in COlumn (hi, Enler tn. 10lal hore and on lino 20. page "
Add amounts in column II). Enler tIle 10lal hure and on line 7. 8 11 .
Soctlon ll-lnlormltlon on Un 01 Vlhlclll
Complll. thlsuetion lor v'hieles us.a iJy a sol. proprillor, parm.r, or 01~1r "mar. IlIIn 5% own.r," or reI.ttc1 p.rson,
"you PfOVIcItd vt/lIcJes ro your.mDlOYHt ~'" 0.,;"" the qlllJtiCnJ in Secoon C to Jet Iryou_, In IICIIl/tOII 10 CO/J'fIItbng /hiJ ucoon lorlllou VII1kIeJ,
~ ~ · ~ . III
Vthe.. 1 V.rue.. 2 V.h".. 3 ViIhll.:lI 4 Vetwc.. I VIhcIe .
000.
2CI
27
SIL -
SIL -
28
2CI
TOI1I buslnuslinVtslmenl milu driven du", 0
Ih. 111I(00 NOT I"'iud. commuliOg mll,'1
TOIII commuting miles dllv.n dUllng Ihl y..r
TOIII Olher pellon.l(noneOmmUIII', ,-,)
millldrivln, , , , , , , , ,
TOlal miles drivon during Iho YI ,II,
Add lines 28 Ihrough 30, , , , ,
~oO,
v.. No
No
28
30
31
8000.
VII
No
x
X
VII
No
VII
No
VII
No
VII
32 Was Ihe v.h,ell Iv.liablo lor POllOIIUI
UII during off.duly houri? , , ,
33 Wu th. vthlel. u.ed pnmanly by .
mor.than 5'16 ownllOrrellltd PIrson1
34 Is another v.hicll aVlJlabl. for p.rson.'
UI.? , , , , , , , , , , ,
Stc~on c-.ouIIUon. lor Employo,. Who Provld. V.hlelll lor Un by Thllr EmploY'1I
Answor Iheso quo";ons to a.tlrmino ii, au meelln exception 10 completing Section S lor vohieles usea by omployees who ...
nol more than 5% owners or "III.a oan;~"s,
35 Do you mainlain a w,,"on policy st"om.nt thaI prohibll. al/ paraonal US. of vohlcl.., including commuting.
by your Imployoes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35 00 you maintain I wn".n polICy 1111'",""11031 prohibits peraanal use 01 vohlel.s, exc.pl eommullng, by your .mpIoY"I?
See page 8 of the inltlllclions lor Vehi":" Uled by corporal. officers. direclors, or tl. or mot. ownl1l , , . , ,
37 Do YOlllrBlt 01/ uso 01 vOhiel.. by omployees as PIrsonal 11.581" . , , , . , , , , , . . , .
35 Do you provide more than fivo vet,;ciu~ 10 your omploy"', oblaln inlormallon lrom your emplOYHssboul
tho us. 01 th. vahieles, and relaln Iho lalormaUon recolvBd? . , , , , , . . , , . . . , , ,
3g 00 you m"lth. lequirem.nts concam".g qualified automob,l. demonstrallon uso? Set page 6 01 Iha InsI1uctIons , .
Naill II r anJW" 10 35, 36. 31. 3,1 0'39 is 'Yes,' u neBd not com ,". Section oS lor Ilia coVllBd v.hleles.
Amortization 0
V.. No
"1
Otacnphon of '0111
101
o..l"olm<.l(hUllOn
I..".,l"1'
III
NnortIllIIOn tot
lIiII_
I.'
AmotllU:JOr1
_01
PtfunllO,
leI
Amon....~
amounl
lell
c-
MCl""
40 AmOl1ization 0' cosls that be ins dUI'I:' \'!Jur 1995 lax ear:
41 AmCl1ization of Calls thai began t.(.J~~ 1995 . . . . , . . . . . . . .
42 TOIII. Enter here ana on "Olher Dl'luC!l;ms" or "Other Expenses" hne or our return
41
42
@ ~.... 0" ,"ft'N ,,"'.,
--
-
-
-
0-
',11 )~~ . Air:iCOME 1:1\.)( RETURN~~"'j lA~lJ..~:;r~~;)1
~.~-.ou IlUST I'ILI ST IlIDNlQl1T lKl' ...v, ,PM ,~ ,eee'" 9 ~~
""'~""" IIfw*lI ,'~~.. ..,.. "."
,/Com/llOllWNII" 01 "-nnl'/tvanl. PA llallInm.nt 01 RlYOnu. 5
~"":D~IJD '0
.... ..::::.. _I ..
"**...,. 0nIw .. PIno'!lNr...... 0
"'"' _. Mill
_ 01' THlIICHOOL ""'II>CT
.... ... ~ t1. ttM
k' \. ,
,," ,. I 1- . " \
to' ....,.
: j-.... .1\..:' J......
,.... ,'1[-"\ I
VU~- ~
J~_..
/ ~~
"
. I...-. Ie .\
-... \
\""
...'o...JI}
E.
[!!iiI:iDJjj~ ..
"'..........
Din ICT COOl
IIaQ]
0iI0<' ""'.... NOT 0" _"' WlIOQKLlT
',.,
..
,. ..
,
CIO
INDICIII HOW IWff
0# IACtt K.lAU OR
1CKlDUU: 1I AnACHID
CIO '''' fonna w.a
00 ''''_UI
00 ''''_A
00 ''''_I
,,,,_,C
''''_Rll.'_
00 ,"'_"
00 ,,,,_,c.p .,
00 ''''_,D
00 ''''_loa 0.71 _
00 ,"'_PMI_
,"'_loal
''''_,J
''''_loa 0.,
II OROSl PIHNSTUlINlI COIlPIHIlIT1ON........".. ,,,,,,,.......................,
18 UNREIIlIUIISED IIlP\.OI1i IUSlNE88 EXPEN"'...... ,.".................... 18
10 WCAIll.I! PA COIlPENBATlDN, _ Una 18 I<om LIn. ,.........................................,............,..........
I TAXAlLlINT!REST, COmplooo "" _II AN.,,, 11.000 ....................."..........,...................."........'
I WCAIll.I! DNIOENDS. COmplooo "" _ I 01_ ...000,..,.."........"".............................."..........,
I NET INCOIlI Of IL068I _ III OPEIWION '" . IUSlNEII8, PROl'ES8lOH Of fAAll......................,
I NET GAIN Of l\.OS8l""'" IIla IAU!. EXCHANGE Of DtSl'OSITlON '" PROPERlY""......".."......"..".."
II AIIOUNT 01 0AlH EXCLUDED on "" _oloo ......"............................ II
I NET INCOIlI Of (LOIII- RENTI, _AUIEe. MI'ENTI or COPYRlOH11I............,........................,
7 ISTAT1I and mUST INCOIlI .........................................................."..............,......,......,..,,,........,............
. CWlIlUHO and lDTTIRI' WINNNGI ........................................................................."..,,,......,,....,,,....,..
. TOTAL M TAXABlIINOOME. Add UnM 10. I, :I. 4, S. .. 'I, and a Do Not Deduct
10 "" TAX UAlIUTY. "".ply UnlI by U..CQ02.I..............,..................,,,........................,,....................,
" TllTAL "" TAX WlTHHE!D............,..............................,.......".........................,................,........,..............'
_ UTIIIA1'IIl ""YIlIHTI AND CIIIDf7I, _ Iho __ on _ 10,
120 CRfDtT Inlm 1* "" TAX RETURN .................,......,.............................. 110
UII 1118I ESTIMATED IHIITILUIENT _..ENTlI..............................,.........., 121>
120 ""VIlENT wtIh 111I EXTEHIlION RECUI8T .......................................... lie
I2d TllTAL ElTIIlIT1!D CREDIT, Add Unoo 110, UII and 110.......................................................................,
'WC ,0000000UI_1'Il1C1tIIlUL.I1II _Iho lnIltuctIona bogInnIng on .s.
III HOUSEHOLD IlEIlBIRB I,.., una I, PIn II, "" _.... BP.............. '1.
lib ELIOIBIUTY INCOIlI ""'". una 1, PIn III, PA 8</loduIa BP ................... 'Ib : f ~
1:10 'l'QUR TllTAL INCOIlI ""'" una 21, llIIp ~ BP WORICBHEIT .............. 1:10 0
'I
1:1d TAX PORQIVINEII ""'" Una e. PIn III, "" Bc:IIId4IIa BP......................................................................, ,:Id 00 '01 _la, 0
14 TllTAL CREDIT lor TAXES PIID 10 OTHER STIUS ..lXlUNTRIES....,..............................,.................... ,. 00 '01_' W
IS 1!loII'l.l7l'U!NT INCENTM! ""VIlENT1l CREDIT,......................,..................,....,..................................,.., " 00
11 T'OTAl. CREDJTS and PAYMENTS. Add Una1t. t2d, ,3d. ,. and 111...................""..."......."......"......." 11 00
17 TAX DUE (tl Uno 10 II _.... Una '" ....... pili. 21 and oompl"'l'Il Pwv..... _ on . as. 17
11 _VIIIHT IlJno ilia ....._ una 10)....................,..................................:...."....,................,...., 11 00
Ilia AIIOUNT 01 UHf 1.10 III REfUNDED ,............................,.............................................."..........,..............................,................,...... ,..
110 AIIOUNT 01 UHI ,. 10 III CRIllfTED 10 """ 'M EBTlMATED TAX ICCOUNT ...........,....,......,........,......................,............,.......... lib
110 AIIOUNT 01 UNI ,. 10 III DONATED 10 WILD RESOURCE CONSERIIATlON fUND .........................................,..............,,,,..........,.. '"
lid AIIOUNT 01 UN! ',10 It DONATED 10 u.s. Ol.VIlPIC COIllllTlEl, "" DIVISIOH.......................................................................... lid
The TOTAL ar LlM. ,.. tf\rOUoh tad MUIT Equal U"" tL
111111'OU1 WUM!, U......... 11.-.,,1'_..... ....1.... ...11.1............,..., ......._,...,......... .-It..... II..., II ..I_I"', Ill....".........
atlol" Oai '1\:)u .,tOt;.
DtIa Spoult', ()a;:upIUon
"
a
I
I Vll
.
I
7
I
.
'0
"
00
00
,a.
00
I
E
-
_uIa SP u('
CC_ only ~ cIalmIng
lax lotg/wntII)
- 0- DO
- 00
00
00
00
IIIUU TOil (AlIO TOIII IPlIUlIlllIM, CHICK AU MATH, A"Al:H AU ICHIIlIILlI AlID fOlMI
r~IH~~!",,: ,..... ..._ .. ..--.-..-..-..... .....~_.-_..
DtWf,1mI ~nt Numotr
.. ~! ;lAr.r) itleptM?nt Nu~
I I
~
-~~"
-
"r
-
1mpIojo(1 _III
_...D...........JoII.._Y...I_~__
,,ulT A: UHlCH CUll (Homo IlIld IIIlOUIIU
'''''1' I: WClM CLDTHO AND UHI'DfIIII (lIoqullod II I condlllon .. ImpIojmInlllld noI _ 10' y ...,
'''''1' C: IIIlALL T-.. AllD _ (lIoq""od II I _Ilon.. -....nlllld no! _.. ... ......,."
'''''1' D: "",nlllOHU LICaHII NIl, IWJOIlACTICIIHIUR'HC. AllII MIUTY ~ '_11.
(1Ioq_ II I __ .. omploymoftll
'''''1'.: TlIAYIL AllIIIIUAGI .... -.. ,.,.. II" ., 'A _... UI., -... _I
TDTAL IIII'LDYlIUIIHIII _ Add'1III A lIlrOug/I e, Em<< """1Ild on Uno 10 .. 'A_
00'
00
00'
001
A
I
C
D
.
00,
1b 00
1995
~ lecunl~ NUft\O!r: '
,.,114t.. 10/;'/
PA SCHEDULE SP
--
"...,.,.,., 01......
"rf'j"" - '!l_
-It-ll.nn t
-.... 1M ~.... -.e, ...lIUIT ~...... WOAKIHEET on _n.
