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HomeMy WebLinkAbout96-00357 . \ I 1 } . .n 7 J ~l ~1 S ' 't c..e ( , $ ~ J c- ;;jl , -5 ,C) {~; a , , . i:-: l; :').., ~p - (~l ~-; p:l.l , '; , 1..~- ..':.: Cj>,- , .,. , @" . , . L..- ('...1 , " ~p', - , " (', .. " -- , .. - ", ,,, ~i L' (" U ~ '" ,., <) ~ J 0 ~ '5 ., 0 V; " :1- "\ .. :)- If ~ ~ . tOU ..1 HI HI It'll' :.111'"'" 10 'Ill . "'.UUH .1 ',..O~" T) 1111 INllO'illn IIIlIIf ." '1IIlI1 H" 1101 f'I.HS r.oJlll !>I MVler III 0' 0.. .to Jurlt.lI4r..l JIll, If ." .toU.toI~StH .... ~U& " DOUGLAS, DOUGL~S & DOUGLAS A: :~l~~':'U~\:IL:,w p,> ft(U q. CAftllSld pefU WlVAtltA . 1)-02 I WI: DO HlItru cunlt' 'HU 'H( WITHIN IS A 'flUl: AND COUIC' CO,., 0' THE ORIGINAL flLtO IN 'HIS ACTION. If GEORGE F, DOUGLAS. III. ESQUIRE ATTORNEY J.D. # 61886 DOUGLAS. DOUGLAS & DOUGLAS 27 West High St, P.O. Box 261 Carlisle. Pa. 17013 Telephone: 717-243-1790 Attorney for Plaintiff . MARION L. FORTENDAUGH VS, EUGENE JACKSON : IN 11m COURT OF COMMON I'LI!AS : OF CUMUIlRLANU COUNTY. I'IlNNA, : CIVIL ACTION LAW, ....- : NO, '11...' ,1 ';'1 u....,....< I ~..-.. NOTICE You have been sued in Court. If you wish to defend ugainst the c1uims set forth in the following puges. you must tuke action within twenty (20) days after this complaint and notice are served. by entering a written appearance penmnully or by attorney and filing in writing with the Court your defenses or objections to the c1uims set forth uguinst you. You are warned tllllt if you fail to do so. the cuse muy proceed without you and a judgment may be entered ugainst you by the Court without fUl1her notice for uny money c1uimed in compluint or for uny other c1uim or relief requested by the pluintiff. You muy lose money or property or other rights importunt to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE. GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrutllr Fourth Floor Cumberland County Court House I Court House Squure Curl isle. Pu. 17013 717-240-6200 DOUGLAS. DOUGLAS & DOUGLAS ~ F. ~1!r G1fORGE '. DOUGLAS. II. ESQUIRE Attorney for Pluil1liff COMPLAINT I. The plulntiff. Murion L. Fortenbuugh. is un individuul residing ut 214 B South Stute Road, Mnrysville, Perry County, Penna. 17053. 2. The defendant, Eugene Jackson. is IIn individulIl residing lit 1915 Athol St.. Apt. 6. Cump Hill, Cumberlund County. Pu. 17011. 3. On Mareh 18. 1995, the pluintiff wus the owncr of a 1988 Chevrolet Sprint. 4. At or about 8 P.M. on the aforesllid dute. the plllintiff pllrked his vehicle fllcing eustbound on Lennox St.. Cllmp Hill. Cumberlllnd County, PII.. 5. At the slime time IInd place. the defendllnt WIIS operuting II 1990 Dodge Spirit in u westbound direction on Lennox St.. Camp Hill. Cumbel'lund Cuunty PII. 6. The defendant collided with the purked vehicle uf the plllintiff IInd ned the scene of the uccident. 7. The collision wus cuused by the negligence of the defendunt in the following respects: II. In fuiling to operute his vehicle in u sufe IInd prudent munner. b. In fuiling to keep II proper lookuut. 8. As II result of the negligence of the defendant. the pluintiff hus sustuined u total loss. It.s vulue just prior to the IIccident less its salvuge vlllue lifter the uccident is $1,308.65. which is more fully set forth in the IIttached Exhibit A. WHEREFORE. the plaintiff c1uims of the defendunts u sum of $1.308.65. IIn amount requiring compulsory referrul to IIrbitration under the locul rules of court. DOUGLAS. DOUGLAS & DOUGLAS BY~~^ r-. ~~Rn.~-nr George F. Douglus. III. EsqUl Attorney for Pluintiff . AFFIDA VIT COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF CUMBERLAND : SS: ) Marion L. Fortenbaugh, being duly sworn uccording 10 luw, deposes and suys Ihul ' Ihe avermenls of the within Compluinlure lrue and correct to the best of affiant's knowledge, infonnation und belief. L . /1. U? Sworn to and subscribed l' before me this the / 'I duy of ..J(l..~~ .1996. ,_I~A~ /A;ttL; Notary Notaria'SAaI AmeM Co, '1.lI''l'PLlllc CnrSslt"Bcro Ct~~:,:,'L,r'!1 Cr.1.ntv MvCt'rr.rl'lisU'J;',EY;,..'~. J..t) 14.1997 ~ COMPANlE6 TOTAL LOSS EVALUATION WORKSHEET ~ ') II Claim Insured (Circle one-oHIce use only): q ~ 311 331 390 Phone ('/''7) ~t:;;ln Permsslon to move salvege granted by: Name Date Vende ldentll~tloo No, ~ [IiJ rn ~ [[] ~ QJ ~ ~ [Q] ~ [&] lLlJ BJ Slale~, loss DAte: ,- -, Vende Uc, /I <;:>, - l./ Ii "MILEAGE ^ 1./ 8 (If unknown, enter "TMlf) CI' TlIlCk $' -t- Yea~ Make: Model: r' '''"' Sub Model: (CrcllOW/ BODY STYLE: (ordo "' Ip"","blel 2DR,4I5ij) .l!lIIiHatcl1bacl<J Convertible Wagon Van Utility f'1cl<up 1/2 too 314 tO(l-., r 'rti5n Shortbed Longbed CrfH/ Cab Cab & Chassis ENGINE DETAIL: SIZE \ ,n \:" eVUNDERS: ([2 4 5 6 8 12 Turbo Diesel GW TRANSMISSION: AT Automatic 56 6 Speed (S5 5 Speed ,:>54 4 Speed 53 3 Speed 00 Overdrive Other Fender we 4W 4 Wheel Drive Fendel1ess TIRES (Tread remaining in 32nds) MAKE RF_ LF_ RR_ LR_ S_COLOR Options: (C,.... '"*"1)At OJ'IION' POWER OPTIONS DECOR/CONVENIENCE ~ PM Steering lie - ~r Conditioning B PM Brakes ('R~')- Rear Defogger - PM WlrdowI '1W - lin Wheel PL - PM Locks CC - Cn.ise Cont,oI SP - PM Cr1ve Seat LS - Leal,..,.. Seals PC - PM Pass Seal DB - 4 WI1I Dsk Brakes AB - Anti Lock Brakes TL - TellSCXlpic Wheel RADlO AL - Auto Load Level , ,--:"\ 35 - 3rd Seal(wgna only) '1"-;- AM ap - EighI Passenger ,R.I.:~ FM DA - DJaI ~r (Tn.cks. V_) ,- Slereo 2P -12Passenger _ - Casselle 5P - 15 Passenger 1;, SeeklScan aT - EighI T,ack CB - CB Radio The loIlowing options will ooly appear for the partioJlar vende on which they are available A Y - AAr>t Wheels WI - Winch XC - Press...e Cast _ LB - Lear Bu:l<el SealS XW - AllXrirun W.. Wheels SF - Brougham RooI XB - ClJstom Il<ITl'O' XD - Exlerior Deca LC - Locking Wheel Cove<s 72 - Refridgermor/StlMl 8M - Bose Radio XS - Spadal Ca1rl>er I'I<g XF - Cta.vn Roof (I U ,=-1.1D<ury IntO<1or 7P - 7 PasSenger BP - Split Bench Sel f>oI - Padded V<nyI Roof SN - Snow ~ /IN":r- Leat""" Wrap Steer WI1I 9P - 9 Passenger CE - ClJsI Ext Moldings RF - Cabriolet Roof W - VISion V , ~ MetaliC Paint AP - AllXrirun Cap CF - Carr1age Roof RM - Ren-oveable ROllI PP - _ ,~ Pl....ltiping B4 - SWIvel BLd<et Seals (4) CI - ClJstom Interior SH - Heated SealS FI - ,<emst ~"D "All'- Royal Exlerior CP - F'<bergIass Cap CR - Coach Roof SX - Sporls Seals GP - Glanwr~' 'Equallz", HI. - HydrBUIc Uftgale CV - Convenience Grol.p VC - Valine> Coach Roof HR - Halo Roo RW ......Rai1y Wheels IE - CUstom InteriorlExlortor DP - Mlondust f'ajnt WG - WOOllgrain JB - JBL ' q tlCl, /:" Lirited IntO<1or 50 - Sheepskin C<M!r.l EI - EJec:troric I....truments WP - Rear Window 'M"", K5 - Recaro s UO' '$ ':.;J FuI CabrIolet Roof so - DJalSurIoof PACKAGElSPfCIAL FEATURES (FactOl'f Installed orIy) ROOF OPTIONS VA - VIl1)'I ROllI ES - Elactric Steal EG - Elactric Glass MS - Manual Steal Me; - Manual Glass FA - FlIp Roof TT - T.Tops GT - Glass-Top CT - Se" Top HT - Hard Top RR - Roof Rack PR - P!laetOo'l Roof LP - Padded lJIndau RooI LA - lJIndau Roof OTHER DT - Deep T1nIed Glass eo - RlXlring Boards BS - E!uckll1 Seals FL - Fog Uglts BL - Bedlner AR - 0Y0me Bed Ralls WO - DJaI Rear Wheels XP -ClJstomPalnt AW - MlTirun Wheels ON -Custom Wheels MW - Mag Wteels WW - WIte Wteels we - WIte WteeI Covers 55 - SYoive/ Caplan Olai's SB - Rear Step Il<ITl'O' SW - S1<l1og Roar WIl'doN lIT - Auxiltaly Fuel Tn SY - Sporl_ 2T - 2,tone Paint D2 - Deluxe 2,Ione Paint TP - Trailering Padulge HB - Hg/l Back BLd<et Seats RB - Roll Bar TB - Tool Box (_I) GG - GnlI Guards PO - Positraction OTHER OPTIONS & ACCESSORIES AddrtJooal OTHER OPTIONS & ACCESSORIES S S S "Other S ill CondrtJoo Salvege 1, Rebuilt 2, Sold for parts s s S Total Other Options and Accessor1es (Enter lor C,C,C, as Pre Tax Adj,) Pre-tax adjustment: PRIOR DAMAGE (If none, enter "NONE") Deduction S l\ II,,. 