HomeMy WebLinkAbout95-07254
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WilliAm p, Dougln., lili!.
6u""",, Courll,D, 11.11926
Driullbl.. Dougln. & Dol/II'"
21 W. UiRh 5/;
C"II.", /11117013
rtWp/f.,1t al1) 243.1790
Cheryl Simmons O1S parent &: natural
guardian of Matthew Simmons, a
minor
IN THE COURT OF COMMON
PLEAS OF CUMBERLAND COUN1"Y,
PENNSYL VANIA
Peti t/oners/ NIII n tlfls
vs
:l( i:). -O')LI-
Judy Fertenbaugh
Respondents/Defendants
CIVIL ACTION LAW
Approval of Minor Settlement
ORDER
AND NOW, to wit this the E day of ....bI.{l/M (.,fY.,-1995, a hearing Is scheduled
for ~ day of _~ law ~ . 199!1,~t -k,U!... o'clock, pM., In Court Room
Number.....5..-.. of the Cu berland County Court House.
J.
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Will.", I', D,lIIll/d., EIf/'
SU/W"" Court 1,0, 1,'7926
o.;u,"", DoUII/d' & DoIIS'd.
27 W, "ISh SI;
Clrll.~, PIll ro/3
T'''Phmrt 1717/ 24,1-1790
Cheryl Slmmolls as parent &: natural
guardian of Matthew Simmons, a
minor
IN THE COURT OF COMMON
PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
I'et/ / 100Iers/ 1'1111 II /I{{s
vs
Judy Fertenbaugh
, Respo/ldm/s/De{errdllll/s
CIVIL ACTION LAW
Approval of Minor Settlement
Petition for Approval of Minor's Settlement
1. Your Petitioner, Cheryl Simmons, Is the parent and guardian of Matthew
Simmons, a minor, all the aforesaid reside at 7-B T-8, Richland LaM Camp Hili,
Cumberland County, Pennsylvania,
2, The respondent, Judy Fertenbaugh, is an adult Individual residing at 505
Slaseman Drive, New Cumberland, Cumber),and County, Pennsylvania,
4, On July 15, 1995, the minor plaintiff was Injured as the result of a dog bite
which occurred at the address of the respondent.
5, As a result of the accident which occurred on the aforesaid date the minor
child was subjected to medical treatment at a cost of $867,00. The Foremost
Insurance Company has paid $500,00, of the aforesaid bl1lleavlng a balance of
$367,00,
6. Dr, Herceg treated the minor chlld, A copy of his bill Is attached hereto
and made a part hereof as Exhibit "A", The Holy Spirit Hospital bill Is attached as
Exhibit "B",
7, The parties are desirous to conclude this matter and have agreed upon a
settlement, as follows:
THE PARTIES AGREE AS FOLLOWS:
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WII/lllm p, PoUIII~.. E""
SU,,"mI ('rlIII'I I.P. JJ7926
POU"~'I PoUII"" It PoUII''''
27 W, hlllh 51;
C~",.It. PA J roM
T'ltphon, /717) UJ.J 790
Cheryl Simmons as parent & natural
guardian of Matthew Simmons, a
minor
IN THE COURT OF COMMON
PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
Petil IOllers/I'II/III I Iffs
vs
Judy Fertenbaugh
Respollden 15/ Defendall Is
CIVIL ACTION LAW
Approval of Minor Settlement
AFFIDAVIT
I hereby swear or affirm that the Foregoing is true and correct to the best of my
knowledge and/or Information and belief.
This is made subject to the penalties of 18 Pa,C.S. S4904 relating to unsworn
falsification to authorities,
Date: ':l. _.~ I . 'l5
HOLY "lltlT H081'.lTAL
In H allT IT
CA"I' HILL. I'A
717 7U-II"1
'11' 13-llla7..7
:1""0:' , ;~;~~;" ALL~~:~~E ";~~j~~i~~i~~t'~l~~i:~r{j~;~~~iE~~~=0 ~~f=~F~---3
I)~n 01111I11.
nAI. OJ
1'llil/lIlll
QUAIlAH'QII
NAMI
CHIRYL U"HON8
'PI ItICHLAND LN
CAN' HILL.'A 17011
AND
ADOIIII.