PAIlT I, C.rtlllcetIon 01 Eligibility:
'(1Ild mr 1pouN) /lI,......... _1lIld CItllf'j lIlIIl.", I.,... 1/011llglOlo'" T..l'oojll...._:
IeotIoJ> Al Filing .. "I", lingle Of "II", ...m.d FIling ..~.I. Il,'um
I, Ii?[ I ~ I potIGtIIIy ",_ II ..... _.. mr -. 1'.... "-' In ll16l1ld I.", IIIgIOIo "'1'11 ,.,\llYO<*I,
llIIIng "II", _'lIInQ '-III Ro'oIIII, ___'I Noml IIld
_......,......... I I
.. 0 I 0Ifttfy IhaI I 11ft. depenclent of. pe,,,,,, """ .. ~1IMe faf ,.. h.utwn.M, I wn h"~ .....-s .. . ~""I "" the rMtMrt'rIN'" r....,..
Inoofrw Tu RlCum of:
Homo IIld _ ......, H.......
_ II Filing .. "J", _1IlcI .lIlmlng Till FOIIII_ JoInUy
a. 0 I.... m,_ _Iylllll.. lit ....._ ...Tlll'otgIY_IIld.....1o ftlo. JoInI'A _..., AIooIIM"" .......... N1lo1nllyllll\onty
onIlpOYM QUAI/ftII tor Tu Porg/vtn... and 1M 011\" tpOUH .. . depIndtne wttn no IaWMI 6ncom,.
I'\.aAll! '1I1HT
_ CI Filing.. "F", FInal Pol. h.lUm 'Of. dac.aNd 'Indlvldul1
_..._ "'''''lIIIngwlIlI,I_IyIllaI:
4, 0 TlII_lolllollglOlo_"ll\oIogIbIoDo"",,*,!"'TII'~_p_.
PAIIT II. Number of H_hold 111111"'" lor Till Forglv.neM PUrpD..II
t." III. for Tu emll ",It," AHD 1I..om itlIt and
Dtpondtnl" Name Illlollonahlp BocloJ .....'11' Numlll.
. dIlm "J" 11\I., "2",
Pol. Tuob.. Income
II... III cI&Imlng ,.." _ II ,.." clIpon""", eotnjlIell Uno 2, " 10TH 0/ ,... I/O .1_ Ind ,... III nil", jolnll"
DO HOT COII,LaT. LlHII,
I
2.
I, 1n"'1IIa Inl_ ... lOCh dIpondonl Child _ bilow, Enllllho numbll cal_ hili,
0,
00
00 DNO
00 DNO
00 D'"
00 Wf,.
G J.
180 .,
I
I
I
I
I
4. TotIl Numblr 01 HouNho6cl MImberI. Add Un.. 1,1 and 3. Entlt hef. and on Unl131 ot rout PA-40R,
...-.
PAIIT III. C.lculallng Your Tu F...glvo"'M Crlldlll
1. IUOIBIUTY INCX)ME from Line 1101 rou' IP WORKIHIIT. "uainQ flUng Itll~ "J"w claiming Tu ,<<glv....... to'nut, tnl" th.
TOTAL (JoInl Column) IUgiblllty lnoome lor You Md YOl,lf Ipou... " lolling flUng IIIIUI "I" lingit, 01 .....1 ....n.. FlUng Separ'l.
RltWnI, 01"''', 0IcHHd, PM Retum. Inl., LhI ElagltMllty Income 110m YOUR Column. Alia, enltf' on Unl13D 01 'tOUr P"-eOR. 1
2. TAX LIABILITY nom Uno 10 .. ,.." 'A..OII, I
I. LESS IIUIDEHT CllEDIT !rom Uno '4.' rour PA-40n. 3
4. NET TAX UABIUTY. SublrKt Lint:l from Un. 'olttoi .,,111 lhe INUit htt.. ..
t. HActNTAOE Of TAX fORGIVENESS ltOtn It.", cll,llbWty Nome T...... 8M W\iltuetlonl a
t. AMOUNT Of TAX FOAGIVENEBI CREDIT. "',"Illpf~ Une'- by Lint land ,nler IMItIUtl heI. and on Unt 13d 01 wau' PA-4OA ·
""
JIM THORPE EARNED INCOME TAlC OFFICE
140 WEST TENTH STREET JIM THORPE, PA 11228
(7171 325,3lI21
TAXPAYER COP
FINAL INDIVIDUAL EARNED INCOME TAX RETURN
19'J~
CALlHDAR YIWI
'WII fiLl THII RITURN IY APRIL 11TH IVIN If NO TAlC II OUI OR IF IT HAS ALL IElN WlTHHILD,
HAMI AND ADDRI88 BILOW,
IOCW. IlCUMY foIQ
J i'1.'~6-''1121
OI.EIM E 1l~:r;KO~1i
,~/J9 1 VlTH (iT Rn:T
J11'I 1'HOflPE PA lB,J:.;:9
llAI ntI"Q fOCOMICI IOCW.IlCl.JlillTl' frjO,. HKlUNh')
...... ..-.
~1:r' Em
" YOJ UOVID .....IIHI ADOf\lU-1CI.U)I Iwn Oft ACMD
ou.... ""
\'IAIl,
COWUTI fOfU.6IJIl ADORlu..IfQ.UOIlTNrr Oft AQAD
IliI f<lUOW.
...,
CHI
"
OlHlll
"lOlI B /ql./
TO
/2 .r-
PRIHT EYPLOVER'6 NAME. LOCAL ADDRESS. cnv. STATE. ZIP IU:~ ('Ill'lER 810E FOR I.IORE TWoN 4 EMPLOYERS I
TOTN. GAOSIlAAAlHQl LOCAL fAll Vfl'~
lIlO-1 INO_I
.
.
.
.
.
.
.
.
I TOTAl. OROSS IARNINOBAS WSTED ABOVE NO RDUNDINO
2 LESS: Allowabl, non.,.UnOulled . 10.. bulln". 'aPtn...
AC R E.f G R U . AN RM
. S 0 DUCT: 1'102" _ _0 OIl _ PNlodllphil CIIy Tu h.. boon poId
4 TAXABLE W.2IARNINOS ISubiroa Iin.. 2 ancl31101l1 Uno II
a OTHER TAXABLE EARNED INCOME. ARlen Form 10ii
INT~AI!"T NnT TAYJAL'
I TOTAl. TAXASLE EARNEO INCOME IAdelI,... 4 0'0 5) NO ROUNDING
7 NET LOSSES a' -. '^
11"'_ ""-- .
"'MIMCNd) f""......\knCI l'IllnI'In'I"W'tIScnfl
. SUBTOTAL (Subtract tin, 7'rom Un. I) It.... thin llro, Inl., UfO
I NET PROFITS lI> '" a a. 0 Ot>
llDAO...... I' .
.....1lIIalIlQ '/ICllIl......tSctlCI 1''''MlW'lQIIcft.f)
10 TOTAL TAXABLE INCOIoIE AND NET PROFITS (Acid 11n0l . ond II
" YOUR TAlC 11.. 01 ""0101
12 CREDITSl (DO NOT INCLUDE PHILADILPHIA CITY TAX A8 . CREDIT. R!fER TO UNE :I.)
CI) Elmld Income Tu Wllhhlld.. IIIlld lbovl I
(b) PIVIMn" on DKlIIlUon 01 E,tllNlld Tu TOTAL _ 0 _
and la,t VU'" OYltplvrntnt H cttdllld . . . . . CREDITS 12
13 "yow CREOITS IU"o 121 010 ilrvor 1/1.. 1M TAX ~UE (11n0 11), 0'10I1lWUUY1WIT.. "", , " " , , , , '" ",13
CHECKHEREIFYOUWANTTHIS DVW4Y111H7 REFUNDEO TO YOU 0 ORCREOI1EOTONElCTYEAR'SESTlIoIATEOTAlC 0
lNO REFUNDS OR CREDITS FOR AMOUNTS UNDER nDO)
14 If )'Gur TAX DUE llln. 11) I, larg" thin your CREDITS lUn. 12), Inl.,.Jt\I.AHl;I 01 TAX RJlit.
15 AmR APRIL 15. PENAlTY AND INTEREST WILL BE CHARGED ON LINE 141K"Ila Pit month II'Id NCtl montnlhtrNhlf1 .....,'.".,..,.... .15
,. TOTAL PAYMENT OUE WITH THIS RETURN. Acid 10'01" ancll. IPAYMENTS UNDER 'I.DO ARE NOT REOUIRED,) ....'""" """" ,,.
P I A
...4,'"
.......... ..........1
.'
2
3
.......... ....... ...4
.......... ....., ....5
.....................
.
I ".
'I;IIIP~ISdlM.O
T
.., ....... ...........
+ 'fIlIllP.,..,.,.,ISctlM.Q
"....""".."",,1 ~ (.,:I.:2.0.at\
t, ,J,ao, UD
NO ROUNDIND
....,...... .."" ...10
11 ' {g".~O
· (g.ll,J,O
..,.."....,..,.....14
~
f
~
c
If / I ~Ok) qZk Poyoblo 10: Jill THORPE AREA SCHOOL DISTRICT
I DATI llGHATuRlOfJ4XPAYlA
~.II1I.filI.I.lIIfILWWILIl.llDWIJI1AN"J4IUWIl
04tlGf'N'AAA11DH fWIMI1CQlr,MllAIIl'0I''''''A''lll
~T"""Gf""'Ml"
........
-
ORTHOPAEDIC ~SOCIATES OF ^LLENTOWN, LTD,
TI106.&AS I. c.CKIOH, JR.. w.o.
wo.C!0e404 ..
'ATRlac '0 ".&PET, W.D.
we.OlIOI...
THClI.IAS D. WEAOE, ".D.
we. D:U111' . e:
11)0 "'-1&1_ NlMlo.n,'" '1'';401'" "*" 1111,.>>-1041
Nom. ~ f).....!4-,,(.... Dal. ttJ/1/1>
1) r~ 10/\
~I .*,0 ({1"'.","/) U
A' '. -r 0'" Q~"" ~vv-- . :1::.. l-
....... IfrCO.AI ,",nolf _ ~
lU.nmmo".'U...I.....L.I /' WOO
"'OllO""'~ A IIlAND"","1 'ItODU '1" '"II'''IICII'IU WUITMAHOW"lT1:
'.IlANO ""ICIlIAIn'" 0" oMAHD WIDICAU.Y fillCUIAIrr IN THI PACe Ul.OW
CU"ORD Q. YERhlex, WO.
wa. D07113.1
P'lTlR A. KlauS", .IA. ".0.
Wl)'ClO683>,E
-.-
~ .} J' ~
J.~' ~ z
q ~ o ~o ~
ilmgf ~ V\ \=='~ ~
jli/ifi j
to 2 .\- , II
! ~J i:J ~ u~
J ~'-Y\. ai'
~ I I ):. ~Ll
. r
i
PATIENT ACCOUNTING SERVICES, INC.
(CAAUSLI! IMAGING ASSOCIATeSI
P,O. BOX 100 15 STATE AVE,
CARUSU!, PA 17013
PHONE 71724112482
~ .......'711
"
, , ., llOC:1UlI
(
~
0.00
KEEP THIS STATEMENT PORTION
FOR YOUR RECORDa
..
1 'I,LV},I JU!i !',',Lr,lJl.r'- -"
DETACH TIllS S1\IB A
RE1\IRN WITII YOUI
MYMENT, .!'AYABLE 1
CARUSLC IMAGING
ASSOCIATeS
'Tltlltlk I\OU
.~.~~~~'\ """""~
~l, 't . l.l\" ' . t, I t 'Ill .l I, ,~ I 'I .11
.... ~ ""11.".'1.11"".1..
(~t (~J 'l.bO,
TAX 10
25.1643669
I;J"HI"
T.""""'..f.""""".'"''''...'''
" ,
" ,II "", ..
:-: -:.,.., I
' ..
,
,.
"
t
"II"'"''
i
I
t't
l).ll,V6'A__
.'.".:.....'.' 'I'
"
.
"
0.00
1.1 t...""
~~u;:,' W
::i4.00
\oJ.1"1 'UH.1l1h),PA j U~.~IJ
TOTAL
$
.....ooIH M:JD
.' -. .-...---...--.----.--.....
CARUSLE COMMUNITY AMBULANCE
P.O, BOX 480
CARUSLE, PA 1701300480
PHONE 717.249-0012
~"';'-.;~"Ir.'Jlk,~
1:1011 .
~
; t' r
,.
....,; 1
. r
~. ['
\ I
i f'
i
'. f
I
,
, \0"'90 225.00
. OUR OFFICES,
lEE MAP ON REVERSE SIDE,
> STATEMENT PORTION
RECORDS.