0 ~ Oamage Pre-lax adjustment: ?THER Add S Deduction S "lito. 0 location Sales Tax _ 9 'fo 1. Front Post,tax adjustment: DEDUCTIBLE (If pan. !!'l'er "NONEJ~ , Deduction S')"I1() . IJI) 2. Skle Post,tax adjustment: OTHERtl.....IJ. ~ Add s...b:ll Deduction S 1<>1"- 0 ~: ~~er Remat1<s l r, :L" \ APPRAISeR'S SIGNATURE & UCENSE NUMBER A copy ollhe COITp.Jtad evaluation was sentlgiven 10 the CXlIlSU 00 TOW1ng $ 'I">(\'-.Q Storage S No-.Q --- perday.from '60.~19 PA P'....led '" USA to . , CERTIFICATION OF SALVAGE RETENTION .10,'1//(-041 CLAIM NUMBIR C heurLou. t cS~ ,) i,l t: YIAA AND MAKI (if/e have exercised the option of retalnlnQour -i q 9 J 50 \ i\\ R ~ 15:<'\k rJ()O<C 43 as selvage for the sum of $ VEHICLa IQENYiJf)C"'16N NUMBER /50. 00 Cf5f. U5 and this allowance has been deducted from the agreed settlement of $ for the vehicle. State Farm Insurance Company will not be responsible for storage charges after t\)JA DATE SIGNE@rl}u.,'m J... ~~ DATE 3 - J I - C;S SIGNED (1.301 Q .'57.3 R.v.7.88 Printed In U.S.A. "'.. . ~" I' ~ ..... , CD' "," )0' Ul' .... )0, ...- m, ..... )0; :Il, ::'. i Sl,II'I: i',Al</1 IN; I.lP;\Ni:~: , II ~ LIHliIUI.N NOAH \ '::~:;~~ ~'~;~ :~:~~~~====~==.:==~~;~=~~~~;~~~~~~=~~=" .~~~:\~==,,-.=, = "',,:== ='~ ~;~~: ~~ ~~~; ,:m;~~Kt; 1'<,; LI Nt;TAI.. TIj'l'~L L,.~;~ IiVALllld10N; ~li~'Oh'l' t... '''IN~II~I( ..... . '. . .~~ ~::~ ~-:::-:: '::':''''':;:':-:'-::0::':. ::'-= ':..:~ ~=-= ~ ~..: :~"':=':";':-, ,,:=-.:::.:::.::.~':.::=:d :-:',::-:::"::':' "; ~ ~ :~'<;. ~.:-:.~::-:. -" ---::' '..')!,"" ;l: j,~-'lJ 1..041 TYPE Ill'-' to:.::--" C(.,IL I .,0" ;tL~.~I';t:~: ':114'( ~ONl" l(lqj!JS l;r,AI.~1 kl':: rJA'I'\):.~C;j,'\ F'l'~r; ,t' '" DATi., IlJ.llj-"~ IN:;lll/I'IJ: [oo.'I<IFNII"'-Io"1 nr: ):;: !:~ :IlF m. ,,~ :Il" me Ul- m' Zl ...' )0" ..., -e << m, , ~ r- MAR LON ~'OI\'n;NBAiJGII 114B S STAn: I<U MANY5VILLE.PA tl05J PHlmE: VIN: Oflolr;,; U:;L:: ;WNER: ,II; lt~;;b: ~,".lU,IOb4',1 l VI,l<lt't:!ll] ~===:~==~==~======~~~===~==::~=======~=-=====.:=:.~~==~=:==~~:=~=':.===~=::==:=~= Vk,HICL~; .. I:,...K lJ~~I;KIPT 11)1'1 --- ----- ---.---- --- ..-----,-_.. -----..-----..---.'----------- I.ll W(;W~: PLAIN 1,0 I!ATl'U VI SPRINT 1'11)\1 Cltr;VROl.J::T .--------------------.-------------------------------------.-.------------..-- . - ----- -- --.. - ---------..------------- --- --..--- _.- ------ --.. '.- ---- ,.-- - -_... -.-- ..'-- g~~ cG,' .. ' ~ ' 0" Ill!:' <' ' ~~; ~ .' ~!': ~ ~9 ~r ~f:; .' CO g ~ ~ 00, "~' .- < ' :!'~ . ii,~ ; o~ . ~~. "'~. oE' ~- ,:;r-i ll~ VEHICL~ VALUE LI~T!NU (IN!:.) INUl('An:s INCl.UUhU ) N BA::>h Vill.ll~; ---------..----------------------------- ----------- ------.--------. --- -..-..---.-- 1\137.50 INl: . :)/.50- INC. lNC. Ii'll;. 12.50" HIC. [Ne. N'JIll( \Jl::RAGE BA5E VAl.Uti I!. I,ll hNGl/Ir. 'II \ hlW~P. :Hhf.P IN" '.1" :)O\oiI.::H W1NLl(lWS ',,; POWhR SI::AT .,!':EKi~';l.:/J~ ,,:-:AK lJhii'OGG~;R :10' CKIJI:;~; CONTROL -~ ~I~ST}{ rp (NG ,,1101< liAJ1AO;E INC. HIe. INr.. I ~. ~IJ" 101,1.0';" INC. W!.:. 4/2.sn- MANUAl. 'l'I<I\NSH I SS ION PO..lEK BFAKES NO hlWhk LUCK:' AJ1,.~'M :;n~r.') TAi'~; Nl,) All< CONllITlONWO NO 'I' ] r:r Wlll':~;[. MliTALl.IC PAINT 1 00486 MII.~:AGli ....-----------------------------------------.---..----------,.._--------------- .--------.,--- .-----------------------------------....-.-.--------------------.. qsf, If) /50 . CO ~ < < <=,,===, U51. ~O 81 ' I~" l~' 01). .~ '. :'('lIAL r;";;H Vo\L1)~; ',,~Ll': 'l'.I<:< ,,~ ""l.~: " ':'!(I\N:)"~;k ~ , " ?,:' ~, i- a.: '" z' - , l 1/.~9 .b5 ~ 501.l.0u, ",l,)USTt.LI VAf.IJE ,'.;'Ol.:TIBl.li ) 9"8.r,~ ,"'!' (,O~:HJ1'ED VAl.iJti ....-------------------------------.----------..-----------...---..-..----------- ._ _.____ __ _.,_ ._....___.__ .-----.-.-_'.__.0_._"-.. ____________ --_.-- -.------ ------- ---- --- lit I"i'!<':I:.: '!'Hl:; TOTAl. W$S EVALUATION f1A:; t;F.;t.N PP,EPARliO In Cc..llt'on.p iN , 'I.'r)~l.'~.N':J; W 1\'11 Till:: PENlISYl.VAN1A Ai'PIlA1SAL I.AW Mill IS AN I\'I":.O\(;I( KI::Tr..1 L 'lI' r,~: ,\PPkuPIlI/lrr. ~;~l['rr'J!js lJ~ TIlE (jUrul; bUCKS IN ..~'n:CT ',ICl 'l'11f. ur.F': uf (,(,S::;. ,. ",r- -cr- )-t': Ulc ",3: >,:: "'" m,. -n~ Jo" :Il:: 3:(.'. n::; r-IT Joe. -c 3;- JJ~ mT ]t me u>.. m- ~). ..;-, ,.", ",l; -0 < , m~ " r- . ,_ _. ,. - - __. - ____... ....__..______.__..____.__.. ______...... ____._.._.._.. ... __u_ __._ __ _____.__ , - - - __ - ~ ___ _......___ __0.--- .._____ .._____.. ..-- - --'.' ........--- ----- . - .- -........--.--... --... - ')MM,"JJ!"~i : ~ r. " ~ ,',' , /, " ..~' ,~"" II '7','".l-..\ . ' . I "'-'~' . , ' _ ___ 1 \J.A...~_ .~--.-_..-;..-..-.~4.-._--...,..--... ,,~...._.0 _,____.J._....._. ...- . \ :l;...\l..~!';!... .' ~.f(:NATU~~:: .rlft~~~l~p ~t. m~v~ ~~lV~a~ gr3~led t)y: --.-.-..--.-... ..---- .--.-.. ':'.'pv 0;: t:ht- cnmf'ur:o'?j "!vC'lu.tlLI)n ....dO:: $l-:NTI'~:"I,N t;o Irl'~ l'-,rl,:.t':'I;'..r I)n: ,',"in!; ~ :J~,')r"8~ .;:h:-1:'\!~'! hav~ l,oll!-11 'IIthcrl;~("1 rl.r'J _.._....._ :'l".lJ'1 .' ,'.IV'F.~.I th1t '~h,1rG'~~ I,t".!r r~.i~l ,I,;\rl.- ~r'~ '/<.ur r~~J','n:"""II'v. . , c: 1)3,'21/]5 ~~:~.. Ii.:!. E~ti.o,. .0: lB'7IJJ'0~1 CmUted Pralil. 10: ,6 2S 13 ~ , .- , ~ f I '- Cl - .. . :> v. , '" , . ~ " I - , >- a .. " ~ ~ .. 2 , v. - ,., z ~ !: ;;: m , STATE FARN ~TUAL INSURANCE 115 LI"EKILN ROAD HEW CW'-SERLANO PA 170;0 C7l71 17\'S021 fOR ANY QUESTIONS RECAIDINO THIS ESTI"ATE FLEHBE CONTACI THE INDICATED ClAI"S HANDLER ........_..........____.._.....__.. OOUie f,mmd By: RA'( SllIID 3001731 Iy~e a' La..: Calli.ian (SFecl Dele a' Lo.~: 03/18/S5 D.duetib1e: 500.CO In~"r.d: "ARION FORTENBAUCH Addrea.: 211 B S STAlE ROAD PARYSVILLE PA 17053 Hale Fhane: (717) S57.3520 "itoh.11 Servie.: SII'86 De,erlplion: ISS8 CNtVROLEI SlAINT 40 H/8 VIH: JG1"RSI5S.~700613 Lteen~e: 653'45S PA "11119': lOO,I8S OEIVAl T: A Seorch Cede: CUIIBER Option.: CASSETIE, SE~CHJSEEK, POUER BRAKES, ELECI"lC OEFOGGER, SIEFEO RADIO, A" RADIO. F" FADIO, '.DOOR HATCHeACk, 3 CYLlHOER ENOINt. IF.D~T WHEEL DRI\<, 5 SFEEO ftAlruAl I"AKS"ISSIOH. @ :::~ .~ " ;" .- ~~ Un. Entry Lebor Une It," 1111 ~ llE;. O..rellon D.,eri.llan 1 900500 eooy 'F.E"DVE/AEFLACE 'IRT eODY SECT 2 IIJIH REFINISH/REPAIR FRT BODY SECT 3 LINE "ARKU? l25,oo , SECIIOH AS NEEOE~ 5 100011 REFIH REFINISH L QUARTER fAHEL OUISIOE . 