Si!.!!. ._.__!.!:i~!!!~~_.~!2't~~~~~A!!!..___ ~~~t!! !~~,un
Hlilcii:l--.fIllRltrltD ----
PLEASE RETURN THIS POflTlON WITH YOUR PAYMENT, 7~ ~cut ['~l(I:.:j,'IN' 1$
U,-,TE
fJlilEO
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t1{)SPllALtiElllirCl5
bl.ll,YI(I'.
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0' CUltRINT CHARlES, PAY
"OXIL 'U81' HI' 01....99936
"OXIL lUll' HI' oe...."'36
ICI PACK 8ML 0114121677
ANDAO. eTATITEOl14125660
IRRitATION lET 0114126767
D VISIT LEVEL 011710eOl
lALA CI "ORIIA"D
IU"" "V OF CURltENT CHAR~ES
PHARHACY 250
MIS SUPI'LIEI 270
EMERIENCY ItOO" ..50
CURR, CHARlES
873,4'
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l~l U,'..I'I~ljr l.'1l (fj\I;Il"'lI lofi' IO\I.II~(di Eril Ct}yf.IlAIiI!
11,1, u) 'il) I It,/; nl r,11 ~ .tHi (l) r;~)~' I/Hi co. NO'"
PAJll!:Nf
"MOUNt'
ENU AND
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16.00
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12e,00
ADJUST"E T8
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16.00
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17.00
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163.00
I'AY"INT 18 DUE UI'ON " CIIPT OF THII 8TA I"ENT.
YOU HAY IUB"IT THIS F R"
TO YOUIt INSU"ANCE CAR IE"
'OR ItEIHIURSE"ENT.
FE[1l!flA~T NO n '~'27~'
TOTALS
PATIINT NlJMBln
I1I:THl ALL OUESTlONS TO Tltl'
mJfit~(:C;S OFFICE
(fill 763.21:.11l
"'4'"a
HOLY 'I'I"IT HOI'ITAL
CAMI' HILL, PA
'61.00
PLEASE SEND PAYMENT TO
HOL Y SPIRIT HOSPITAL
5il3 NOIHH 21ST :-;rfl[ET
CAMP HILL, PA 1l011:'201l
flAY THIS A"OUNT
~(.ltJITION"'_ l'^rIUjIIIIUII~r'l MIlY H I~r(r$li/lm' H)ll ANV
n,Mtf1I'!\ '-jOI l'l)r\l~[) V.HU, 11101; 11111. WAr, I'I'fI'MUiD
(111 II, Hj!;u!IM-j(,1 (MH1lnl~; Ilt) tjrH p,,\, "'j'l' PAIl! 0,.
Iltl" M.lflll'll~. rillllVirj 11I-.1[\.11 rr'/IM'dlll It.~,ltll^N(f'
11'~IIIM,1
CONTINGENT FEE AGREEMENT
I, C"::lIVV'" of CQW\I-:e \\,\ \ , ()"',
Pennsylvania, here employ the law firm of Douglas, Douglas &: Douglas, of 27
Westl-Ilgh Street, Carllsle, Pennsylvania 17013, to negotlah! a settlement, or
Institute suit, and carry it on to final determlnallon, If necessllry/ the clldm arising
out of ,the accldenl, which occurr~9 OCI..__ ~~\.."-l\:.._-,-\.S"-~H~~ in
N..I-l ~'J""'\::.>'\\1O-..J( ...(Townshlp), ~. . (County),
Pennsylvanla, against ~'..J<L') (".,,;;;=~,;;,:...... - - and/or
______.______..__n_.._ ____h____':Glls Insurance com pan
The client Is responsible for any and all necessary cosls In preparation and
prl!sentatlon of the aforesaid suit.
Thl! attorneys' fee shall be 331/3% of any rl!covery, Any settlen1l!nt must
be approvl!d by the clll!nt.
IN WITNESS WHEREOF, I havl! Sl!t my hand and sl!aI this ~ day
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of . N~ ') '\ -___ 1995,
Witness:
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