12/0U.'Y;S
DETACH 1 H," t TUB A,
RETURN Vii rH VOU!,
""VMENT, r'AYABLE T
CARLI .t:~ ~OMMUNI1
AI.,.."..ANCE
Th."I, )'UU
-1L ~..~
la,"'IlV. I~UI.1l
L. '."lIf'I'I"'''TIm...
1:.>/00/'13
,',
TAX 10
23.2298422
Gler,"
~..!l..ll'l~*""""',",.t:...:Dt:. '.~~.
f'!,EVlllllU lif,l.lltlU,"" )
:r.r.'.~..'J'-1L::' ~
4;:2:.1.00
k
~
fI .,..".. 'I..............."....... ''''
~! '
,
, .., ~,'
.i'
,
1
~~~.....c~m :'
1;" :...,f'!II!", fl"\"~III'III.!!
0.00
O.f/O
0.00
0.0"
, .;....". -. lilT d..,.'
:;,!OO U N;dlrl3,lIl flt.r....,l
"hW.
TOTAL
Ue.. quu-honi "y, PA llJ.!4<'>
$
.WOUI" MID
.
l!
LEHI~~AILEY
HOSPITAL
ACCOUNT HUlllIA
5 .
1AIDIC.u. NCOftD NO.
IRS NO, 23-16898!
'AGl Me.
,1 OF
,DATI or K.L.
lSDEC93
l'l'~'.r "lnnlOTHlI
aCClvu,\lll,uIolIIiR ON ALL ....
CHICKlAND
COttIQIPOHOINCI
DETAILED BILL
OlWlANTOR'S NAJ./E AND ADORESS
PAnlHf MAMI
elLENN E DERK08H
_mOATI nNOfIII"YlCI
04/05/195 OUTPATIENT
""",""",PHYIlCWl
L.AIIIU!NCE STEVEN
...-
J 7e9,5
~PROCIDUI\I
IL
r 1
-.."
J ONOV9'
IllICIt.."
JONOV':
elL.ENN E DERK08H
eoe II RAIL.ROAD BT
N!SQU!HONINel PA lee40
L
. PUASlTUAATPf"'ORATIOf4N<<JRETURNTOPPOflTlOHWlTHPAYWHT .
alAYlCI CHARDI DIICAIPllON CPT4 UBU OTY, PAICI
DAn COOt!
---------- ROL.LUP SUI1I1ARY ------- --
, NUCL.EAR /lED 340 1 eso.s.
.. ..
".k_' .. ., ... ""- ._, ... '- ...
- ..., '.-- .... ." _. ...."..- ..-,....-. . .
, '. ., ,. ".-. . .....,' .... --_..- .. ...._- . .-. . .-
,-,' ....... ... . . .. .. .,. ... ....
....- ~. ..... ". ..... ,.... ... ..... ." ..
"
..
..
,.
. .. ,
." ,'.. '.' ..
., .. , .,
..
..
TOTAL CHAROES !-80, S,
ADDITIONAL BILLINGS MAY BE NECESSARY
FOR CHARGES NOT POSTED PAYlIENTS I AOJ,
AT TIME OF BILLING,
BALANCE DUE ~80. 5_
THIS BILL IS FOR HOSPITAL CHARGES ONLY.
YOU WILL RECEIVE A SEPARATE BILL FROM
OTHER OEPARTMENTB FOR PHYSICIANS SERVICES
THE AlIDUNT Of THIS SILL IS DUE UPON RECEII
PLEASElEND PArA/ENTro: ~ LEHIGH VALLEY HOSPITAL
P,O, BOX 4120
ALLENTOWN, PA 18105.4120
(215)402'9485 Of (215) 402,2207
FAX (2151402.9-434
PA-ol........'
4646e1l0'
o CLIFFORD O. VERNICK, 1.4 0,
1.40, 007'ilE
o PETER A. KEBLlSH, 1.4 0,
1.40 ' ODei35E
o THOMAS B DICKSON, 1.4 0,
MO. OOi-4004E
aUARANTOR NAME AND ADDRESS
Orthopaedic Associates of Allentown
1730 CHEW STREET
Bll NO OUESTlONS CALL (215'.35.3917
Ut;)IIUN~\,;"
o PATRICK B RESPET, 1.4 0,
1.40, OllOl<E ,,[!I.: 'l
THOMAS D. MEADE. M 0
MD.0321181E
STEVEN J LAWRENCE, 1.4 0
MD . 049373l
DOCTOR NO,
y
FED 10 NO 23.1851130
PATIENT NO,
PATIENT NAME
DATE
In[{o
?t 6,vAl
D t-~ t oJ H
10 (II:
DATE OF BIRTH TELEPHONE NO
INSUA/M:E
coo.
D15CHlJ'llOli
CU".flCATI: HUW8EA
e;,e.
II..JN D ;/,41',
PL PRCJ!l, CR. CD,
CCI
CC2 CC3
RVS I DESCRIPTION 101 ISSCOOEI AMOUNT RVS I DESCRIPTION I 01 155 CODE I AMOUNT RVS I DESCRIPTION I 01 las CODE I AMo,
~' I I I I I
. ... NOW INJEC OR ASPIRATION ORTIlO APPLlANCO
INTENSITY I
'10 L",.., H205 '04 T.ndon Sh..I". L .mam 20550 PPIA IXTR!WITY
;#! l.....14 "'04 " ,'Pl..O ',on
Level] it '06 SmaU.IOlnL'BuIII '0600 ... M..nn.Wr'll "' mo"
" Len'Z .07 Inhmn~l' .bnl BUII~ 20605 37 WnllG.unllt' "006
,- IA...'" U' I' '01 M. rJOlnVlh..,... 206'0
'0' F.lell 20i99 KHEI!
I. ,. II & U UTAIUSllIll 137& Pl1hllt.brall,e.1 &4'''2
INTENSITY p;nln.rv'.lumba, " t(n.. Immobl~", IIUO
701 "'","5 "215 CASnNGS 1321 Mu1llcenlr.c.pull0rl L1AIO
123 Levt'" g921.. loon ell' .s. l.luttQnlllC'W, 211125
, Lewat] 13 S ,I " Plt.~o1' Btacl l11110
'" h~' g9212 1327 C'ulehel EOl2il
..... h'i'ell 89211 '" . R. "OIlCIlI
,
1 OV. To"l elrl Uge2" fOOT I ANKLE
'38 ov. NOCt\lIOI SURGICAL PROCEDURES
"" Hold tor F.. .. Al, SI,r,u
127 Othce CNr . 1M' T " o.bflde Wound L'm l1G40~2 1326 Ai,S"rru l .
. .. tee COH8Ul TI HEW I EST .. o.btlCSl WOund 0.. I 11G4152 1335 C "'''' "'
7. I & 0 Ablel.. . Siln Ie '0060 337 Lvnco Arch Su ,
13' Conault 15 6245 7. I a 0 H.mo1tOtNl. Sl . 10140 51 elll Boo1 l3:.GO
13' eon.ull" "2.... 100 Rlmovt But.-d WIII'Pln 2067052 .7 ConwlleSCInt Shoe LJ~t.iO
13' eon.u" 3 gi2"J 01"", ., ......e ,... LJ 00
12' eon"" , 62..2 .. U.to1larulPld . L3~0
n. eon"" 1 i9241 .
SPECIAL SERVICE OTHER
CONRRMATORYCONSULTS , Clnell Rltchedule I F::::=E
707 ConfirmS lillil275 . MlfdICal~'A" 99080 , 8A
706 Conllrm .. i9274 7 MedICal R IHnl 99080 AEFERRING PHYSICI.'
13. Conl"m3 i9273 11 Cl,.bol, Form 99080
'" Confirm 2 1K1272 " EVId.nc. From RICO/d 89080
13' Conlllm t 99271 IS Co Medal Record 99199
DIAGNOSIS REMARKS '-, <!) (tor DATE OF
~ , ~ LAST PAVMENT
-
v-. fl PREVIOUS ~SUAAHCE PATI[Nl
BALANCE /\ . II t1 .. 1-4-.
TOOAY'S CHARGES -.,.,
- -,
PAID ON ACCOUNT
CHECK CASH
, AOJ
TOTAL DUE. ::.. -r ',/1
AUTHOfUZAnoN TO PAY BENEFITS TO PHYSICIAN: I her~'br lulhorlZ' p.~menl clllecll~ 10 Ih, RETURN TO WORK NEXT APPOINTMENT
unotrllQlIed Ph~&iCI.n ollh. SurglCll 1"'1;01 Mtclal Olnel'I.. I In)'. otherwise p.1~lble 10 me lor ,--.1; ,.I.A'....,..
hi. IffVlCel II dtKtlbed hlllln but 00110 Ilctecllhl r..ponSibll .00 cUllomary chI/g. 100lnose
1t1VlCe1. ~ "'-~-
ON: tJCr I~#
CATE I
DATE I : )4 ~ts}" ./ /
SIGN4lURE DATES DISABLED: \
AUTHORIZATION TO RELe:ASIINFORMATlON: I he'lb~ lultlonz. the uflOlHllgnild ph~llCla" 10 OFFICE
IIIt,," any in'ormllloll acqulfed In tha cour.. 01 my 'Iamlnlt'on or 'rulmenl mOM: '-... ~
^,AAV
,
CATE TO. OOP
SIGNATURE
'.'.
---- -----.-.---- -_.. -- --------
------~- --- ---_.
CLIFFORD Q. VERNICK. M 0,
MO.OO7183E
o PETER A KEBLISH, M 0
MO ,_mE
o THOMAS B DICKSON, M 0
, MO. Q08\O<E
Ort~~paedIC AssoclateR 01 Allentown
I I 1730 CHEW STREET
I ALLENTOWN. PErINSYLVANIA 11104
BILLlNO OUESTlONS CAU 12151 m 3077
OTHER QUESTION!. CALL 121$1.3360<15
fED 10 NO 2318S1130
o PATRICK B RE8PET, M 0,
MD.01IOI4E .'_
o THOMAS 0, MEADE, .. Dti ~. )
MD, 032"IIE '"''
nAfEVEN J LAWRENCt, 0<./
/'- - MO. 04U313L .-.
-
GUARANTOR NAME AND ADDRESS PATIENT NO, PATIEtlT NAME DOCTOR NO, DATE
C'LENN E: DERf.:OSIf 1~7,,~(I I-;LENI~ E DF.RKnSH (1(11)4 1 LI/1ElI
208 W RAlLRnAD ST 11 :!(1
NC:SOUEHONINO PA 10240 DATE OF BIRTH TELEPHONE NO INSUf\A..c[ Cf.R'I~k:AIl fIILJI~~
COOk DEbCluPIION
PL PROC, CH. CD. CCI CC2 CC3 39 (717) co COMrN F:ED .r NFll \
04/0ri/34 '<'69-1>416 814 8SPA 1714601?1 n~' 7~,
N .I '
RVS I OE8CRIPTION I '" 185 COOEI AMOUNT RVS I DESCRIPTION I '" IBS COOE I AMOUNT RVS I DESCRIPTION I '" 185COOE "MO\
I
., NEW INJECTtONS OR ASPIRATION ORTHO APPLIANce
INTeNSITY "
III L.....15 om5 10< lIndon S"..lh l am.nt 2OS!.I' uppeR lXllU!:UITV
117 L.~.. 4 "'0< T' ., PI,O. loOn
III l.....13 09203 101 6'TlIIlJotnI1h.uu '0100 ... M,IMIW'lI1 ,"' L3~v8
118 l.....12 09202 ,., Inltlmedllll Joml'8ur'l 2Of.oS 31 WnIIO'unU.1 l3\1G6
12. llv.lt 8\1201 ,.. f.l. t Jo,nl Bu'''' 20610
,.. fUtl, 20999 KNEE
.6 U ESTABUSHED 1376 P.r,w'J1llbr,II'celt 64....2
INTENSITY I MI\I'. klmb", " Kn.. ImmOlklll., llll'JO
101 L.velll 8;215 CASTINGS 1321 MultlC'l\lllC,PuIIOn LlblQ
123 Lev.I' Og214 lion e," ... MultlClntrlc,WI Z1U:'!I
'" llv,l] DQlf3 " 63 PII,II" Br.e. LUlID
, .....12 '" 1321 C'ulth.. E01.!O
,. 'veil VUlI R.. !GallOn Cu'
S ,,'