126180 BODY RENOVE/REPLACE L CONBIHATJON LAKF ASSENeLY 1 LINE ~ARKUP 125.00 8 S3107S BODY REPAIR 'LEFI QIR PAHEL S 336011 ~D'L COST APPEARANCE ALLO~ANCE 10 SClAPE RR Bl!IlPER 11 AUlD ACD'L COSI PAIIIl HATERIALS . JudS,..nt II.. ~;~ -. :.. ::.-;: ~~ Perl IYF.I Oall.. Lobor Part H:J:abef fi!wL Ilill.. QUAL RECYCLED PARI 600.00' 10.0' 1.0' 150.00 1.3 QUAL RECYCLED PARI SO.O~' 0.5 12,50 4.0' 75.00. 7S.70' t"':= ~;. ~= ~~ ;;:= ~~ 'r_< i: ~ J-A QRP P~R1S LOCATED Al hUNILLERS ~E;I AS. FCP. alLL I.BVO'521-":61 ~AftAGE IS noF.E 5EVEF.E ESTI"ATE :CHfIRNS TOIAL LOSS !:~ - - ~ - ~ , >- ~- (..,:; I. lebor S.~lctel~ ~ ~ T,lel~ Bad, 1\.5 :6.00 Jj7,CO Rellnlsh 5.3 26.00 153.\0 Labar Subtot,1 530.10 ldbcf TJ_ ~ 6.CO~ 31.82 lJ~cr SUI.Jry r~t3J~ 10.; ~t~.~: II. FJrt ~ep!~ceJent SUI'dry ",obi. Pari. 'Jrt! ftdj~st.ent Sele~ Te. i S.COl iut,l ;,pi,:...nt /,rl~ Alcunl: AJount 650.00 :5~.SO IS.75 ECl.:5 ::::; " ~: ~~ .' [SliMlE IWlL SI;1I/El: 03I111S5 09:51:30 38-1111'011 hitchdl Data :;er~IDI1: Pl~R.9S.,' (CPif1:1ht ((i 19~O. "ltche:! Illtelf...t:::r."J ,,1 i ;; i!;f~ ;e~cr".Cll PJ:JC J of Z -- '" te: ~3;,1. jS 13:~i n,~. E~ti.... ID: 38-7111-011 Co..iU.d Profil. ID: ZS :8 13 III, Addition.1 Co~t~ T~..ble COlli S~le~ I.,. ..001 lot. 1 Additlon.l Co~t~: Alount 76.iO ...0 BUD I. Tot.ll.bar: iI, 10t.1 R.ploce.ent Port.: III, Tot.1 Addili,",1 Co~I.: Cro~~ 101>1: Cu~to..r Allowanc.: 75,00 Point 0' I.po.t: IS TDIAL lD.S 80dy Shop: UNKNDWN Cu.to..r R.~pon~lblllly: 50D.00- In~p.clion Sito: FIELD Ilet lohl: iN CDRPlII~CE WITH SECTIDN IB21 DF ACT. OF 1990: ANY PERSON WHO KNOWIHClY AND WITH INTEHT TO INJURE DR DEFRAUD ANY ItISURER mES AN APPLICATION OR CLAIR CONTAINING ANY FALSE, INCDlIPlETE DR MISlEADINC INFORMATION SHAll, UPON CONVICTIDN. SE SUSJECT tD IMPRISDIIMENT FDR UP TD SHIEN YEARS AIID PAlMENT DF A ru~ DF UP TD 115,000, ... CAUllDIl ... FAlllNO TD PRESENT THIS ESTIMATE TD THE REPAIRIHG CARACE BEFDRE REPAIR RAY RESULT IN ADDITIONAL EXPENSE TD YOU. ANY SUPPLEMENT TO THIS EST IRATE KOST SE AUTHORIZED 8Y A STATE FARM ADJUSTER, NOTICE: REPAIRS TO THIS VEHICLE RAY RECUIRE SPECIFIC ~ELDING EQUIPMEHT AS RECCMENDEO BY THE ~A~urACIURER. LKQ PARIS LDCATED AT: .._....._......'._......................_._ PHONE I: .........._........_.__..._ PRICES REFLECT A 251 RARKUP. ESTIRATE RECALL IIVREEP.: D3/21/95 09:51:30 38'7111-0\1 Ritchell O.t. 'I".lon: r.loRJS.A Copyri~M (C) mo, ~il,~..lI I.t.r.,tion.1 ~11 l\i'jl.h Re~er'.cd .-.-- . ----_Y.,.-.---~ " S6Z,22 861.:5 BI.30 Ill, ~ )0, ~.: " 1,50\.7'1 ~, ~ ~ ~ c' ~, i:: 8 tl'- ~= m- z: >- """:: :::.: r~ . 1,079,71 ~ > Ill~ ",- )ot L CII- ...- >~ ..... m;. ..: ~:.~ ~i;, n ~: ~~, ~~ M: 't: . :n:-. ~~~ r.'" z ~. ...; >" ...' <: ~~ m', , -. ~. ~ P"ye Z of Z > ~:: >~ "':" ... - ~.: f'T',' ..,:.: ~ :~ ;"'- i:: n=- ~: ~ ~. t..; r.;~ ",- - ' m:~ ",-, m" 3:" )0'1 ~." < (' Ml: ~ L:J ~-: - ~: 2> ...... .. lI~P t~;~: ( '-:r .'- r-~ ' .' ... ~~ ..:; ~., ~~~. (:} "or . ~, ) - ~!~ N ,,1/, -- II r .. ; ;",;,) 0: ,-,:: I\J.. r:.: -, -: ll. lr' :~ .; u 0' u . ,ou .". Ul 1I'!1f WI 1"111111 10 "\I " __.,111 Jol If. '1'<1"'01 I' 1111 l'l(tO\lll ",1.0.. r""~,, Ilflll'.~'; '"r}.. q."U;1 "'MlO' UII " 1lI1"."" 141 M",nl' IHIIIIIO "''''''~I 'HI)J ~ _ 'r' .. ).6.:VI1~\~ I . Inv:J.; \(j\ ."01111" J DOUGLAS, DOUGLAS & DOUGLAS f''' tun ,"', WI DO NUn, CElllrY 'HAr 'HI WIIHIN II .. '''Ul "HD CO... CI CO'", 0' THI O.IGIHAL. fiLl 0 IN 'HII "'CllON, If ArronNf''1'''' lAIV tit ""'''"I..r.'Af'l GEORGE F. DOUGLAS, III, ESQUIRE ATI'ORNEY I.D. # 61886 DOUGLAS, DOUGLAS & DOUGLAS 27 West High St. P,O. Box 261 Carlisle, Pa. 17013 Telephone: 717-243-1790 Attorney for Plaintiff MARION L. FOIHENUAUGH : IN HIE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY. PENNA. : CIVIL ACI'ION LAW.. _ ( -r- : NO. q(,., ,H''] (!~ ,~ VS. EUGENE JACKSON NOTICE You have been sued in Court. If you wish to defend against the class set forth in the following pages, you must take action within forty five (45) days after this Request for Admission and notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Fourth Floor Cumberland County Court House I Court House Square Carlisle, Pa. 17013 717-240-6200 DOU LAS, DOUGLAS, & DOUGLAS - lID BY George F. Douglas, III, Esqui ' Attorney for Plaintiff ...,.....'... . GEORGE F. DOUGLAS, III, ESQUIRE ATrORNEY I.D. # 6111116 DOUGLAS, DOUGLAS & DOUGLAS 27 West High St. P.O. Box 261 Carlisle, Pa. 17013 Telephone: 717-243-1790 Attorney for Plaintiff MARION L. FORTENBAUGU : IN TIIIi COURT OF COMMON PLEAS : OF CUMIIERLAND COUNTY, PIiNNA. VS. EUGENE JACKSON : CIVIL ACTION LAW : NO. REOUEST FOR ADMISSIONS Plaintiff, by his attorneys, DOUGLAS, DOUGLAS & DOUGLAS, files the following Request for Admissions on Defendant, pursuant to Pennsylvania Rule of Civil Procedure 4014, and requests the Defendant to admit the following. Failure to respond within 45 days will constitute an admission of the following: J. That the attached repair bill is an itemization of charges for labor and materials used in repairing the plaintiff's vehicle, and is a direct and proximate result of damages sustained in the collision of March Ill, 1995. 2. That all the aforesaid costs are fair, reasonable and necessary, and are reflective of those customarily charged. Respectfully submitted, DOUGLAS, DOUGLAS, & DOUGLAS ,- BY W George F. ouglas, III, Es uire Attorney for Plaintiff Dated: JAN 2 2 1996 , 0_ -A , STATE FARM INSURANCE COMPANlE6 I . OFFICE, . . 1. ..4 ... I J , TOTAL LOSS EVALUATION WORKSHEET ''111 ... ... Vand Oairn InsI6ed r , (circle OIllHlIfkle use only): ~ 311 331 390 Phone (,,'7) q ~t:;;ln PemillSlon to move saJyage granted by: Neme Date Q VeNde ldentil~tm No, Rt [frHEJ ~ [[] ~ QJ ~ ~ ~ ~ [lQ] [0 [3] Stlteit' Loss Dat0 - -, VeNde lie, /I C;'" - L/., 1\ MILEAGE ^ l./ g (II unknown, enter "TMlf) ear TIIlCl< S' -\.- Year: Make: Model: r' . '"' Sub Model: IC"""'-I BODY STYLE: Car..... -I 2DR ~ .J!!lIiHatc:hbacIY Convertible Wagon Van UWily Pickup 1 t2 ton 3/4 lCl(\, r 'rtOO Shortbed Longbed Cum Cab Cab & Chassls ENGINE DETAIL: SIZE \ .n \::" CYLINDERS: ([2 4 5 6 8 12 Turbo Diesel GW TRANSMISSION: AT Automatic 56 6 Speed ?S5 5 Speed -='54 4 Speed 53 3 Speed 00 Overdrive Other Fender we 4W 4 Wheel Drive Fendef10ss TIRES (Tread remaining in 32nds) MAKE RF LF RR LA S COLOR Options: cc- .._...""" POWER OPTIONS DECORICONIIENlENCE ROOF OPTIONS OlliER ~ PM Sleeri'9 ~c. - AJr Con<itiOO'9 VR - Vnyl RooI SB - Roar Slep !lurj:ler or - Deep TlnIed Gas. PM Brakes ('Rci)- Roar Oefogger ES - Electric Steal SW - Sliding Roar W/TYJaN BO - FlIning !lolwds - PM WI_ 'iW - Till WhoeI EG - Electric Glass Xl - Auxillaly Fuel Tori< as - ad<ltt Seel. PL - PM lcck. CC - CtUse Control MS - M.w.oaI SleaI SY - Sport Wheels FL _ Fog lIgts SP - PM 0rIve Seat LS - Leall&' SealS MG - M.w.oaI Glass 2T - 2,1"'" Paill Bl _ Bedliner PC - PM Pass Seal DB - 4 WhI Dsk Iltak.. FA - Alp Roof D2 - Deluxe 2,1"'" Paint AA - Ovcmo Bed Ralls AB - AnIllcck Iltakes TL - TeIesoopc WhoeI TT - ToTcps TP - T_'9 Pad<age we -lXoaI Roar WhoeIs RADIO AL -AuIoloodLllvel GT-Glass,Top HB-HghBackBucl<etSealS XP -CUslcmPalnt 1- "" AM 3S - 3rtl Seal (wgla only) CT - Soh Top RB - RcII Bar AW - AluTirun WhoeIs , ~ 8P - Eight Passenger 1fT - Hard Top TB - Tool Box (Permanent) ON -CustcmWhoel. FM DA - lXoaI ,., (Trucks, Vans) RR - Roof RacI< GG - GIll GuNds Wi - Mag WhoeI. ' - Stereo 2P - 12 passengor PR - Phaeton RooI PO - PcsI1raction ww-Wn WhoeIs ' - Cassette 5P - 15 Passenger LP - Padded lJIrdau Roof we - Wn WhoeI Ccwers !;, SeeklScan LA - Landau Roof 55 - 5'MveI Captah Chai's 8T - Eight Track CB - CB flad;o The loIlOwing options will only appear for the particular vehide on which they are available AY - "lot WhoeI. WI - W_ xc - Ple$sure Cast Wheels La - lIlar Bucl<et Seal. )No/- AlI.mirun WIre WhoeI. BF - Brougham RooI XB - CUslcm !lurj:ler XD - Exterior Oocor LC - lod<lng Wl1eeI Covets 72 - Relrldger81orISI0\/8 8M - Bose RacIo XS - Speda/ Catrjler f'kg XF - Crown Roof r I U '~"Y Interior 7P - 7 PasSeng.r BP - SpIrt Ilend1 Sel PV - Podded Vinyl Roof SN - Srow mr /liIi';" Leather Wrap 51.... WrI 9P - 9 Passer9lf CE - CUsI Ext MoIdir9s RF - CatJioIet Roo! W - Vosion V , ~ MetalIc Paint M' - AJIITirum Cap CF - Carriage Roof RM - RenoveabIe RooI PP - """'" p ,~ f'Inslripi'9 B4 _ 5'MveI Bucl<et Seals (4) CI - Custcm Interior SH - Healed SealS FI - FrerrlS1 P,' 'D '%I'- Royal Exterior CP _ ~ Cap CR - Coach RooI sx - Sport. SealS GP - GIamolr~' Equalzer HI. _ HydraLlIc UI1gate CV - CorlVenIenc:e Group VC - Valilo Coach Roof HR - Haio Roo RW:::;.RaIly WhoeIs IE _ CUslcm InteriorlExterior OP - Mx>ndusl Paint WG- Woocl!1ain JB - JBl ,51 tl<~, t'_Lmled Interior SC - SheepskiI Covets EI - Electrorlc Insl~. WP - Roar WIndow WIper KS - Recaro . UO' 'lfIl;l F" Cabriolet Roof so - lXoaI &nool PACKAGElSPECIAL FEATURES (F8C1ory 1nS1a11ed only) OTHER OPTIONS & ACCESSORiES Addrtlonal OTHER OPTIONS & ACCESSORIES $ $ $ oOthe(' $ ffi CaldItJon Salvage 1. Rebui~ 2, Sold lor parts $ $ $ Total Other Options and Ac:cessor1es (Enter lor O,O,C, as Pre Tax Adj,) Pre-tax adjustment: PRIOR DAMAGE (If none, enter "NONE") Deduction $ "1101.. 0 WJ Damage Pre-lax adjustment: 9THER Add $ Deduction $ ,),.,., Q Locatm Sales Tax -' % 1, Front Post,tax adjustment: DEDUCTIBLE (If pori, ,enter "NONG:t , Deduction $')1Vl ,UI) 2. SIde Post,tax adjustment: OTHER~I-o.\J. ~ Add $h:!tl- Deduction $ \'11"- 0 ~: ~~ 3, Scrapped Remas1<s i ( APPRAISER'S SIGNATURE & UCENSE NUMBER A copy 01 the COOllUled evaluation was sentlg/ven to the oonsu on Towing $ \'-I(\'-.Q Storage $ No-.-Q ~ porday, Irom '60'~19 PA Pml~.... USA 10 TOlal storage $ State Farm Insurance Company will not be responsible for storage charges after 1\) ~ . DATE SIGNE@,fl)a/I..I'.m ).., r~~ DATE 3 - J I - 95 SIGNED 'CERTIFICATION OF SALVAGE RETENTION .1o'1/J(-O~1 CLAIM NUMUA ~' ,/,\ I ()OJ Chr'u/lOu.t jp';'I',1f::: \ _'lJNe have exercised the option of retalnln~our -J '1 J l, VEAA AND MAKI - - 1 b I j"v\~c~ Ib?:~X~)S~~A3 as salvage for the sum of $ 15 0, 00 and this allowance has bean deducted from the agreed settlement of $ 05f, t.v5 for the vehicle. (130) G "157,3 AeY,1.8S Prln1ed In U.S.A, " i ST.., 1'1: r'P,KM J N;l.lPl\Nl,~!': I II ~ LiM~KLI.N ItOAIl \ ,,'\'~''': '11 ,7.1 .! ')ll~ NI::W ':UMIH..ItLANI1 PA 1/U 0 '1'J~lE: Ill: If' '~"~. "==="====::::====",=="=="===="==",,,,,,,,.,,.,,,,,,==,,=====\====,,,===""."==,"= .",,== == ='"" ,',,",:l!Kt: 1"; LI IU~"'AI.. 'rO'I'.'oL L,,~,~ IiliAl.lIAlll.iNl \I::~'O~:T I.~, 'JLN~II~I'. ~'i. '"~"..,"==n..,"'===..,n..."..==,=~",=.."=...,"'...=.a.a==.====\="'e::::...=".::~.==..=="'.~-= " .....!,~ II: ~"'H/;~ l';t~: ,I' ,;: IJATL: .I,~-/IJ l-l'O' t";-O( ~()Nn ~i.ljJllJ'.S 'l~-Pj-"~ ,WNER' MAR LON ~'OIl'n;NBIIUGtI l14~ S STAn: ItU HARY5VILLE,PA 11053 ~====~==~~=~======~~====~===========~=======:=~============~~=~===~=::====~= :'11:11.l ClliiVROLI:;T :" :=::: ==== ===:.: === ==:==:::= = ===== ==== = ====.: .:==== = =.:::=== ==== ::=:= :.=:: =:-: =::::=:': =::= .;:: = ~ ;. r. L:: T'tl-JE f\~' (...l::~- ~ Cl.!.!.., ..0.. ~r.A 1.~1 kl':: NATtl:;COi,' f' 1', r: I N~lIl(l>l.i: h'KII'NI"\I.h;tl Ill' 0(' ><: Ul' ...- ".. ..." m, -n,.: ".' ,,: ~, 0,: r-r ".:: -" 1:' "1' m_ '0.; ",. me Ul- m- Z' ...." ".-; ...= -e << ""l0- r' PilON!!: VIN: On!r.~ '.):;1::: JGI"~bl5~J~i~Ob41 l V'iI< H'llill] Vk,HICL~; .. C!\K UEl,iI; III 1'1' tON 1 '137.50 INC. :)1,50- IN': . INC. IN,;. 12.50, INC. we. NON~ SPRINT - -- ---- - - --.. --- --- -. - -- --.. -... _____.. ..____u____.___ ____ ---- V'. " PLAIN 40 I!ATCH 1.0 WGLN~: MANUAl. TKANSHISSION POWER B~AI\ES NO POWhk L')CK:' AH..l'M :;n~t;l) TAH: Nt) AIK l~ONLlITIm:lfJl; NO 'I'lr;r wmi!::!. MeTALLIC PAINT 100486 MILEAGE IN';. INC. we;. Il.~U+ 10',I,lJ1J.. [Ne. INC. 412.50- ~~. ~~; !ij<;:~ ..2 oz' li:~; <"' '"o~ ~~: ;!:: ~i5 :~ ,. z ~ ~~, 'V,..; .r ~~- Zz'. ~ ~'~ .<:- :Jr.' ~g~ o z' ;;~. 'Vir.' "0' ~~. ~~ . ": ' ?So. ( : ~, "l." ~: ~~ S~ VEIIICLE VALUE LI:;TlNG (LNC.) INOH'An:S INCLUUJ;O IN BASI:; VAI.U~; ----- --- -.. - -- --- -- ---- ------ -- - -- -- - --- ---------.. --------------- ----.--..-----. '''!::RAGE BASE VAI.lI~: ;!. 1.0 I::NGWr. 'Ill H.lWi:.K Sn.ER IN" 'I" !-'m;I:;I( WINllOWS ','j P()W~;R SI:;A'I' ,:i!::Ki:.;t.:N~ <liAR l.Jel'OGGt::R I,) C~IJlS~; CON'J'ItOL -J~NSTkLPING ,,110K llA11A',i:: .-----------------------------------------------.-----------------.----------- .---------.---...-----.--------------------------------.--.---------------------- ,,:'!'lJAL t;/\~H VALI;t:: ;ALES TA.X Ii: "l'l'Lf. .;. 'rKI\N,;~'~;k "l\,JUSTel) VAf.UE ''';:JUt.:'I'llll.~; '"T l'IJNHH'IW VALiJE -; LlSl.SO 81 . 1 ~,.. 2S.0Q, qsf, tJ) /.'JD . CO ~ <((_.._-- ~ , " 1 145!l.b5 ~ 50').00- $ 9':>J:l.r,S ...". -- - --- --... -.. ...-- -----.. ------- --- ..------- ---.----- -------.. .. ..- -....... ...- --------- _... _____ _ _ __._ ._ ._n_____ ._ ____._.__.___.. _.... M ___ __ _______.. __..... ____ ___ __u___.. --- --- U! 1':';-:<:1;.: THI$ 'I'L'TAI. LOSS E'/AJ.UAHON flA:i t;ElN PP,I:;I'ARIW 8'( CljrWU'fI..ll iN "":I)~l)Jl.N':I: Wl\'l1 THI:; PENNSYLVANIA Ai-'I'I(A15/1L I.AW MW IS AN A"/i-:/lIlr.;E IUiTAIL 'IF !,t: /''pI''RUPHIAl'r. IitH'f!I.lrjS l.l~ 'CHI:: r.U[u~: bum::; IN .:t'n:t.:T '.Irl Tlii': IJ~,T:,;, \)f 1..0:;<.. :l;...\l.:d':l<.".i SJr.NA'I'UtI!-:: 'rm~~'.~i"r' r:e,. rn.')\1,:a. :':~lv.'''~t: grln'"e:'J by: -_._._..._._--~. -.-- ----. ". Illr' o(r' ".<r- Ule: ..." ".;E "'1'" m", ~;;. ".- ,,:: 1:(.1' 0::: 1"'"' ".c -e: 1:- JJ~ ~" JJ! me ~Jl Zl' ...., ".'" ...Jl ;::0 m< .' r 'JM11r.;N !'~i: .. ._ _. n_____ _____.__..___________..____.__..__n___.._________n_ --.- ........--....-...------...- .-----------....------....----------------------...----------.------.-------..---.- (-.. ....-""\ ~ ' " ", I' , ~! '- - - \ '.', I .... . '.'. ~ .-1.,' .' . '-1", ) ~ .. , ~. r"l -r'., .! __n l u..A..--L_,_--..-,~-,"-- ____,___..'_Ll_,__._~-\_' -- ' ,~.:IPV I)T. t:h(l c"mr.\Ir.~'~ t&v~lU..ll"n ..,rdJ ::it-:N'l'/i;:\/IN t.o Irll~ (">(lall~lh..r \)n: ,',..,inS & :)t.'r.l8~ .:r'Lq:~q1 hav'o.' t,."1-?1I :\'.IthC'rl:~c'fJ r:a'J __....__._..' :-'l..)o1'":!' ~. t\.IVlf..\t1 t.h!'lt '..:harg.:-c .1tt'.~r Ih;~1 d.:\rj:o !Jr.) '/':-UT r~9r"":411)i lilv. f.'''' ....,..,. . c: 03.21;35 j9:~i ".~. E.U.... .0:, JB'i1Il'O~l CUIIltted Profile 10: 26 2B 13 ~ !!( I ;l '- STATE fAR" IWTlJAllHSURANtE 115 Ll"EKILH ROAO HEW C~BERLAHO P~ 17010 (71Tl 71\.9021 Q:: -<.. > , ~: ::: mo' ;'. -=i9 FOR ANY QUESTIOHS REGAROING THIS E9TInATE FLE,ISE COHTACT THE INDICATED CLAI"S HAHOLER .._........._._..___._............. Oa..s. A......d By: RAY BCND 3001731 >c r:~ ;l:: "'.. ;.1: -, Typc of La..: CoIli.Io. (Sp.c) Date of La..: 03llB/95 D.ductibl.: 500.00 In.ur.d: "ARIDH FORTEHBAUGH Addr...: 211 8 S STATE ROAD ~ARYSVlllE PA 17053 Ha.. Phon.: (717) 957-3520 '" ~~ "'- :.::: - ' >-; -- <: m:: nitch.11 S.rvlc.: 91\IB6 D..cription: 19BB CHEVROlET SFRINT 10 K/B VIH: JGI1lR615B.A(700613 lic.n..: 653-\5B PA KlI.es.: 100,186 OEft/ALT: A Search Code: CUIlBER Optia..: CASSETTE, SEARCK/SEEK, POWER BRAKES, ELECTRIC OEFC>GER, SfEREO RADIO, An RADIO, F" RADIO. I'DOOR HATCHBACK, 3 CYLINDER ENGINE, fROIlT WHEEL OWE,S SPEED IIAHlJAt TRANSnISSION. :- 0_- " )...: Lin. Entry Labar Lin. Ilea Pari TYF.' Doll.r Labor l!l! ~ ~ Do.r.tlo. Ot!.criDtfcn P.,t H..ber 6!wL l1nlL 900500 Booy -RE"OVE/REFLACE 'fRT eDDY SECT QUAL RECYCLED PAlT 600.00' 10.0' Z REfIH REfIHISH/REPAIR fRT BODY SECT 1.0- J liNE ~KUP 125.CO ISO.OO 1 SECTION AS NEEDED \ 100011 REFIN REFIHISH L QUARTER PANEL OUTSIDE 1.9 6 \26180 BODY REnOVEIREPlACE L ClIIIBIHAnON LAIIP ASSEnElY QUAl P.ECYClED PAllT 50.00' 0.5 7 liNE rARKUP 125.00 12.\0 B 931079 eDDY REPAIR 'LEfT QIR PANEL 1.0' 9 936011 AWL COST riPEnRAHCE ALLO~AHCE 75,01). 10 SCRAPE RR BCIlPER II nUTO AOD'L COSI PAINT nAIERlALS 76.70' . Juds..e n\ Itea ~ .~ T,;' T~ ~:: i: :.~ ~~ i:= ....t':; ~~ !;::: ::. :: :;.: .,:.. I' ~: !mrJu J-A QRF PARIS LOCATED AI AUftllLEiS WEST A5I: fOR BILL i-eOO-521'OZ61 CAnAOE 15 "01.E SEVERE ESllllATE C~IFIR"S TOTAL LOSS ~: ....:.: "': ~ , :.a.-.. en:: -' ~:: -" .,,=.: >~ .:~ .~: 1. Labar S.~lot.l. Unitl.J!4il 101.1. Body 1\.5 26.00 377.00 !etinlsh 5.3 16.nO 153,10 L'~or Sublot.1 530.\0 l.llo, Ta;. 6,00: JI.a2 l3~cr SUIUry Totah ZO.; ~EZ.n II. P.rt F..place.enl S....ry h.Jble hrt~ Parh Mjllsla.n~ 5.1.. Tal' 5.CO: ruI31 F.pl"e..nl P"l. ~eunt: A.",nt 65~.00 152.50 \6.75 e61.~5 J: '.. .' 1; ~~ [Slin"!E ,ECALL HlmIEA: 03/21/95 09:51:30 3B.7111'~\1 ",tchrll Data Vcr'lon: r!I1RJS)\ Cop,'nght -:C) 1~30. "itch.:l! illttl !loIll:Jt\oJJ 1111 P'Jhh ;e~tr..er1 F.1~C J of ~ < , 1":',;0, III, Addillo..1 Co.t. TJ,oble Cc.h Sale. la. I 6.001 Tot.1 ~dditional Ce.t.: te: "MUS 'J3:Si n.n, hti..,. Ie: 38-7111-011 Cmitted Profile 10: Z6 :8 13 ,- ,"" ~ ~ .. '~.;, ~ I. Tohllabor: II. TelJl R.plament PJrh: III. TolJl Additiof,.1 Co.h: Alount 76.70 loSO 01.30 562.22 061.:5 81.30 ~, ~ ? e C ~: i:.' [. Oro.. Total: 1,504.77 . Cu.t..er Allo..nce: 75,00 Peint 0' I.pact: IS TOTAL l06S Body Shop: UKKNOWN Cu.te.er Re.pon.lbilily: 500.00- In.p.clion Sit.: FIELD lIet TolJl: 1,079,77 IN CO~lIANCE WITN SECTION 1827 OF ACT 6 OF 1990: AHY PERSOOIlHO KIftlWINGlY AHO WITH INIENT TO IHJURE OR DEFRAUD AllY IIISURER FilES AN APPLICATION OR ClAln CONTAIN1110 ANY FAlSE. INC~lETE OR "I$lEADINO INFORKATION SNAll, UPON CONUICTION, OE SUBJECT TO I~RISONnENT FOR UP 10 SEUEN YEAPS AND PAynENT OF A FINE OF UP TO 115,000, ... CAUIlON ... FAILING TO PRESENT TNIS ESII~AIE TO THE REPAIRIKG CARAGE 8EFORE REPAIR /JAY RESUlT IN ADDITIONAL EXPENSE TO YOU. ANY SU1'PlEnENT TO THIS ESTlnATE nuST BE AUTNORI,EO OY A STATE FARn ADJUSTER, NOIICE: AEFAIF.S TO THIS VEHICLE ~AY REQUIRE SFECIFIC WElOINO EQUIPnEHT AS RECO~ENnEO OY THE MANUfACTURER, lKQ PARIS lOCATED AT: _._.______...____....._____....__......__.. fHONE I: ............__......____... PRICES REFLECT A 251 ~ARKUP. OJ~ ... >t (11- ;::: ~.. fT'. .. T~ ~:-- ~;; ~:: :!:" i:::: =;.: " ~~ ,"e: .'J' .~ r.~ .. 2' ~: >" ~' ;::'; "'., ~ ~ 'I.:' ~ :> ",- ...- >~ c.''"': E,~ rT':; ~- .....;: ~;<< (1; -- ~ ~. :...:. ESTlMIolE RECAlllll~EER: 03il1,'95 09:51:30 38-7111-0\: ~itchell D.lJ fler.lon: ~JJl)S.A COP'lfI~ht ~C) 1550. ~i!~~,ell lhlern.tio..1 I'll H,ihh ~Ucr..tiJ ",0 ." ' ..,- - ' M:~ (.". m" ;;:-. ,,- ,.-, -OJ < c.' ,., ~: P.)~e 7 of Z SHERIFF'S RETURN - NOT FOUND . CASE NO: 1996-00357 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MORTEN BAUGH MARION L R. Thomas Kline , Sheriff, who being duly sworn according and inquiry for the within VS. JACKSON EUGENE to law, says, that he made a diligent search named defendant. to wit: JACKSON EUGENE but was unable to locate Him in his bailiwick. He therefore returns the COMPLAINT AND NOTICE REQUEST FOR ADMISSIONS NOT FOUND , as to the within named defendant JACKSON EUGENE RESIDENT AT ABOVE ADDRESS STATES DEF. MOVED LAST JUNE. POST OFFICE HAS NO FOWARDING ADDRESS. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 8.40 .00 2.00 So answ~: " -",--'. - . ~ ..----'l.- /' ' /' . I -.::;;.r'r'~'~~ /' 'r'~ R. lhomas K11ne. Sher111 $2~ DOUGLAS DOUGLAS AND DOUGLAS 01(30/1996 Sworn and subscribed to before me this .J"...,( day of .1..h-...........] 19 C;/,_ A. D. ~,~ ~,1J' ,Qt'-,J 4..0./.J.!1-:--- ro honotary' " ....-J'I I' -,~') r..::..~ r~~/ ~) ~f ~ , . ,.: i' ..-~. .. 1 ;, ..,;I 'OU .111 fit "lit, 511 'WI"I 0 10 flLI .- WIIITHH '" '1"()~\1 Tl IIl1 IlfClO..ll) ~ Utllll 'WI HI' tlOI OA'S '''ON SUYICr It 11'(0' ON ... ...lUllI. '4 I NT MA' Ir : ' .. ""~':.t"Uf)~v ~,.:.~ I ""OHNLY - ~ . DOUGLAS, DOUGLAS & DOUGLAS .. 0 no. 't,' WE DO HUn, CUflFJ 'HAl THE WITHIN'I A lIIU[ l"bCO.NI~TCO" ., ~o'uaINAL '1l'~H 'Hl~... _ ACT. . (. ~, 111 I' ___ ._"'o..~- . . IdTORNr.'I ' ATTOltNU5 AT LAW 1'.....'U..!l'lllf' . . GEORGE F. DOUGLAS. 111. ESQUIRE ATTORNEY 1.0. # 61886 DOUGLAS, DOUGLAS & DOUGLAS 27 West High SI. P.O. Box 261 Carlisle, Pu, 17013 Telephonc: 717-243-1790 Allorney for PlnintilT MARION L, rORTENIlAUGIl : IN HIE COURT or COMMON PLEAS : 01' CUMIlEl(LANU COUNTY. PI1NNA, VS, : CIVIL ^lfTION LAW7 /l' . ( : NO, (,{&-35' l/IUI NOTICE EUGENE JACKSON Yuu huvc bccn sued in Courl. If you wish 10 dcfcnd ngninstthe claims sct forth in the following pnges. you must tuke uction withiu twcnty (20) dnys lifter this complaint and nut ice ure served. by entcring 1I wrillen nppcnnlllcc personally or by lIllnrney lImlliling in writing with the Court your dcfcnses or objcctions to the claims set forth against you, You are wurncd th.1l if you failtu do sO.lhe cnsc may proceed wilhout you amI njudgmcut mny be entercd lIgninst yuu by the COUll without furthcr noticc for nny moncy clllimcd in compluintor for .IIlY olher c1nimor rclicf reqncstcd hy thc plailllifr. Yuumny luse money or propcrty or othcr rights illlpOl1nlllto you, YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE. GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, Court Adminislrulnr Fourth Fluor Cumbcrhlllu County Court House I CUl1l'l Housc Squnrc Cnrlblc. Pa. 17013 717-240-6200 DOUGLAS. DOUGLAS & DOUGLAS ~F.