, OV . TOl'1 e'f, , FOOT I ANKLE
"" OY.NoCh" . SURGICAL PROCEDURES
2:,' Hold 10f' FH .. AI,SI"'uP
121 Othee CIW . 1M' TI 17 OIbrlde WOUnd ILlml 1 104M2 1326 ~'5hr'u l
DPP'tcl CONSUL T8 NEW / EST eo D.t>>1M WOund lOll... I t1~152 1335 C Ale" Su Of
" 1& D AbICln. s.m ,.... m LwflCO A/en Su .,
132 Con.~5 89245 " I " 0 H.m,tomA . So lOUD 56 CII' Bool L3;\iO
131 ConSUlt. 182.... '00 Remov. &lIIed W.,. Pin 2067052 51 Conv'l..,.nt Snot L3;I,Q
\JO Conlul1] ..,,, "..,,, .. H."Cu Tuhl L3~JJ
120 Conaull 2 119242 5' M.l&I.ruIP,d l3..10
'" eonsult 1 89241
SPECIAL SERVICE OTHfR
CONFIRMATORY CONSUL T8 2 I Cant.l AIlCh.ault I I
,., Conlllm & i921!l 5 MtcllCo1l RlIporUnOl 99080 3 B' I I
101 Confirm" 9927. 1 Med.cal R.por1.lnl 990lhl REFERRINQ PHYSICIAN
135 Conhfm3 99273 11 o.ubohl FOIm ..."
13< Conlirm2 99272 " htdtnuFromRec;ord 9110110
133 Conlllm 1 i9271 " C. MId,eal RKOld 9919'.1
DIAGNOSIS REMARKS u( DATE OF
CRU~;H INdURV FnOT 11)4~ LAST PAYMENT (l11l' ,/'?:
PREVIOUS !Pi!iURANCE "A'IU.T
BALANCE :"/!'i. ( ()
lODAY'S CHARGES -::..~
. - ',-
~J~d 'I<-'4}f PAID ON ACCOUNT
CHECK CASH
AOJ
d- ~ II rrr/7 TOTAL DUE. ..;'rd.
AUTHORIZA' ..,.menl dlr8CU.,. 10 Ih. RETURN TO WORK NE)<T APPOINTMENT
underligned I 'Ie pa.,.'bItIIO me 101 ~ l~il.C
his ..Met. . r C-',ic.... , nary charge lorlhoao
"MelI. 0"....:::: ~, _ ~..-
ON /pd J I '7/C.-C
CAlt
E f'9~"
HOO,WANT,HELP DATES DISABLED: \ ' t. ,-
AUlHORIZA" OISCOVER RECOVERY AT tualQnlld ph.,.llClilnlo OFFiCe ~-z
r.I.... .n.,. It COLLEGE HILL MEDICAL CENTER Of .........
FROM.
SUBSTANCE ABUSE mEATMENT PROQRIMS X,RAY
1-717-424011233' HI()()'926'B435 TO OOP ./
FAX 215-424-6380 E
-
-~---- ~- ---.--------- ----- ..----- --- --.-- -- -- ------
- ---- ..._- --.-.- - -- -- ..- .-
CLIfFORD a Vl:RNICK. MO.
MD' 007\8lE
[J PETER A KEBLlSH, M D.
MD ' ooe8m
OrthopSllcllc Assoclales of Allentown
, 1730 CHEW STRtET
ALLENTOWN, PENNSYLVANIA 111104
BILLING QUESTIONS CALL 1215i 435 3917
o PATRICK B RESPEl. M D
MD.OIIQUE
o THOMAS D. MEADE. M D.
MO'D32118IE
,
[J TIiOfo4AS B DICKSON, MD, OTHER OUESTIONS CALL 12151433,6045 ~EVEN J LAWRENCE. M 0 ,
, MD ' OO!WO<E FED I D NO 231851 130 MD.049313L
GUARANTOR NAME AND ADDRESS PATIENT NO, PATIENT NAME ."" DOCTOR NO, DATE
OLENN E IlfiRKfJSH 157850 C;LF.NN E OERKOSH /(~ r- orJ04 12/10.
200 W RAr LROI\D ST "l,r,
NF.SQUF:HON t NI) P(\ IFl?4(1 DATE OF BIRTH TELEPHONE NO , t\ANCE
COOf PESCRI CUnl'IC""[ NlNOIR
PL PROC, CR, CD, eel eC2 eC3 39 (717) (:16. 2l~'''A :;06:; 1 01 1 r932~J,I)
M/O~/~I\ 669-1,4 II, BIll B8PA .1711\1,0 I.).! O!'fF 0,
RVS I DESCRIPTION I " In COOt I AMOUNT RVS DESCRIPTION I " Is~ COOE' AMOUNT RVS I DESCRIPTION "IS~ :WE AM,
I I
~, ,"1." . I' HaW INJECTlOHB OR ASPIRATION ORTHO APPUANCI!
INTENSITY '-<- I
"" L.....la "'0' .0< T.ndon Sheath, l amenl ""50 UPPER IX'TRE&UTY
117 L.YII4 ..... To .rPlllQ. ''"
". h....l:I 89203 '01 Sm.lI .bnl Bur.. '0600 55. M,..nn..Wrl'l '"' L3908
110 ,...., 09202 1 Inll/medlal. JO,"lOUIII I , , l1 WItIlQ.aunllal L3906
." h.,..11 ""201 M.. lJoinl'Ourll 20610
.0. hiCI, 2og99 KNEe
I' U !BTABUSHED 1316 P..ra.,..I1.blallacel 64401;>> /,1
INTf:NSITY )Olnl nerv., lumbal " Kne. Immobollltl l18JO
'01 L.....la Rllmi CASTINGS 1321 Uu1hcentllc'Pull On l181Q
.., Le....,,. I; ""lIOn Ca'l ... Uulloetntnc.W. ZI82S
12' '....l . CII~ ' OJ PIIIIIII B,It. LI81Q
" L.....I;2 ~ 1327 Crutches E01:'0
I L..,.IIt, R. lion CII'
SpeCIfy
. OV. TOI..' Caf, ..... fOOT I ANKLE
'31 OV . No Chef t SURGICAL PROCEDURES
'34 koId IOl' Ft. 54 All Sliflu
121 Othct Chaf . IMt TI ., Debrldt Wound Illm t 1Q.40~2 1328 AJtShrtu Lo
" flel COHBUL TI HEW / EBT II D.bud. WouncllD't I 1104152 13lS C ""enS .,
11 IIDAblC....SlITI . '0060 3Jt lvnc:oAretlSu ,
130 Conault5 8Q2'5 ,. I I 0 H.matoma . S,mOI. 101.0 " Ca'I8001 L32bO
'3' Con'UIl4 !lOU' 100 R.me.,.. BUllId WIII'Pln 2061QS2 " CGn.,....l(enl Shoe Ll260
130 Cootlul1l O92U 011'1., .. He.ICu lulll L3430
... Con.ull2 8i242 . " M.lal,rlll Pad L3040
"" ConIulll 09;>>41
~8~5 SPECIAL SERVICE OTHER
CONfIR AlDRY . C..nc.IRnthtdul.
'01 Con/lima , Mtooe" R. 11....110 090" 3 ..
701 Conrllm4 8Q214 1 Mldleat Report Ins 99080 REFERRINQ PHYSICIAN
13' Conhtm :I 88213 11 Dlllbohr.,.Form 99080
'34 C4nhtm :2 99272 " hodene. From RKOld 89080
133 Conhrm t 09211 " COP1 MIId,cal RICord 99'9~
DIAGNOSIS REMARKS FOnT (Ed DATE OF
CRlISH INdUnV JOQ2 ........ LAST PAYMENT ,. ,." ,~-..-.
. . PREVIOUS INSURAACl PATIEN'
BALANCE -
.'")....!':' I.,
TOOAYS CHARGES C-If../,q
. PAID ON ACCOUNT
CHECK CASH
AOJ
TOTAL DUE.
.' AUTHORIZATION TO PAY BENEFITS TO PHVSICIAN: I hereb~ lulholll. payment d,"Clly 10 the RETURN TO WORK NEXT APPOINTMENT
UncNtligntd PhYliclan ollh. SUlgical and'Ol "'ldal Olnollll, Illny, other""... payable 10 me lor '7j'
hi, HrvlCel '1 dtlCflbod h."in bul nollo '.ce~ Ihl ".ponllblll and cUllomary chlrge for thalo
"MelI, 0_ w~~'MY2
ON
DATE
DATE HOSP,
6IGtiA'URE DATES DISABLED:
AUTHOFUZATlOH TO RELEASE INFORMATION:' h.reby 'ulh:JIII' Ii'll Und8".gned phYSICI,." 10 OFFICE
r.I.... any ;nlormallon acqullld in Ihe cour" 01 my ...mmallon Ot lltalm~nl FROM
X,RAY
.
DATE TO: OOP
SIGNA lURE
-------.-.,--,.. - ---- --..-
. .----- "---- -. --..--.. -- '-.
1 ClifFORD G, VERNICK, 1010,
1010 .007183E
PETER A, KEaUSH, MO.
UO t DOeQ3!lE
Orthopaedic Associates 01 Allentown
1730 CHEW STREET
AlLENTOWN, PENNSYLVANIA 18104
BilLING OUESTIONS CALL 121S1 435.39n
o PATRICK a. RESPET, 101 0
MD.Oll014E
o THOloWl D. MEADE, 1010,
MO.0321111E
THqIoIAS a. ~8ON, 101 0, OTHER OUESTIONS CALL 121!l) 433-6045 ~T .-.-:
STEVEN J lAWRENeE, II II I' Y
1010, O<E FED 1.0. NO. 23.1857 130 1010, 0<8373l I _ eo
GUARANTOR NAME AND ADDRESS PATIENT NO, PATIENT NAME . DOCTOR NO, '-o,(TE
-
Gl.ENN F. DF,RI<I1SH 5785(. GLl:NN E nE.R~:I:I:-)11 01)(1'1 .'I/C'3/
~oe w RIH LRnAD $T 1...../.
NFZSQUF.HONING PI\ 18240 DATE OF BIRTH TELEPHONE NO '..faUfW<<;E
coo. OEICRI'" CfHYlfICAU h"YOlR
PL PROC, CR, CD, CC2 CC3 \ IV
CCI 39 (717) C)f.,. >ew\ l;{E ':iO/-.':i1 04 I 1',1, :;?07,1~
.. 111/0::1/34 6(,9-(,41/> BIll ,:;rA 171460121 062700D
-.
RVS I DESCRIPTION T ,,'1M; CODE I AMOUNT RVS I DESCR'PTION I " hWCOOEI AMOUNT RVS ~ DESCRIPTION I " la, CODE I AIoI.
1& 101 NEW INJECTIONS OR ASPIRATION CAnto A""UANCI
IHTlNSlTY I .. I
II. hv.c& 0020' 10< Ttodon Shulh, ~nl 20'''' UPPER IXTAEUITV
117 L~et04 00... -lnnn., PI....GaMbon
118 Llnl3 00203 .06 SIN_ JOlnt/Ou'1I 20600 '" LLann. Wnl' I "'011
110 level 2 0020' '.7 IntllmllKiliotl JolnVBUIi..;a ...., 37 Wnll a.unlltrt IJ:.ofi
'20 ,-" "20' ,.. U.&lO,.IoInl/Buru 206'.
,.. "ON ..... KNEE
, . & II ESTABUSHED 1311i P"Il'tlf1l1btllllacal ....,
WTEHSJTV I Mrv., ~mblf ., Knee Immobl".' 11830
708 l.,." ..." CASnNGS 13'" UuIllCenlnc.PulI On llDIO
123 lhet. IV"'" ~allon CAI' 8M l.lulllC8nlllC.Wr Ild2S
"'"' ~.....13 '7 .SiMKi,;'-- .3 P,I.Ila, BtACM Lj810
O. ..." 99211 1321 ClulChea [(U2O
..E!' ......., A. lUflOne."
I
1 ov. Total ell. ..." , :;:~"EB fOOT I ANKLI
.30 0'1 . No Cha BURGle , R
'34 Hold lot h. .. Au SllffU
127 OtlaCNf ... T " IJrobndII Wound ,m 1l040!l2 13'" AU SIl'
OfftcE CONSULTS NEW I ElT .. o.tMlCM Wou~ 0. II041S2 1335 Arch 5 .