~~ GEORGE '. DOUGLAS. II. ESQUIRE Allorney for PllIintiff TRUE COPY FROM RECORD , 'I T es:lmony whereof, I here unlo sel my hand J lho seal 01 said Cou al Callisle, Pa. l,iis ~'I"5- day of' 19<1C. , ~ . ...~. >C. ot.. (....L. F . , Prothonotary COMPLAINT I. Thc pluinliff. Murion L. Fortcnhuugh. is un imli\'iduul rcsiding ul 214 B South Stutc Road. Murysvillc.l'crry County.l'cnnu, 17053. 2. Thc dcfcndulll. Eugcnc Juckson. is un individuul rcsiding ml915 Athol SI.. ApI. 6. ClI'mp Hill. Cumbcrlllnd County. I'll, 17UII. 3. On Murch 18. 1995. thc pluinliff wus thc owncr of 111988 Chcvrolct Sprinl. 4. At or IIhout 8 I',M. onthc IIforcsuid dute. thc pluintiff purkcd his \'chicJc fllcing eustbound on Lennox SI.. Cump Hill, Cumberlllnd County. I'a.. 5. Atlhe sllmc timc und plllcc. thc dcfcndunt wus opcl'llling II 1990 Dodge Spirit in a wcstbound direction on Lennox SI.. Camp Hill. ClIIllherlHlul Counly I'a. 6, Thc dcfcndant collided with thc parked vchiclc of the plaintiff ami ncd Ihc sccne of thc uccidcnl. 7. Thc collision wus caused hy thc negligence ofthc dcfcndunt inthc following rcspccts: a, In failing to operatc his vchiclc in a sare and prudentmanncr. b. In failing to kccp a propcr 10okulIl, 8, As a rcsult orlhc ncgligcncc orthe defendant. the pluintirflms sustaincd atowl loss, It's valuc just prior 10 thc accident less its salvage vuluc after the accident is $1.308.65. which is more fully sct forth in the all ached Exhihit A. WHEREFORE. thc plaintiff claims of the dcfcndmlls a sum of $1.308.65. un umount rcquiring compulsory rcfcrmlto urbitmtion undcr the locul rulcs or coml. DOUGLAS. DOUGLAS &. DOUGLAS BY~~A r-. ~~~. 11i" Gcorgc F. Douglas. III. Esquil - Allorncy for Plaintiff , '. ',' AFFIDA VIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND -" . ';;h' : SS: ) Murion L. Forlenbuugh, being duly sworn uccording to luw. deposes und suys lhut the uverments of lhe within Compluinture true und correclto lhe best of uffiunt's knowledge, infol1llulion und belief. L, .".....,/" ,iJ/ L'iu'>l-/-'-"'\, '''' ,( Murion L. F0I1enbuugh Sworn 10 :lIld subscribed, bcforc mc this lhc I "I .~.... uuy of ,Itc,- .1996. , : ._~11 ,.'-f,. !./~, L,r< NOluiy flea",' :;",1 Am9M t.:'f(, 't~:jI\,Pt~ ~fj~~'.::~o ~>'~":':"';'~i~*.1~ M\'Ct;~rl'~:~..l~~';.':. .'~\;4, ;.~7 C1l1lm Insured r \ (circle DnlHlHIc:e use only): ~ 311 331 ~90 POOne (,,'7) q :;;:t:;;ln Permisslon to rrove selvege granted by: Name Date STATE F4RM INSURANCE ~ I COMPANlE6 , ' OFFICE, . .4 "v~-;;: in<~JC1~ )~ I' ~~ lion;, C::-io \ f\ 'f.., . Apptaiser'sN~ f().. V:if,~~\.'" O,'t~l Damage Type: Web T SI P F'we F1oocImal\r Vend Owner 00. i ~ Address .. -,' TOTAL LOSS EVALUATION WORKSHEET ~ ') II ~~..:: :!~t.< CD ,IE. ~.llP. J4 10, KJ ,qJ~~ If.1o I OJ 8~ q?J.BL ~ '"U1 ell Truck l' ~ Year: Make: Model: J f)' ,.,.." Sub Model: re".OrtIJ U" BODY STYLE: IOfcJe II IPp/oelbll) 2DR ~ ~atchbaC@ Convertible Wagon Van Utility Pickup 112 Ion 3/4 10/\ . {' 'non Shortbed Longbed Crew Cab Cab & Chassis ENGINE DETAIL: SIZE \ ,D L\ C'h,NDERS: <f2 4 5 6 8 12 Turbo Diesel GW TRANSMISSION: AT Automatic 56 6 Speed fiSSS~S4 4 Speed 53 3 Speed 00 Overdrive Options: rChKA.' ~b. DtJllOtI.} POWER OPTIONS DECOR/CONVENIENCE ~ Pwr Slocnrg lie. - Air C<nlot<nrg B Pwr Brake. (R~")- Roar Defogger - Pm Wlrdows '1W - Till ~ PL - PH< Lock. CC - C"'''' ContrOl SP - PH< Drive Se.t LS - Leal"" SealS PC - Pwr P... Se.t DB - 4 Whl Dosk Br.kes AB - Anti Lock Brakes TL - Teleoc:opc I'.l-.cI RAll<O AL - Auto Load Level , '~7' 3S - 3'" Se.t(wgna only) " p.,...~ AM 8P _ Eig" Passenger r:F1.l.-- FM OA - [)..<aJ Air (Tn.cks. Vans) (;;:t; - Sleroo 2P - 12 P.ssengct' W-.rc Casselte SP - 15 P.ssengct' 1$1;:. Seek/Scan 8T - Eight Track CB - CB RaOO The follOwing options will only .ppear for lhe particular vehicle on which they are available A Y - NIt:1( I'.l-.cIs WI - IVII'Ch XC - Pressure east I'.l-.cIs LB - Lear Bucket SealS '/;W - NlITirum Wore WhoeIs BF - BrO<.gh:lm Roof XB - CUslom Bumper XO - E>1anor Decor LC - I.tlcking WhoeI Covers 72 - ReltidQerator/Stove 8M - Bose flad;o XS - Spedal Carrj:o' Pkg XF - 0""," Roof 1" U ,-=-tuxury Intanor 7P - 7 Passenger BP - Splrt Bench Set P>I - Padded Vinyl Roof SN - Srow m / v"v.:r Leat"" Wrap St.... Wt'/ 9P - 9 Passenger CE - Cust Ext l.'oIdings RF - Cal:rioIet Roor w - VisOn V , tM~ Melal" Paint AP - NlITirtJm Cap CF - Carriage Roof RM - ROfTCWeab/e Roof PP - _ P ,~ Plnstriprg 54 _ Swivel Bucket Seals (4) CI - CUSlom Intanor SH - Heated SealS FI - F.<>rist PJirI 'D 'roF- Royal E>1anor CP - Fiberglass Cap CR - Coach Roof SX - Spor1s Seats GP - Glam:xx ~ai~' Equalizer HL _ HydnIUIc: Uftgate OJ - Conven!eml Gloup vc - Valno Coach Roof HR - Haio Roof RW,/RalIy WhoeIs IE - CUslom Intanor/E>1anor OP - M:>ondust Paint WG - Woodgrain JB - JBL <:( tlC~, t; UtMed Intanor 5C - Sheepskin Covers EI - Elec1ror1lc Instn.wnents WP - Rear Wordow Wiper KS - Atx:aro s 00' ~ ';) FuI Cabriole1 RooI SO - [)..<aJ S<.nroof PACKAGElSPECIAL FEATURES (Fac1ory installed orly) TIRES (Tread remaining In 32nds) MAKE RF LF RR LA ROOF OPTIONS VR - Vinyl Rool ES - Elec1ne Steal EG - Elec1ne Glass MS - Manuat Stoat MG - Manuat Glass FR - Flip Roof TT - T'Tops GT - Gl...,Top CT - Solt Top tiT - Hard Top RR - Roof Rack PR - Phaeton Roof LP - Padded Landau Root LA - Landau Roof SB - Roar Step Bumper sw - Sliding Roar WIf'dcN Xl - AWl1l111'( Fuel Tank SY - Spor1 Wheels 2T - 2,tooo Paint 02 - Ocfuxe 2.10flJ Paint TP - Trallertrg Pad<age HB - Hgh Back Bucket SealS RB - Roll Bar TB - ToolBox (Pem\1"'"'1 GG - Gntt Guards PO - I'osrtractlon OTHER OPTIONS & ACCESSORIES Other Fender WB 4VV 4 VVheeI Drive Fenderiess S COLOR OTHER OT - Deep TInted GI.ss BO - RUflrirg Boards BS - Buckql Seats FL - Fog Ughts BL -llo<Jiner AR - Chrorro Bed RaIl. WO - [)..<aJ Rear WhoeI. XP - c..Slom Paint AW - AJurrirun WhooI. ON - Custom WhoeIs MN-Mag_s WN - Wore WhoeIs we - Woe WhoeI Covers 55 - SVoiYOf Captain Chairs s S $ Total Other Options and Accessorles (Enter for C,C,C, as Pre Tax Adj,) Pre-lax adjustrrent: PRIOR DAMAGE (II none. enter "NONE") Deduction $ ~ 1:.... 0 ~ Damage Pre-lax adjuslrrenl: OTHER Add $ Deduction S ~_ Location Sales Tax I 9 % 1. Front Post,lax adjustrrent: DEDUCTIBLE (II pen. enter "NONl;) Deduction S')"'\f1 . rll) 2, SldQ Post,tax adjustrrenl: OTHER~\'-o.I), ~ Add S Y:;,t[) Deduction S Ill', 0 ~: ~~er Additional OTHER OPTIONS & ACCESSORIES $ $ $ "Othet" S W Ccncmlon Salvage 1, Rebuilt 2, Sold for parts Remarks i ( f', - .\PPRAISER'S SIGNATlJRE & LICENSE NUMBER 10 3, Scrapped Tot aI slorago $ ,.., , ,. CERTIFICATION OF SALVAGE RETENTION 3o~1/1(-D~1 CLAIM NUMBeR Chtu;2.o&-t 5~';)I'/lt: YEAR AND MAKE as salvage for the sum of $ 15 D I CO q~.I/. I _C: and this allowance has been deducted from the agreed settlement of $ J;1 ~ (ji;Ne have exercised the option of retalnlnQour -I q ,9 J ~fb\i\\ KW f5~~~~(~o(c43 VIHICLIi IOEN CATI N NUMBER for the vehicle. 3 c- OATE - J I - 70 1\) flr DATE SIGNE@iPJd/U'n1 J.. r~~d <-.I State Farm Insurance Company will not be responsible for storage charges after SIGNED II:JOI 0 4857,3 A..... 7.88 Prlntld In U.S.A, .... ..' ... _. . ~L" ..... . ... .. ... .. .. - -~ -. -. ..