7. I I 0 Absce.. . 6lm 'D060 331 l "'ch Suooort,
132 eonlU" 6 MilU 7. II 0 Hemlllotnl . 10140 .. C'll Boot L\2<lO
'3' Conlull. 00'" '00 Aema.... But1<<l W""PIIl 20670S:i' " eon......lCenl Shoe tJ260
'30 ConIUItJ 89243 "'.... ., .....C ToO L:\4JO
'20 Consllll2 W242 .. ....'.I.v..' Ptld I1~o
". """'"". gnU -,
SPECIAL BERVtcE OTHER
CONFIRMATORY CONSULTS , C.~R.KMdoI4t
7.7 Conlltm Ii "275 . ..""""A ." .80.. 3 ...
708 Conlllm" R9:i'U 7 Meck.lIA '"' ..... REFERRING PHY~CIAii
'n ConI.rm3 6273 II Otublhl fOfm ..... '
'34 Confirm" 99272 " Evidence Flom ROCOfd ..... .
133 Confirm , ...71 " ""~IAlICOtd ..,..
T ,
DIAGNOSIS REMARKS DATE OF
, 7~' lAST PAYMENT ,.. " .. ,,-
CRlISH I NoJURY FOOT .
., " PREVIOUS tNSURANCE PArlE'"
, - ./
(9)1-d,-I"~ftf \ BAlANCE ')711 ..~,
{X"- , /' -.--.
TODAY'S CHARGES ...L -
.
PAID ON ACCOUNT
..
CHECK CASH
AOJ
<'
TOTAL DUE ~ :; ,-.~
AUTHORlZAnoN TO PAY DEMEf1TS TO PHYSICIAN: I h8'eb~ .ulhonZI paymenl dll&ClIy 10 the RETURN TO WORK NEXT APPOINTMENT
l.lndtfSlQntCI PhylWeiln ollhe Sw'gtCal.OOiOl MedICal Benvllll. II .n.,., Ollllll'WlW parablt 10 me 101 P'~'~
hit Wrval .. Deacnbed her,ln but nollo ..CHd the ,.lpOI\llbIe and customary charge 10f thou
-.. - ~. -
ON: ~ .>-cl/biJ
DAlE /
DATE DATES DISABLE(
SIGNAtuRE. HaSP.
AUTHORLZATION TO RELEASE IHFORUAnOH: I hereby aulholll8 Iht! Unduf5IQned phr~an 10 I:s <If" OFFICE
. -teklaM anr InlOfmlllOl1 acqUlfed in lhe cou,,, 01 my elamlnatiOn or IlIlalmenl
FROM:
, ...... "- X.RAY
DATE TO: COP
SIGNATURE
Cl CLIFfORO O. VERNICK, M.D.
...0 . 001l83E
Cl PiTER A, KEBLlSH, ... D.
MO ' 006835E
orthopaedic Associates of Allentown
1730 CHfW STRHT
ALLENTOWN, PfNN5YLYANIA 111104
SIlLlNO OUESTIONS CALL 12'51'353171
OTHER OUESTlONS CALL 1211U 433 6045
o PATRICK B NESPET, ....D,
...D, 0110,.E 3S
o THOMAS D, "'EADE, ....D, ::
YO.0321l,IE ,
Cl THOMAS 8. DICKSON, M,O ~?EVEN J LAWRENCE, "'D,
. "'D. OO'I404E fED 10 NO 23.1e57 130 MD.04&313l
GUARANTOR NAME ANO ADDRESB PATIENT NO, PATIENT NAME . , DOCTOR NO, DATE
('I.ENN E DrRKOSH I 1:571350 GI,ENN E DERf;0SH ()(I04 (') I/~~Oi
::-~(uB w I1AI LROI\[J ST 11 ~':Jj
NESQUEH0NINO PA 18?40 DATE OF BIRTH TELEPHONE NO INSURANCE
COO. DESCRIPTION CERTifiCATE NUUBEA
PL PROC, CR CO, CCI CC2 CC3 3':' (717) ell.. (,:NA !;j06~;1 O~ I P98':!.0~?/
H/(I!;/tl<l 669-t,416 1114 SPI~ r 171<l601tA 0I~1()'
v
RVSI DESCRIPTION I tI las CODE I AIoIOUNT Rvsl OESCRIPTlON I tI las COOEI A"'OUNT RVS I DESCRIPTI()I4"" tI lB1lctloE A""
I I I I
.''''NIW INJECT10tUl OR AIPtRAnOH ORTHO APPUAHCI
INTINSlTY
,,, L..,..a 00205 ,.. TtlllMt Sneith, lMiimenl 20~50 UPPER IICTREIIITY
'" ....... ..... Tlf~'P\,<Q.I ",n
111 LIVtt' .."" "KI SmJ~ Joinl'O\,lru ro6OO m M'lnN Wnl' I ,,"01
'" ,...U 88102 - tOl InI".m~.1.JolnV8ur" 2060' " WIlli a.unU.1 L3906
"" Lev'" .."" 101 tr.4;I~ Joont'OUfU ""0
ID' f.~c,. 20999 KNEl
I" II EITAIUSHED 1J16 P,.:",'oI11801&1I.c.' (,,40442
INUNSrTY IUorll nerv" Iumblr -- " t<i"IH Immobo~I" LISlO
101 '1Vtt5 "'15 CASTINGS 1321 ,",ulloC.nlflC'PuIlOn l1ll10
'" ...... ii214 ahon e.., 1M Mul\lt.nlllC.WrlD tIns
.;l< vii 3 S I ., P.I,",' BIICe LillO
, 5 Uv.12 ilil212 1321 eru'che. EOI20
l......' ./J R. C,hooC,.1
I
, OY. TOC.1 Clle ..... POOT I AHKLI
.,. OY.NoChll I SU-RQICAL PROCEDURES
234 HoktIOl F.. .. Ail blrll
121 QrluCrw 1M' T .. O.oneI. Wounc:l llm 11040~2 1326 Ail 611111.1 'LD
or'M:1 CONSUL T8 NEW I EST .. OGbtod. Wound 101111 1 '1(),41!12 Ins Capr Alcll SUDlXI11'
" II 0 AbK4ru . SIm ,.... '" lne4A,," .
,3> """"" . t02'S " II 0 H.m.,om,. . 50 10140 .. C'" Bool l3260
13' Con,u114 ...., '00 R.mov. BUlled WIII'P", 20670!l2 51 Conv.lnc.nl Shoe L326<l
'30 Con'lIII :] 82'3 0111" II H..IC '"' l34J0
"Ill """"". 6242 .. ....1.'11..1 Pad '3040
121 Con.ull' 19241
SPECtAL SERVICE OlliER
NflRMATORY CONSULTS , C.~~R.lCtledule
101 Conlllm 6 119215 5 MedlUl R '..."no ....0 3 .'A I I
101 ConI"'" . 99274 , M.oc.al Repo11.ln. ""0 REFERRING PHYSiCIAN
to> Conlllm:] 89273 II OIubolll FOlm .901<1
.'" Conlrnn 2 i9272 " EVldInct Flom RtcOfd ....0
133 Conlll'm 1 11927\ 15 MetdrUIRlKtlld 1I1i1199
DIAGNOSIS REMARKS DATE OF
CRUSH lNdURY FOnT L~ 10'1:- LAST PAYMENT OIIlM9='
I'IHN IN t.EO/FOOT 9(14 PREVIOUS INSURANCE PATlfh~
BALANCE 224.5 I
. TODAV'S CHARGES .:;OJ
--
PAID ON ACCOUm
CHECK CASH
, ADJ
TOTAL OUIi-r .i!.' ...-..
AU'THORlZAnOH TO PAY BENEFITS TO PHYSICIAN: I hOlob~ aulhollJl Po1VmOn1 d1'0Cl1/10 Ihe RETURN TO WORK NEXT APPOI ~TM1 NT
undlfllOntd Phr'iclan ollht BUlgal .ndlOI MedIcIl Benel.',. Illn~. OlneMIII parable 10 m. 10'
I'M. ..rylce. u dtwlbld ht/ein bul nol 10 ,Ielld Ihl rllponu)!. and eUllomary Charge 10f those ~ ~-.,
..mc:... /' 0_ ,-+- J.. -
ON: /A Iy~
DATE DATE/
SIGNATURE DATES DIS~: 5/.11 HOSP,
AUTHOAlZAnON TO RELEASE INFORMATION: I h.rebr all,hOrlJlthe lInctefiigned phy,iCla11 10 OFFICE
rellua any inlottTlihon acqUl'ed in thl course 01 my elamlflolllon Of Ilnlmenl. FROM.
, AY
DATE TO: COP
SIOHA TURE
CflFFOIlO G. VERNICK, M.D.
· . Me. 0071t3E
.
~ R A, KEBLISH, M,D,
~.Im , OOll~IE
, .~ ..
I S B. DICKSON, M.D,
, MD.' ODi4IME ,
Ol...opaedlc Assve/aler. of Allenlown
,..3 S CEDAR CREST BLVD
ALLENTOWN,PENNSYLVANIA 18101
BILLINC\ QlJESTIONS CALL \"01 0l'3m
OTHER DUESTIONS CAU \"01 03-60.5
FED 10 NO 21.1857 130
CJ
PATRICK B, RESPET, 11.0.
1I0.01l014E
0, MEADElII,D,
MD.032I1I1.
STEVEN J. ~WRENCE. M.D,
IID.IMB373L
'I.""
,:'\;:,1.
,';/~' -t~~,';
. '~~~1i'
.,!.~:i.'
..
" GUARANTOR NAIIE AND ADDRESS PATIENT NO, PATIENT NAMe DOCTOR NO, DATI
ENN E DERKOSH 1578':,1) GLENN E DERKOSH 0004 0~~!,~~:4
,a:w RAILROAD ST
:sqUEHONINO PA 18240 DAlL or DIR'H TELEPHONE NO INSUMAhCt
, . COD' DUCAIPllON C'RlI"''''1 HUMUR
PROC, CR, CD, CCI CC2 CC3 ~9 (7171 C16. 2CNA 506~1041~~320pp~9
v ,,4/0:'j/54 669-6416 914 ~SPA 1171460!,~~, 0... 00
..... ,r'--
II DESCRIPTICN I II Iiw CODE! AMOUNT RVS I DESCRIPTION I II IMCDDE AMOUNT Rvsl DESCRIPTION II IMC E AMOUNT
-+., ....N W ~.CtlON.o.1.PI.~T~H ORTHO AP,!iitic'l
. , ."
INTINlllT'l ., -, 1.:1..
~. ..... '04 TIIOdOn &hUlh L.olmllfl' ...'" - PPlfllXTRUUTV '.
~... ..... Tlloo" PtIlG. on
~3 ....3 '00 SmaN ,JoonLBu.u 2D6OD 1St ....Itv\IWn.' mo.
~... 88202 '01 Inllllfmlldl.,.JOIIl~B..... 2060. " WIlli GlunllM "",..
~'" ...., '00 ... Joon~ Bu. w 2<16'0
... fue" ;tOe"" KHU .
,',- I II UTAlUIHID 1316 Patlw.r1lJt)t...,,,,.1 .....
" INTIH"TY I ""'11 Iumtul " K,," 1n'\rTlObdo.I., LllJO
~I H215 CASTIHOS 132' . WIII\lCtnl/lc.PulIOn LillO
Le.." 4 11214 hOne"" ... "'uIlan~.W' %1111
~.., H213 600<,' 13 'Al.llIllit1ee L'I'O
~... m 1327 ""'''''', Eono
~, .., .. oC.IIIOflClII. .
, S ,I
OV.101&1C." ..... POOT , ANKLe
ev. No CIw IURGICAL PROCEDURIS
HD6d tof ,.. .. MSIM'
""",,C,,", .. T " OetMll2tI Wo.md Lllnl 11G40~2 1321 All SW. L
, "I, OfIf1CI CONSULTS NeW I.IT .. O"btlCl. WOund 10.. 11004152 133!l C At'" .
" II o AbKlIU'S. ,.... '" lnc.oAlcn
ConNII H24' " 1& 0 H.lTWloml' 501 10140 .. C." Boot L3260
. ..... '00 R.mo... iklrotd WIl", P.n 20070$2 " Cotwalllltent snoe L3'"
. 'COnWIl 3 11I24:1 """' " H,",C T~M ......
, ConouIl' ..... .. "",..wUlPIl1 L:JG40
ConouIlI H241
SPECIAL IIRVICE OTHER . ,. :
., . . CDHlI.IIATORY CONSULTI . C.~R...ctled","
Coo'.rlll I ai276 . I.lltClocalR. An'" V801l0 . "'A I'
~~~m4 8i27. 1 Mw.c.aIR .Ins .....0 REFERRING PHYlllCIAN ..
. COII'"m3 (lli27J " DI'.~1 Form U9080 ,
ContII'm :I . H272 .. EWllM'''' flom RllCOId """"" ,
,"
I ConIwm I g8271 " MIICSIUIR.wd "UUI ,!
DIADHDSIS REMARKS DATE OF
PAIN IN LEO/FOOT 904 ~ST PAYMENT n'IOA,I",,,,
CRUSH INJURY FOOT 1042 PREVIOUS .,.SURAhCE P."I~NT
BA~NCE ";I!=i n I -; (\
'.. -
. TOOAY'S CHARGES V'l '1 ...
. PAID ON ACCOUNT
I . CHECK CASH
ADJ
TOTAL DUE . U'/ .ole;
ITHORIZATIOH TO PAY BENEFITS TO PHYSICIAN: I hlleb~ lulhO!lllI rurmftnl d11ectlr 10 Ihu RETURN TO WORK NEXT APPOINTMENT
je,1iQnt(J Ph;&i01O ollhl SU/gal ancL'Of MIIC\IUI Ben.hl.. II In;. Olha""'lll Pirib10 10 me 10' lolL
HfViCI' u cMlICnCMtd h.,.1O but (101 to lac.eld &hi "1pO~ and Cullom..,)' CNtg. 101 It\OU
...., 0 w_
ON: ,3jr I~
DATE
DATE
SIGNAtURE DATES DISABLED: .HOSP,
ITHORlZAnON TO RELlASlIN'ORMAnON: 1 hllaltl; IUlhOfLl. ItMt undtll&ignlld phr'lClOln 10 OFFICE
1tUI1IlJ' kllounI\lon acqulfld Ul ttlI cou,... 01 m; .aiIMl&1I0n 0' ItMlllmenl FROM:
, X,RAY
DATE TO: OOP
5K:iNA1URE
t/,
.
..--.....
.
;m11
;m ~
~
Qm
~~
I"l
~
...
...'
,
...
'...
,
.;,'!F
\It:'. ~~
I
a s
I ~N
t!g
l::!CJ;
si;
i~il
~ , :' .'
,.~. -.....'
,11.6.-"'......
,
-
.
,
.\,.
"
J:
,.
'g
i ~
~ ..
,Go "
'... ....
~ 01.
" t' ,.
j" t
!' I
i I
, \
..1.1
I " .... ..
8 ~ ~I \ \ ..,;:::i~~~f.:,:f '
& 9. 'l-~_ , :\' ':.', .~~.."i'I'i',.'i."
IN. '-, I 'l'~'." ~'\'::t. .~(:l
" . ,:-::",~,,:,,'1 :1,.,',,' .:i.~'I',~:~,~,~,,",(
....' ~...~I'(. ..
I .' '.;~ . ~ .i.. "
,.. : '.1 -, ...,
l:.~ 1 '?{':-:\~'~:.~:
...... iiI '. ,,"!'< 01.:.."
; ! J.:: ,~1!;~~i
, :il ., ' . :." ,,,-;;;,loit.w.
) . .. !~"'.;~:J~~
.... ..... ~ ~t:~.~t'''-!~'
I ~~':;', :,""::"'\;"(1'
U) :" ., "f.~~r.l~'l~',
. ~ . . .!\~:.,~:',~:~.:;;:J::I
u...,' ;.i;..::"\O".;;.u....~
~ ~ /:.~-"" ~ 'I '. ''',JV':.~",,,4,.
/:. ..,' : ,/j",7i~~,;, ,It,,~~w'
~ i~' ',.y', . 5 ~ ~;:.l,:~t' \:'~;;')~j
U i .ft : &"\' . . .~"1If o;:~~":
~.. . . "11 ~I" ')"~ .
a",~<r~ " .' :J;.\ "i" .I,~,.
. .,,, :. I. 'l,I\ .
., ! '. r ,~~)::.. .;.-,;,
00, ..''''' 1.,.,<-
..eN ,.; ....:t..;..,I14...,.
.., i ~... . . - .~4."'';::J,~''.~~:.
. "OIf "~'."'I".-~I Ie \1.....;I~~~;.'lJ\."1fI..:..
, . .'~~" :",.n"".,'~e!
~"'t'::--',','~:::Jr..~":a~;: ,....... ~""',
. "r:.'~'''',-,;.\~;
" ". ,,,y",..:..,,I\
,. ''1'::tw'...i'.),.''
,,' ,f ,<'n'" "U
iJ.':'t-.:~,.1~';J.I,
.J.tl..': '....1:'''' ~
'.r.t.;:',l./~... ~.,_~:.t.:,
: ~~,..!rr,:~~'~':.t\!~.
",L;I;.~,~t,,, nt, .
~..:'.' _~,~. 1_ ..
'." .,.,.",..; ',lI;'
.,..... '.01'" 'J
::'~1t~ I"
;,t}'~~~:\',:it,{~
. .,.\~Y .~, -~:
l'li<'f ' ;;rf~, \J-},
.. ~..'''?- '..'.- \.0{,
, '''o(,;'iiJ{;:~t:J
'.f,".;.:~rll~.
:'.',8. i),.
," 0 ~
,/:rl ri
.:1 ':N~
'!~ .'
"""',
! ~
i\
, lJ
I',J'
,... y
.u ,U.' .,' ". t"1:'
'.' U.U : I'J, ii ".
"~" ,. i.1...i : )\~;,'. .;
. ;'
"
,.'.
...~ ,'; .
.,. ."
1"
?~,: ;
'~~';'g
l~ ,
1'\
..~~: .
II':!
"'1',
~. ..
\' N
,\;,..,
,.~..:.~
:\~ ,;
1'11'1
000-
~~
00 ' ,
: I" .!, ' .':~"',I,.o-.
00. .,:!",'" ,d.'
.4.-4 ..-t-;~~;,'\f~',!>~""
..'"
lit
i
..
~
Ii
i~ I~
8~h
~! ~~
~~h
i
I
o
..
N
III
..
~
il.
.
~
...
~
o
i
8-
"
!
2 VIlllUlnl' w~'MirilllMlllO ~v 1~~iU
C ^ 8 ~ H.... Y " C l
:
(' _ _. .- .larmacy
- IIEL 669-6600
ANGELINI AVE. CVS, INC.
NESQUEHONING.PA 1824 BC2635312
.. C336083r:lt' 00" LAWRENCE
DERI(OSH GLENN
80S W RAILROAD NESOUEHONIN
TAKE 1 TABLET EVERY 4 HOURS A
NEEDEl) FOR PAIN
l
~
I
.
a
I
I
i
~
i
~
RETAIN IHIS
RECEIPT FOR YOUR
TA~ RECORD~
PRICE 10.0~
DUE
10.09
ROPOXY-N/APAP 100-650 TAB
IMYLAN ~. 30'~ CW
1::. 11/05/93 ~J. 11/05/9~' 11/94
AVOID WAITING...CALL REFILLS IN
. -.. ....- .
.
J'- ~ THOR' _. .1ARMAC\~
30 RIVER STREET. JIM THORPE. PI. 18229
PHONE 32503521 . FAX 325-8789
EIN 123.2252642
RX C::36112'7 10-07-93 SM
DERKOSH GLENN
DR. LAWRENCEtSTEVE CASH
PROPOXY NAP AB APAP 100
REFILLS LEFT NONE
DTY. 30EA 59.65
RX 3612S8
DERKOSH,GLENN
DR. COYLE JOHtl J.
ANAPROX OS TAB 550NG
REFILLS LEFT NONE
OTY. 20EA
10-08-93 SM
CASH
526.63
R X 361 2S9 10-OS-93 SM
r,ERKOSH GLENN
DR. RESPETtPATRICK B. CASH
tlMITRIPTYL NE TAB lONG
REFILLS LEFT NONE
OTV. 20EA $4.01
I
9.65 +
2G.63 +
4.01 +
~
~ /b!
to. , r. rL-r
003..............
40.29 *
--
o. C
L I-ll()().WANT'HELP
DISCCM;R RECOVERY AT
COLLEGE HILL MEDICAL CENTER
SUBSTANCE ABUSE ffiEATMENT PROGRAMS
107170<124-6233 'l.llO().926-8435
F",! 2150<124-6300
THANK YOU FOR SHOPPING JIM THORPE PHARMACY
w
---.- -',-_.,.-..._-~
~1HXC:lIC - lClID:ww MIa> ~
A ElM_ON Of' HlallIIIOlJIO, '.,IAIlNQ
BOX 3On, ALLENTOWN, PA-18106-oon
(215) 781'2228
l-eOO-......-~ez~.'I..
~ WE ACCEPT VISA AND MASTERCARD
THE ABOVE NAMED PROVIDER HAS REFERRED YOUR ACCOUNT TO US FOR
COLLECTION.
S~C~~~~NgE~~tP~gbI~H50~D9~olY~~ O~ r2Uw~I~~~~EwT~~I~A~&OAI~s.
THIS IS AN A TEMPT TO COLLECT THIS DEBT AND ANY INFORMATION
J OBTAINED ,WILL BE USED FOR THAT PURPOSE.
IF YOU HAVE INSURANCE AND YOUR CARRIER HAS NOT PAID TO YOUR
EXPECTATI.ONS~ WE SUGGEST THAT YOU REMIT THE BALANCE DUE AND
SEEK REIMBUR~EMENT FROM YOUR INSURANCE CARRIER.
\ DO '~OT CONTACT'THE PROV. IDER. WE ARE THEIR AGENT. PLEASE SEND
T"!E PAsT ,OUEA/lIOUNT ,NOW TO AVOIP FlJRTHER ACTION. ,
t., ",' I' -"".. . .
-~oiT~HIIl~ ,.,. .."iiiRiTu"iW. ~~iTUi"~7~."":-.~_..._'".-:----.---_._- ._-"-_.._--;;;;;'.;;"-"--7._._.~.I-:;;;
'jp ;> . , '~j'" ...". - ~ , , , , PAY,....CI\,.. lIIl ' I' ,,,
~'~<.:'lt;.t"I''';J..l~':'e';$&~~.,j~ "/4.llt::P:"'\:':..\~, BY 0 Lr 0 I I '" I; I, , I ' , ,',I
":q- '.1:n'.,o,.,.,OP't1 ~i;''''; ,,\l lllf..2:79...' ,
';, Gt.:ENN "l)ERKOSH (,' .' .'" , \, " " , IIWI...""
oi, Z08 W RAILROAO'~.T,'~ .,..... ,::.,', '. ,"j,;.,,:., ,',,:., DCIlOII DCAAI f'OUCYNO, _ ,
1,:NESQUEHClNING,'.. ,:,'PA '.....182..0 .... ,
-:. ,.' ...'. .. ". .
--------..--
ACCOUNT NUMBER OATE
0031885452 r' 02/2~/94
RE: 'ATIENT GLENN E DERKOSIf
I'lIOVIOER LEHIGH VALLEY HOSPITAL
DATEOPBERVICE 11/30/93 .. Faa
AMOUNT DUE
.Z80.e:O
031'
KUP THII TOI'ITIIB
POR YOUR IlICOIlDI
AMOUNTPAlDI_
DATI
CHICK NO,
weD
VIlA D "
'/Z3/9" GLENN E DERKOSH
.,..,", . .... , ~h..."....., ',. .
$ IZlilO. 50
NUMBE
'I'
....~.:r,""lIIn..,_III.lII.,I"'..Ioo'''..!I.IIIU...:l/~l.IIl..IUII> J
Iw
"f :: f,
,. "" "j ."
-.
11""'\
I
I
I
I,..,
I
I
i
I
[
~
RWC EMERGENCY PHYSICIANS
117 N. HANOVER ST.
PO (tOX 177
CARLISLE, PA 17013
\"
TELEPHONE:
717-249-9432
BIWNG OFFICE HOURS
10 a.m." 4 pm
TAX ID~ 23-2259396
GLENN E DERKOSH
20B W RAILROAD BT
NESQUEHONING, F'A 18240
..' ~ J'!r:t". '. ~
STATEMENT DATE
':'l!.~.' '. .' ':'~ ~n:r:'
101 ::!/9"l
KEEP THIS PORTION FOR YOUR RECORDS
10102/93 9283
CASE HISTORY 01
EMERGENCY DEPT VISIT
DX-924.20
96.00
'~
At OUNT -
CURReNT
96.00
, BALANCE CUE i(
IMPORTANT,
~b:":>,1.1~:",IT,~ "'I'~U,l"l \,":'f ~,
;., .'-
, ~ DETACH tH:nr ~ .