- 't', r. ~ i , ST.-In: j'PKM IN: 1.lI'Mlf.'~; I II~' LJ,M~;I(LI.N IlOAIl I ,.-\':'1;: l)j'lI'l"'I~ N~W ':UMllhRLANl1 PA IIUI~ n"lE: In: 1'.' "'0'" =~, ~=,== ,,~==::=,=="===': ,,=======,~""--==="='''',\::,=:=, =";','.,= ,.=, ,:::.:: ,: :." ,'..,,:l:"~: I",: 1.1 ~t;;'J'AJ... '/OlHL L',.S:i ~;\:AJ.lIA1!l.iNi ~tifOf,T '.., 'J1N"I:~I\ .':. _~,~~~=~~~=~~~~~~~~~:~=~.:~~=:~~~~.~~;~.~~~~~~=~~~===i =~~:~~~~:~-~=.~~~=~~~~~-_.: Ill' -c' ..' Ul' ....' ... ..... m, .,,;. ..' ,,: ~'. '..'l!.."" 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E~lj.... .0: ~B'illl'O\1 Cuullltd Prutil, 10: :6 7B I] .- "( l~ STAlE rAl" IIUTUAL JIISURANCE 115 LI"EKILH ROAD HEW CUlBERL~ P~ livi~ (711) 171-90:1 c:::: ..... > ' ~.; ::= ;.... fOR AHY QVESTIONS REGAROJilO IHIS ESTlM!E FLEliSE COHIACT IHE INDICATED CLAI"S HAHDLER .............'..................... O"'S' A..,..ed By: RAY BeHO ]001131 ? 7 ~ .~ ::;)t: m TYAO of Lo,,: Coli hi., (!.or> Dole of Lo..: 03/1S/5S tiedudihle: 50o.c~ lr..urod: "r~ION rORIEHSAUON I.ddreu: m S S STitTE 1.01.0 ~ARYS'JILLE FA liDS] He... Fho",: nJ7) 5\1,3\20 ~ i ~~ .....: >:.: - - 2: rnt Mitchell S.rvico: 9111E6 Oemipti.n: 15BB (~!UROLET 51>!HI 40 HIe VIN: JG1MR615B.r.100613 Lic".e: 653'45S PI. Mileos.: 100,186 [k OWALI: A S..'ch Cod,: mm Oplior..: C,SSETiE, SE~CH/SEE" POWER SRA,ES, ELECIRIC OEFCt;E" SIErEO RADIO. AM !AOIO. rM rADIO, ;'OCCP. HATCH,ACK, ] CiLlh~ER Esmr, HOST ~HEEL omE, 5 SPEED ..Aii,r.t !'.ANIMIsmH. ~ ,J, " ~ -"" lir., Entry L.bor lir.e It.. i1f! ~ ~ Operatinn C~!~rigt!cn 1 :00500 eOOy ',EMO\{/REFLACE 'FRT EeOY SECT ; F!nN mINIS~JF.EPm m BOOY SECT J L!lIE MIKUI m.~~ ; SECTION AS NEfDEO \ 400011 REFlN REF WISH L ~L~RTB FMlEL OU1SICE e 42S~SC SDOY P,[~~~Ei~E;LACE L CO~BINATICH lh~P ~SSEnElY ; LINE ~ARKUP \2\,00 S 931079 eoor REFAIR 'LErT QIR PANEL 9 9J5011 ~O'L COST APIEARANCE ALLO~AHCE 10 SCMrE 1.1 p.C~PER 11 I\UID (,OO'L cm PAWl M!HlntS . Jodg..errt He, Part TYF!/ P.nt ~h:bfr QUAL F.Eey,LEO ,",I ColI.r Lobor h,~unt UllL 500.0e. 10,0' 1,0' r. :- t;': f.~ 5. .~ ~ - - ~ ~~ 150.CO 1.9 50,OC. 0.5 12,50 -, - !.::= QUAL mmEO FAAI ~:1 4.0' '" ~: i5.~O' 16,70' t.~."rk~ 3.A (" ,ARlS LOO"lEe AT AU~ILLE.S WEST ASK reI. BILL l-EOO'521'C,EI rA~ASE is MORE SEVE..E ESIIMAIE C~IfJRnS TOIAL Less fr: '.:: - - - - " >< :::.: :: : ~ .,. " :.: ~ ' ~.~ 1. tob,r So-l:lctoh l!!!i.ll ~ 101.1, SCdt 11.5 ;6,00 m ,M I,fin!oh 5,] ,5,1,0 153,40 L'~or Sublotal 530,-0 l.,b" 10, ~ 6.00: 31.:2 l3~or SU"3r~ TCt~J3 :O.~ ~t~.~~ II. PJrt F.erlac:3tnt E~c."ry lA'table rad~ ?Jrt5 "dju~t&er.t S.I.. I.. ~ 5.00\ jol.:!) Pepi.!:esent rJrh AilCUllt: A.lt'unt 65..00 ISZ.5Ij ~S.iS ~t1.:5 " ;: ~: l;Tin;,!E '[U,ll HliO![!: 03/11/9\ 09:,l:,O 36-7I1Hli nltc!lrli Datu ::tr~ICI1: I":':'R.5SJ' CCP,.fl~ht ':Ci :~30. Mitth,..il llltt'I!I.lt;:;r..tl F.l:JC I D~ ~ rl'," " te: ~j::l> Jf. ~J;~1 n,~. , . E'lI.... Ie: 39-illHIII Ca..iltod Pr.file 10: :5 :9 13 " "- III, Additional Ca,ll lJ,.bl. Ce,h ..10. la, f 6,00\ 10\,1 ~dditlan.l Cc.I,: ~'(1unt 76.10 ;.60 al.'j~ I. lut.l L,bor: II. lat.1 Ropl.co.ont P"t.: III. lata I .dditic"a1 Cal\>: SSl.:Z 861.:5 21.30 ~. :>:. '~,: ,. ~, ? ?i Grcu lohl: 1,504.7'.' !: ,.: i:.. . Cu~tQ.er Allowance: 15.00 ~ciot of I.p.tt: 15 101.L LOSS Sod, Shtp: VKKNO~N Cu,lt.o, R"P,n,lbility: Inlpottic, SHe: FIELD 500.00- Uet Ictal: 1,073,77 r, ' '.1,:- ~, . ~. -, ;11 CO~PlJ(,I1CE WlllI SEClIOH 1m ~f m 5 OF 1950: MIY FERSOIl .110 I.KOIIN.LY AND wnH 11l1EHI 10 IHJURE OR OEFItAVO AUY ltisvm FILES !<II mucmON CR CLr.J~ CONTAJHIIIC AII'( fALSE, IIICOII.PLETE OR MISLEADINC INFOR".IIOII SHALL, VFell CONVICIIOH, 5E SVSJECI to IlI.P?lSlitll\!:lIT FOR UF 10 SE~'EII YWS AIID PAYHEHT OF A Flh'E OF VP TO IlS,OOO, ~:. .:- r-t ... C"UllOI~ ... f~ILIN\ 10 PRESENT THIS ES1I".IE to IHS REPAIR III' CAR ACE EEFORE F.EFAIR HAY RESULT III ACOiTtOllAL EX/ESSE TO YOV, ANY SVPFLE"EHI TO tHIS ESII".tE HUSt SE "VI,O?11EO SY A SiAIE FAPH ADJUStER. HellCE: mms l' TlHS ,trim "r,y REOVIRE SPECIFIC UELOH/\ EQtumN! .5 mc~~no:o 2Y IHE ~AIlUf.CIUF.ER, I.,Q ~.?lS LCCAIEO At: ..''.'.''.'..'.....''................. fHOt:E ,: ........................... ,RICES ;[FLECT . 2:~ ~h?r.~P, r:;: l~ c::: <, ;.' , =.;: =.:: r--:... ~~. i.:~ -, ~S ~ ;: r::.' ~.; ;,~ I.: z ~. ;..-: - ' < .: ,.-:.:.: r:~ I, . Co', :> -" ,,- >~ ~:; :~ .: \",' .....:..:. ~:~ 0;: .~ . '...; iSll~I'I:E ~EC(lLL Ir.!~EEP.: C;/:I:~: 1)9:S4:3~ ~B-7!l1'iH: ~itthcIl O"U 1.ler~lwli: r.1~P.JSJi \"r-frJ~M ~') ::j~, :\1~;;~.cl1 t::tCftl03U:ni\l .;j: :.:;t.t~ ~:f:.enr.d ::;~ Pl~r. ~ of Z (;:: l'" ,n .. ~:. ;. " -" ;..[. ri ~: . ':~J ,,'~~::J 1;'v~'l l!':'::'j C:!t " _h.~! ~l~) 'I' 'I _au Ul HI III "' '" QUUltD '0 flU A 'IUlflIN 1I1""ONU 'f) IHI 'HClO'UU .1'"1"1 '..-UU' 1101 nUl no.. a"vler III"~' 011 A JUPliNIH' N It IHI "QAI"U~ ., ,Itn"ll L '?~"OI"U , DOUGLAS, DOUGLAS 6. DOUGLA!:; A"on/jt'l'~ Al l"W " " "'11" ~ '''II . C""U~LJ:, "(lHj~.n.V""'jlA 1101)'0101 WI: DO ""un CUlIf. THA' 'HI WljlH II A ".ur A"DCQUICfeo.., or Ht ORIGINAL "~IH , IS :: i:,...... 0 _ ,n.Q,.6- ~1.j'~ANI:' Gi .. II htU IfI' / ut. GEORGE 1', DOUGLAS, III, ESQUIRE ATfORNEY !.D. # 61886 DOUGLAS, DOUGLAS & DOUGLAS 27 West High St. P.O. Box 261 Carlisle, Pa. 17013 Telephone: 717-243-1790 Attorney for Plaintiff I\IAI~ION L. FORTENBAUGH : IN THE COUIH OF COMI\ION PI.EAS : OF CUl\mEl~LAND COUNTY, PENNA. \'5, EUGENE JACKSON : CIVIL ACTION LAW /'. . ( : NO. 9t.o - 351 uVL NOTICE You have been sued in Court. If you wish to defend against the class set forth in the following pages, you must take action within forty five (45) days after this Request for Admission and nutice are served, by entering a written appearance persunally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail tu do so, t1w case may proceed without yuu and a judgment may be entered against you by the Court withuut further notice fur any money claimed in complaint or for any other claim or relief requested by the plaintiff. You Illay lose money ur property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Fourth Floor Cumberland County Court House I Court House Square Carlisle, Pa. 17013 717-240-6200 D UGLAS, DOUGLAS, & DOUGLAS --- BY ~ G rge F. ouglas, Ill, E quire Attorney for Plaintiff RUE COpy FROM RECORD 'n Teslimonywhereof, I here unto sat my hand :id the seal of said Cou at Carlisle. Pa, i hi~ Jof "!' -fay oIC/tt...OA"" 19'71, , 7 " , '. {I ...._ . ~Lft~. .l....yJ~" , " Prothonotarv . GEOI~GE F. DOUGLAS, III, ESQUIRE ATI'ORNEY J.D. # 61886 DOUGLAS, DOUGLAS & DOUGLAS 27 West High SI. P.O. Box 261 Cilrlisle, I'il. 17013 Tdephone: 717-243-1790 Allorney for Plilinliff I\IAIUON L. FOIHENnAUGl1 : INTI IE COURT OF Cmll\fON PLEAS : OF CUMBEI~L^N() COUNTY, PENNA. VS, EUGENE JACKSON : CIVIL ACTION LA\\' :NCl. REOUEST FOR ADMISSIONS Plilintiff, by his illlorneys, DOUGLAS, DOUGLAS & DOUGLAS, files the following Request for Admissions on Ddendilnt, purSuilnt to Pennsylvilniil (~ule of Civil Procedurl! 