.[~~~;~;~;;~:~~~~~-------- -- --------r-L~~=j:~~~~~f~~:~J
PAYMENTS RECEIVED AFTER STATEMENT
RETURN THIS STUB WITH YOUR PAYMENT DATE ARE NOT REFLECTED
PLEASE MAKE CHECKS PAYAOLE TO,
RWC EMERGENCY PHYSICIANU
1 n N. HANOVER ST.
PO BOX 177
" PA 17013
PA"
HlH(,rnr.r ':..r_:!',l"Y
)
J
"
,':),
,
- w
I",..
1
"! v
. p.llent: 1:Jl~ ~l" ko..JI... Oootor:. ~/\ It /.... I.~, SKp..I#Y\(O..lI.,~Kt .
D.te 01 Aooldenl: II) - .1- i2, ._ Addren: '/(.'~ tJ{'~ I.h.... St :J I~ Ihc,t:.et'.. Pa..
I\:LI,/
NOTICE OF DOCTOR'S LIEN
I do hereby .ulhorlze ~,I'\<'t:!.+ V:u::6,"l K, _10 lurnleh YOII,
my eltorney. wllh . lull reporl 0' hie U~1I0n, dlagnolll, tre.lmenl, prognolll, elo" 01 mysolf In
regild 10 Ihe .cold.nlln which I WII recenlly Involved,
I he"by .ulhorlz. .nd dl"cl you, my altorney, 10 PlY dlreclly 10 nld dootor luoh lumlll mnv hn
dUllnd owing him 10' mldlcollervloe rende/ed me bolh by reaeon ollllls acoldenl and by reRS"" nf
Iny olher bills thlla" due hie olflce Rnd to wllhhold such sums Irom Iny selllement, Jlldgmnnl or
verdlol.s mlY be neceleary 10 edequelely proleot eald doctor, And I hereby furlher glvs R Lion nn IIIV
ORse 10 seld doctor agelnal eny an'" nil flrocnocls 01 my aeltlnmonl, JudgmAnt or verdict wlllch IIInv h"
paid 10 you, my altornay, or "'Ylelf, al the result 01 Ihe InJurln lor which I have beln Irealed nr
In/urln In oonneollon therewith,
I agrea never 10 relolnd Ihls dooumenl and Ihll a relcllllon wlll'nol be honored by my ellorney, I
hereby Inslruot Ihal In Ihl! event enother altorney II aub.lltuled In Ihll maller, Ihe new eltornny
honor Ihls flen IS Inherenl to Iho IOtllemonl end enlorceable uRon the oese al lilt were exoclllecl
by him,
Ilully undersland Ihellam dlteclly end fully responsible 10 eeld doctor for ell medical bllle ellbrnlltnrl
by him 'or eervlce rendered me and Ihal Ihls agreemenlls made solely 'or sold doolor'e adcllllonol
prolacllon and In oonaldelallon 01 his nwaltlng paymen!. And I lurlher undorsland thai euch paymonl
Ie nol conllngenl on eny sOlllomonl, ludgmonl or verdlcl by which I mey evenlually recover aold Inn,
Please acknowledga Ihls Ie Iter by elglllng balow and relurnlng 10 Ihe doclor'e ollloe. I hove bnon
ndvlsed Ihalll my ellorney doeo nol wish 10 cooporale In prolocllng Iho doclor'a Inleresl, tho doclnr
'will not Iwalt poymont bUll1l3Y doclare Iho ollllre bnlnnco duo end poyebln,
Oaled
Pallenl's Slgnalure
The undersigned being eltorney 01 rocord lor Ihe above pallant doee herehy all'ee 10 qbeervn nil II'"
lerms 01 the above end aglell to withhold such eums hom OilY setllement, ludgmenl, or verdlel, n.
mey be neceaaary 10 edequalely prolecl sold doclol above.named, Allorney lurlher egrees Ihot III
Ihe avent thle lien Is IIl1geled thallhe prevailing palty will be awarded allorney 'eee end oosls,
Doled
AlIorney's Slgnalure
Pineo dale, elgn and return one copy 10 doc lor's olllce. Aleo keep one copy lor your records,
Clot
_ "J,..... Co. f"~ ...""
McKISSOCK & HOFFMAN
A 'ROrIUIIONAL CORPORATION
ATTORNEYS AT LAW
101 NORTIl FROOT STREET
SUITE lOI
IIARRISDURo. PENNsYLW\NIA 17101
1100 NAunmUT
MTI_
'U1LAIELPIIIA. '" IflOl
(Wiatt-liDO
Mx. ew) ."'lIM
BDWlN AllICII""RTZ
IlOOlCT DIAL (117) J~OJ
PIIONE: (717) l14.()JOI
FAX: (717) l14,1ll0
.. NOn1I raAHIUH rn.ur
MTlooo
POYLU1'OWH, PA I_
(JUIMf.<tJ41
MlCI(UI)S4HJOI
. IOUTH 11I011 mur
'.Q lOX lOW
war alurn,.A It)ll
(1Ig)'.....SO
I'AlCI(6I0)1M.flU
March 8, 1999
lit HAOOOH NEH\1I
SUrrBtoJ
WI!In<<JHT. HI 01101
ltOIlllI-llSO
f4)C,ltOtIIJl.I4M
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, He 2 Box 2287
Jim Thorpe, PA 18229
Rei Glenn Derkaosh v. JoseDh L. U1lam
CCP- Cumberland County
Docket No.1 95-5204
Our Pilei 8350-19
Dear Mr. Mousseau:
The purpose of this correspondence is simply to advise you
that the file has been transferred to our Harrisburg Office and
that all future communications and correspondence regarding this
matter should be made directly to this office.
It is my understanding that you have recently requested this
matter to be assigned to a Board of Arbiters for determination.
Please be advised that before this matter may proceed to
arbitration, you are under an obligation to provide full and
complete responses to the previously served discovery requests.
I have reviewed the file in its entirety and I am surprised to
find some information still lacking. Specifically, your Answers to
Defendant's Interrogatories are deficient. 1 It is my understanding
that you provided your responses to Defendant's discovery requests
on or about December 20, 1996, and to date, have not supplied any
additional information with respect to supplementing the deficient
responses contained therein. As you will ~ote, the second sentence
It should be noted that you were compelled to provide full-
and complete responses to pursuant to the December 5, 1996
Order of the Honorable J. Wesley Oler, Jr.
Gregory L. Mousseau, Esquire
March 8, 1999
Page Two
contained under the caption and title of the Interrogatories states
" It] hese interrogatories are continuing in character so as to
require you to file supplemental response to the interrogatories if
you obtain further or different information prior to trial." In
light of the fact that your responses to the Interrogatories are
over two years old and you originally failed to provide !Yll and
comolete Answers to the Interrogatories, I would have expected
supplemental responses to be filed thereto. However, in review of
the file, I have ascertained that no supplements have been filed.
Therefore, this correspondence will serve as a formal request
for supplemental responses to Defendant's Interrogatories in the
above captioned matter. I would direct your attention to second
paragraph in Judge Oler's December 5, Order wherein it states "It
is further ORDERED that Plaintiffs, Glen Derkaosh, shall serve !Yll
and complete Answere (without obiectionsl to Defendant's
Interroqatories and shall produce all documents requested in
Defendant's Request for Production of Documents within twenty (20)
days of service of this Order or suffer further sanctions uoon
aoplication to this Court." (Emphasis added).
While I believe your responses to the Interrogatories to be
woafully inadequate and in need of substantial supplementation, I
do feel obligated to point out several obvious deficiencies and
request for your immediate supplemental responses to the same. For
example:
Interrogatory 201 State the name, last known address,
employer and present whereabouts, if known,
person whom you or anyone acting on your behalf,
believes to have been a witness to the incident
this suit is based.
Answer I To be provided upon discovery.
name of
of each
knows or
on which
Interrogatory 29(c)1 The name and address of any person who has
taken any photograph showing the injury.
Answer I To be provided upon discovery.
Gregory L. Mousseau, Esquire
March B, 1999
Page Three
Interrogatory 301 When, where, and by whom did you last receive
any treatment from a medical practitioner or hospital,
whether or not related to the injuries allegedly
sustained in the accident?
Answer! When, to be provided upon discovery. Where,
Orthopedics of Allentown. By whom: to be provided
upon discovery.
Interrogatory 31 (b)
unpaid medical
so, state:
(b) the
Answer! To be
and (c) I Are you claiming any excess or
expenses as a result of the accident? If
dates of service for each such bill,
provided upon discovery.
and (c) the amount of each such bill,
Anewerl to be provided upon discovery.
Interrogatory 321 Do you claim any aggravation of a preexisting
condition as a result of the accident? If so, state:
The nature of the preexisting condition.
I previously injured my foot.
How long had it existed prior to the accident,
since 19B3.
The names and addresses of all persons and
institutions treating you for the preexisting
condition prior to the time of the accident.
Answer I Allentown Orthopedic Associations (see attached for
address) others to be provided upon discovery.
(a)
Answer I
(b)
Answer I
(c)
Interrogatory 371
as a result of
amount claimed
Answer I To be
Are you claiming any excess or unpaid wage loss
the accident? If so, set forth the total
and how it is calculated.
provided upon discovery.
Interrogatory 40 I Identify each person that you expect to call as
an expert witness at trial or arbitration in this matter and
with regard to each such person state the following:
Answer! To be provided prior to trial or arbitration.
(a) Subject matter upon which the expert is expected to
testify,
Answer! No answer provided
Gregory L. Mousseau, Esquire
March B, 1999
Page Four
(b) Substance of the facts and opinions to which the
expert is expected to testify and a summary of the
grounds for each such opinion I
Answer 1 No answer provided
(c) Qualifications upon which [expert] intends to relate
in order to qualify as an expert at trial.
Answer 1 No answer provided
Interrogatory 411 Identify with specificity all insurance
carriers, government agencies, and/or other sources from
which you are receiving benefits or to which you have mme a
claim for damages and injuries allegedly sustained in the
incident in questions. Please supply available policy
number and claim number and describe the benefits received
and/or claims made.
Answer I No answer provided.
Interrogatory 431 For each such insurance policy [as identified
in your response to interrogatory 42] the group contract or
other similar plan or arrangement, describe the nature and
terms of the coverage benefits available to you at the time of
the accident or subsequent thereto.
Answer I See policy (note no policy was attached in your
response. The only information regarding the insurance
information available is your insurance identification of
coverage card.)
These are just examples of the more obvious deficiencies in
your Answers to Defendant I s Interrogatories. As stated above,
please provide full and complete Supplemental Answers to the
Interrogatories immediately.
In 'light of your incomplete Anewers to the Interrogatories,
please be advised that I am in the process of preparing Defendant's
Interrogatories addressed to Plaintiff (Second Set) for further
clarification of additional discoverable information.
Gregory L. Mousseau, Esquire
March 8, 1999
Page Five
On a related note, it is my understanding in review of the
file that an offer of Five Thousand Dollars ($5,000.00) has been
extended for full and final settlement of this matter. I would
appreciate if you would please contact me with respect to your
client's position regarding this offer.
Sincerely,
Ed~~[Elz
for McKissock & Hoffman
EAS/sg
.
o
(1
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
GLENN DERKOSH
Plaintiff
DOCKET NO. 95-5204
v.
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
JOSEPH ULLOM,
Defendant
DEFENDANT. JOSEPH ULLOM'S.
INTERROGATORIES ADDRESSED TO PLAINTIFF. GLEN DERKOSH
(SECOND SET)
TO: Glenn Derkosh
c/o Gregory L. Mousseau
Pine Ridge Professional Plaza
Route 903, HC 2 Box 2287
Jim Thorpe, PA 18229
You are required to respond to the attached Interrogatories
within the time prescribed by the Rules of this Court.
These
Interrogatories are continuing in character so as to require you to
file supplemental responses to the Interrogatories if you obtain
further or different information prior to trial. Where the words
"incident" or "occurrence" are used, they refer to events which
took place on or about October 2, 19993, as alleged in the
Complaint.
DEFINITIONS
I. As used herein, the word "Plaintiff" refers to Glenn
Perkosh, his agents, representatives, attorneys, prior business
entities (if any) and all other persons acting or purporting to act
on behalf of Plaintiff.
.
n
.....'"
r,
II. All references in these Interrogatories to "document"
shall include the plural and shall mean, without limitation unless
otherwise indicated, the original and each copy of each and any
writing, evidence of indebtedness, memorandum, letter,
correspondence, telegram, note,
minutes, contract, agreement,
inter-office
communication,
bulletin,
circular,
procedure,
pamphlet, photograph, study, notice, summary, invoice, diagram,
plan, drawing, diary, record or note of telephone conversation,
chart, schedule, entry, print, representation, record, report and
tangible item or thing of written, readable, graphic, audible, or
visual material, of any kind or character, whether handwritten,
typed, xeroxed, photostated, printed, duplicated, reproduced,
recorded, photographed, copied, microfilmed, microcarded, or
transcribed by any means, including, without limitation, each
interim as well as final draft and each revision which in the
possession or subject to the control of you or your present or
former agents, employees or representatives, including counsel and
including any related corporations.
III. Whenever in these Interrogatories there is a request to
identify a document:
a. state the type of document (e.g., letter, etc.);
b. set forth its date;
c. identify the signer or signers and the addressee or
addresses;
d. set forth the title, heading or other designation,
o
(1
numerical or otherwise, of the document;
e. identify the person (or, if widely distributed, set
forth the organization or classes of persons) to whom the document
was sent; and
f. set forth the present or last-known location of the
document and of each copy thereof having notations or marking
unique to such copy.
IV. Whenever in these Interrogatories there is a request to
identify any oral communication:
a. state the type of communication (e.g., conversation,
telephone call, etc.);
b. state where and when such communication occurred:
c. identify by full name, title and job description,
all persons who participated in such communication or who observed
or heard such communications at the time of their occurrence;
setting forth which person effected such communication and which
person received the same;
d. identify all documents embodying or in any way
relating to such communication, if any; and
e. state the substance of any such communication.
V. "Accident" or "occurrence" refers to the events described
as taking place on or about October 2, 1993, which form the basis
for Plaintiff's Complaint.
o
I'
INSTRUCTIONS
I. In answering these Interrogatories, you shall furnish all
information available to you at the time of answering, including
information in the possession of your agento, and shall supplement
your answers in accordance with the Pennsylvania Rules of Civil
Procedure.
II. If you claim, in your answer to any Interrogatory, that
any requested facts, documents or other information are
"privileged" and not subject to discovery, you shall so state and,
in addition, state every fact supporting your claim that such
fact, document or other information is "privileged" and with
respect to any document, you shall identify the document by stating
the date and subject matter of the document, the name of the
person who prepared the document and the name of the person for
whom the document was intended.
.
('
(1
2. With respect to your previous Answer to Interrogatory
Number 5 of Defendant's Interrogatories Addressed to Plaintiff
(First Set), which stated, "Describe in detail the part or parts of
each vehicle damages as a result of the accident," to which you
responded, "The only part of damages was my left foot due to a
right front tire and mirror striking my person", please provide the
following;
a. ) An itemized list of all damages and costs claimed to have
been sustained as a result of your alleged injuries;
b.l An itemized and chronological accounting of all medical
treatments sought as a direct result of the alleged
incident; with such itemization providing specific
information (ie. name and address) of each health care
provider, the treatment rendered; and
.
o
o
c.) The dates of each such treatment.
.
a
n
3. With respect to "Doctor Thomas" as identified in your
Response to Interrogatory Number 21 of Defendant's Interrogatories
to Plaintiff (First Set), please provide the following;
a.) Dr. Thomas' full name;
b.) Dr. Thomas' former address;
c.) Dr. Thomas' date of death;
d.) Any and all information regarding whether or not Dr.
Thomas' practice was subsequently sold, merged,
consolidated, or transferred to another health care
provider; and
("\
n
4. Since the date of the occurrence (October 2, 1993),
please provide the name, address, and nature of treatment for any
and all physicians or health care providers you have subsequently
treated with.
o
n
5. With respect to the accident report as attached to your
previous Answers to Defendant's Interrogatories to Plaintiff (First
Set) please provide the following;
a.) The identity of the person or person making, preparing,
or submitting the accident report;
b.) The identity of the person or persons to whom the
accident report was directed to or addressed to; and
c.) The time and date of the preparation for such accident
report.
o
n
c. ) Whether or not you have been issued any disability
certificates or indications from any of the health care
providers hereinabove identified to remain off work or
reduce daily activity.
.
o
(\
7. With respect to your previous injury to your left foot,
please provide the fOllowing;
a.) The nature and date of such injury;
b.) The specific treatment provided with respect to such
injury; and
c.) All health care providers to whom you sought
treatment with respect to such injury. Please
provide the names, addresses of all such providers
together with the dates and nature of their
respective treatments.
.
.
o
0,
8. Have you been involved in any accident or suffered any
injury or illness of any kind since October 2, 1993? If so, for
each occasion, state;
a.) The date and place of such occurrence;
b.) The nature and cause of the injury or illness;
c.) The names and addresses of all attending physicians
and/or health care providers together with their
identified medical specialties, if any;
d.) The names and addresses of any hospitals where you
were treated as an inpatient or outpatient for such
injury and(or illness;
e.) The treatment prescribed; and
.
o
n
f.l The need of treatment and/or disability resulting
from such injury.
.
o
n
8. Please provide an itemized calculation for all damages
for which you are currently seeking to recover, this itemization
should include any and all claims for wage loss, pain and suffering
and out-of-pocket expenses for which you are seeking recovery.
(1
(l
9. Please identify any and all insurance contracts or
policies that were enforce at the time of the October 2, 1993
incident. With respect to such information, please provide the
following.
a.) The name and address of the entity providing such
contracts or policy;
b.) The identification number of such contract or policy (ie
policy number, group plan, etc.)
c.) The effective dates of such policy and/or contract;
d.) The nature of such coverage provided under such policy
or contract;
e.) The tort option chosen under such policy; and
n
(l
f.) Whether or not any claims for benefits have been made to
your first party carrier.
(In response to subsections a,b,c,d, and e, of this Interrogatory
you may provide that Declaration Sheet for any insurance policies
that may have been in effect at the time of the October 2, 1993
incident. )
McKissack & Hoffman, P.C.
~~.
Edwin A.D. ~~
I.D. No.: 75902
105 North Front Street
Suite 205
aarrisburg, PA 17101
(717) 234-0103
DATE: .j_ff_?'f
..
('I
n
CERTIFICATE OF SERVICE
I hereby certify that I am this day serving a copy of the
foregoing document upon the person(s) and in the manner indicated
below, which service satisfies the requirements of the Pennsylvania
Rules of Civil Procedure, by depositing a copy of same in the
United States Mail, first-class postage prepaid, addressed as
follows:
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2 Box 2287
Jim Thorpe, PA 18229
McKissack & Hoffman, P.C.
BY:
~$~--
Edwin A.D. schwar~1 Esquire
Supreme Court I.D. No. 75902
105 North Front Street
Suite 205
Harrisburg, PA 17101
Telephone: (717) 234-0103
Attorneys for Defendant,
Joseph Ullom
/(;1
DATED: 3-?-7'f1
CERTIFICATE OF SERVICE
I hereby certify that I am this day serving a copy of the
foregoing document upon the person(s) and in the manner indicated
below, which service satisfies the requirements of the Pennsylvania
Rules of Civil Procedure, by depositing a copy of same in the
United States Mail, first-class postage prepaid, addressed as
follows I
Gregory L. Mousseau, Esquire
Pine Ridge Professional Plaza
Route 903, HC 2 Box 2287
Jim Thorpe, PA 18229
Ruby Weeks, Esquire
Arbitration Board Chairperson
10 West High Street
Carlisle, PA 17013
Jacqueline M. Verney, Esquire, Arbitrator
44 South Hanover Street
Carlisle, PA 17013
Lindsey Dare Baird, Esquire, Arbitrator
37 South Hanover Street
Carlisle, PA 17013
McKissack & Hoffman, P.C.
DATED:........'?'~ /???
BY: Ed~~squire
Supreme Court I.D. No. 75902
105 North Front Street
Suite 205
Harrisburg, PA 17101
Telephone: (717) 234-0103
Attorneys for Defendant,
Joseph Ullom
GLENN DERKOSH
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
v.
.
.
: NO. 95-5204 CIVIL TERM
JOSEPH R. ULLOM
.l.ti-'~E: APPOINTMEMT OF ARBITRATQR$
ORDER OF COURT
AND NOW, March 26, 1999, the appointment of David Schanbacher,
Esquire, to the arbitration panel In the above-captioned case Is vacated, and
Lindsay Dare Baird, Esquire, Is appointed In his stead.
By the Court,
P.J.
Ruby D. Weeks, Esquire - C b-tIJ.-l. I"'~,.c 4!J(J/~'1,
Chairman v () IS :(' .
Court Administrator
, It.) f:l
..t-) "II
. J
. 1,:'1
"., ..J .I:~J
',) "
',0 i
-j ~.-I
;"j
,( ~
'(I
t;: '::~
',1 ">
,,) ~
:ss9
A.J~" 11.
GIWGONl'L MOUSSHAU
Attonll',I'-At.Lmv
Pine Ridge Professionlll Building-Route 903
HC 2 Box 2287
Jim Thorpe, PA 18229
(570) 32~-944H
(lAX (5711) 325-9110
VIA FAX and REGULAR MAIL TO FOLLOW
MIlY 14, 1999
Edwin A.D. Schwartz, Esquire
McKissock & Hoffmlln
1700 Market Street
Suite 3000
Philadelphia, PA 19103-3930
CO?y
RE: Derkosh v. Ullom
Docket No. 9':5204
Your File No. 8350-19
Our File No. 94-0082
Dear Attorney Schwartz:
My client has not provided me with the requested Discovery and I do not want you to be
inconvenienced on Monday. I..ct Judgment be entered Ilgainst my client and in favor of yours on
Monday. If my client provides the rest of the materials within the appropriate time frame within
which to file an appeal to the Arbitration, 1 will get that information to you. Thank you.
Very truly yours,
Gregory L. Mousseau, Esquire
GLM/eJe
cc: Mr. Glenn Derkosh
Ruby D. Weeks, Esquire, Chairmull, viu fux/regulur muil to follow
Jacqueline M. Verney, Esquire, Arbitrator, via fux/regular muilto follow
David Schanbllcher, Esquire, Arbitrutor, viu fux/regulur muilto follow
c:\wpwln6O\ datU.\cnsCI\94.(XlK2\n'hwnrtl. I
.' "
..I
IN THB COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
GLENN DERKOSH
Plaintiff
v.
DOCKET NO. 95-5204
CIVIL ACTION - LAW
JURY TRIAL DEMANDED
JOSEPH ULLOM,
Defendant
PRABCIPE TO MAKE ARBITRATION AWARD PINAL
TO THB PROTHONOTARY I
Pursuant to Pennsylvania Rule of Civil Procedure 1307 (c) ,
please mark and index the May 17, 1999 arbitrations award of
Judgment to Defendant final as the Plaintiff has not appealed said
Order.
Date: -;:r.;;".L';?S', /Y? 5>
Respectfully submitted,
McKissock & Hoffman, P.C.
~~-,
BYEdWin A.D~
Attorney I.D. No. 75902
105 North Front Street
Suite 205
Harrisburg, PA 17101
(717) 234-0103
(,Y
~,
cr-
I;:';
U.l~ j
("J"
I;~ "
"
()~
2.1f
u:,'
i/'
;'
p.
o
o.n
~':
.....
j
j
~
~ 0'
1 JJ
? ..
&. ..P:
. :>
..I ~
~~
<<..1) C3
:~'!
C';'"
, "
,.y-;;
0-'
(1''\ : j
0', i')
!r~ I~ bE,/!,!!
j, ..(J' t ~ p .-;>-....v,~~r"!;-fJ
, ",(,?,,,V I A-I" ~ l)
,,'f")' \1')):0
)? c")'J.?C-l J)r'~ G~ 't r
. "-.\ r>~-rriJT1, (:s""rCj
_____ .J
. 7- ~'l,rcJ "f'r0