4014, i1Illi requests the Dl!fendilnt to ildmit the following. Fililure to respond within 45 days will constitute an admission of the following: J. That the allached repilir bill is an itemization of charges for labor and milteriills used in repairing the plilintiff's vehicle, and is a direct and proximate result of damages sustained in the collision of March 18, 1995. 2. That illlthe afoJ'esilid costs ilre filiI', I'l.'ilsonable ilnd necessary, and are reflective of those customarily dlilrged. Respectfully submitted. DOUGLAS, DOUGLAS, & DOUGLAS tM Dated: 'JAN 2 :> 1996 ; . .t...;._.....,.,_ , - ... .... Claim Insurad r ' (Circle one-olflce use only): ~ 311 331 390 Phone 1/''7) q ~..;;ln Permission to move salvage gr8lltad by: Name Date .. COMPANle6 V.nde ::v .JCtad Appraiser's N Damage Type: Owner Address , ~~"'"~:.. qt.., Q!l@.Ilf. JfV J.!~,~llfoJ^I041R;J ~.!L ~ ,,.,, C.r Truck ~' \- Year: Make: Model: , r"" Sub Model: #C"II """I BODY STYLE: IClIcJo.' .pp"'...., 2DR ~ .l!lll7Hatcl1backJ Convertible Wagon Van Utility P1ckup 1/2 ton 3/4 to(\, r 'trciO Shortbed Longbed Crew Cab Cab & Chassis ENGINE DETAIL: SIZE \ ,\) ~ CYUNDERS: ([2 4 5 6 6 12 Turbo Oiesel GW TRANSMISSION: AT AUlomatic 56 6 Speed ?S5 5 Speed ':;>54 4 Speed 53 3 Speed 00 Overdrive Other Fender WB 4W 4 Wheel Drive Fenderless TIRES (Tread remaining in 32nds) MAKE RF LF RR LA S COLOR Options: rc:-.. _... "''''''' POWER OPTIONS OECORiCONVENlENCE ROOF OPTIONS OTHER ~ PM Steeri~ lie - Nr CclrntlOf'i~ VR - V<nyl RooI SB - _ Step Ilunl>er OT - Deep TlnIod Glass PM Brakes f'RO)- Rear Dologger ES - EleariC Sleal SW - Sliding Rear WIrdtHI eo - RI6Ving _cis - PM VMdows 'lW - lin Wheel EG - EleariC Glass XT - AlDlillaty Fuel Tn as -Ill.d<l!l Seets PI. - PM Locks CC - Cruse Control MS - Manual Steal SY - Sport WteeIs FL - Fog ugts ' SP - PM Drive So., LS - Lealhof Seats MG - Manual Glass 2T - 2,tore Paint Bl. - BecI..... Fe - PM Pass Seal DB - 4 Wl1Il)sk Brakes FR - Aip Root D2 - Doluxe 2,tooo Paint AR - ClYorre Bod Ralls AB - AnlI Lock Brakes TL - TeIasalpic Wheel TT - T.Teps TP - Trai1eri~ Package we -lXoa/ Rear-. RADIO AL - AlJto Load lDvcl GT - Glass,Top HB - Hgh Bacl< Buckel Seats XP - Custom PaInt ''jj.t~ AM 3S - 3rd Seat (W!1'8 only) CT - Soh Top RB - Roll Bar AW - AIurirun Wheels 'rAC BP - Eight Passmger liT - Hard Top TB - Tool Box (Permlr>lnt) ON - Custom Wheels iiJ:TW- ~ DA - ~ Nt (Trucks. V.....) RR - RooI RacI< GG - GrII Guards Wi - Mag-. , - areo 2P - 12 Passenger PR - PI1ae1on RooI PO - Posilracllon ww - Wlte VvlleeIs , - Cassette 5P - 15 Passmger LP - PaddOO Undou Roof we - WIre VvlleeI C<wars , SeeklSc:an LR - Undou Rool SS - Swivel Cap1ai1 Chairs BT - EigtC Track CB - CB - The following options will only appear lor the particular vehide on which they are available A Y - AJoy Wheels WI - WInch xc - Pr....... Cast WteeIs LB - Lear Buckel Seats '1:W - AIuTirun WIre Wheel. BF - Brougham Roof XB - Custom Ilunl>er XO - Exlerior Decor LC - Locking Wheel Covers 72 - ReIr1dger"or/Stove 8M - Bose _ XS - SpodaI Carrc>cr Pkg XF - Crown Roof (' I U ,~l.f'( Interior 7P - 7 P8sisenger BP - SpIrt Bench Sot Pol - PaddOO VIflYl Roof SN - Snow mr / iNi".. Lealhof Wrap Stear Wl1I 9P - 9 Passenger CE - Cust Exl Moldings RF - CabrioIel RooI W - VISion V . ~ MetaliC Paint AP - AIuTirun Cap CF - Carriage Roof RM - Retroveable RooI PP - _ p I,?W:'}- P1nstrlpi~ B4 - SWIvel Bucket Seal. (4) Cl - Custom Interior SH - Heated Seats FI - F'om~'S1 P' "0 '%1'- Royal Exlertor CP - Fiberglass Cap CR - Coach Roof SX - Sports Seats GP - GIatrn.r~' 'EquaI,ar HL - HydrmJIc lJItgate CV - ConvenIeR:e Gtoo.4> VC - Val..., Coach Roof HR - Halo FWl5- Rally Wheels IE - Custom lnIor1oriExterlor DP-MoondustPainl WG-Woodgain JB-JBl. "r:{ Jl<k Lmtodlntcrlor SC-S/1eepIlkk1C<wers El - Eiodrcnc Instrunents WP - Rear WIrdtHI Wiper KS - Recaro s 00' 'lfR FUI Cabriolet Roof SO - ~ Suvool PACKAGElSPECIAL FEATURES (FllC1<xy Installed only) OTHER OPTIONS & ACCESSORIES Additional OTHER OPTIONS & ACCESSORIES $ $ $ "Cthe(' $ ill Cond'rtlon Salvage 1, Rebuin 2, Sold lor parts $ $ $ Total Other Options and Aa:essories (Enter lor C,C,C, as Pre Tax Adj,) Pre-tax adjustrrent: PRIOR DAMAGE (If none. enter "NONE1 Deduclion S "1,\... 0 ~ Damage Pre-tax adjustrrent: OTHER Add $ Deduction S .1,... 0 Location Sales Tax '_9 % 1. Front Post,tax adjustment: DEDUCTIBLE (II pon, .enter "NON!;) Deduction $')'lV1 . r/,) 2. Slde Post,tax adjustment: OTHER~I--.\I. ~ Add $ )';,l.() Deduction S \>1"- 0 ~: ~~er Remart<S i ( \ APPRAISER'S SIGNATURE & UCENSE NUMBER -,. ~ ~ CERTIFICATION OF SALVAGE RETENTION ,1o'1111-0~1 CLAIM HUM"A f;' ,0. I () 0 y C hpuJJuut ,<, 1s.-1, i,l t: \ _If"e have exercised the option of relalnln~our _I ~J;r ; l. ""VIAA AND ?:Ai:: _ _ -reS I i"\ K (.;; 15Xi'k 'Juo(c43 as salvage forthe sum of $ /50 I 00 veHlcLIIDIN:n~I~N NUMBEA and this allowance has been deducted from the agreed settlement of $ CJ58', t.v5 for the vehicle. State Farm Insurance Company will not be responsible for storage charges after 1\) ~ . DATE SIGNE@i(IJa:-t./n-'I J... 6u:z.~~ 3 Q- DATE - J I - J:J SIGNED (130) 0 ..87,3 A.",7.88 P,'nt.d In U.S.A. r;, L: 'o" I lIP -c' >' (fI- -<, >, -<, m' "'" >' :D: ::'. Sl,Il'I: 1'''~M J N, UP J\1~1 :~: I I I~' I.J,M"'OI.:/ HuAII I . "\':''': Ill'U-!'~'/~ Nf;W CIlMIl"-H1.AlIl1 PA IIUIlI'PIE: In:I" ",,~. ~ .=': "=~== ""===""=="=:"'~=,, :,====='''''''=="=" :",,-.:,\:==~,,=,; "';="..=,~=, .=~=, == :,." ,'/I:;l:/{!'.I'I,; 1.1 Rt:rAJ.. 'f01HI. I.,,;;:! h~'A1,lII\'lluNi l~;f'Of,'l' ',., ""N...lI~h f'i, .. ~..':":';':. :':'~::':: ':: '':'~~'; ':.. ~.': :~~.. 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'}~'.l CIII::VRO~I::'I' SPRINT Pl.AIN 40 I!An'lt VJ l.ll l':flr;fNl'; -----------..--------------------------.-------------------------------....-- .. -_______ ___ - _________u_ ____________ _____.____ _ _______ __.. .______.__ __ ...__ _.__ ..__ gJ~ c~' '0 Q ~ oz: i::~: < 7.'. ~o: ~, .>> ' ~ ~. ~g' ~ ' > . Z Ili' o. 'Q l: ~ >" . .c ~~: ..., o~ ";r , >., ..~, ~g 0:0' ~S' "I;V' "0 0= ~~ '::0. a: 0, t ~: ~~ ::~ VEIlIeLI:: VALUE LIHING (lNe,) INllICAl'r.S INl'WUW IN BAS~; VA1.lI~; ---------..----------------------------- ----------... ---- ---- - ----..-- ----.. -.-..--.-- \'JIiRAGI:: BASE VAl.U~; .. '. J ' U liNl.iIII r. 'I'I rl.\IoII:.R sn.F.p IN" '" I };O~il::H WINDOWS I') P(1\o1~;R SI::AT . :';!:'K"'~; t:1\N <":I\R Ut;~'OGllt:R jo) C1I11l51'; CONTROL '~NSTH tp LNG "I lOR LiAM.....,g 1~37,50 INl:. 31,50- 1NC: . iNC. INC.;. 12.50. 1M: . INC. tH.ltl!; MANUAl. 'I'1<1\N5Mi~;SJON l'OiiER HRAKES NO PuWhk I.'JCK~, AJ1..FM Hrli~l:.l) TlU'1i Nl.l AIR l'UNLlIT\O:~JrJI.; NQ 'l'lJ;r W/I E~;l. Ml::'rALLIC PAINT 100"86 MII.EAllE HIt:. !lie.: . Ill'; . 12. ~ll~ 101,l,1I'J" HI-::. INC. 412.~1!- -..-----------------------------------------.---.----------------..----------- --------_._-- ------.-------------------------------...---------------------..-- ':TlII~[, I;I\:;H VALIi!-; ,\:'lS TAX ~:!; " 't'LE " 'l'l{I\NJr'hk .~ t:JSl.:>o ~ &J.J~,t ~. 2~ .OOt qrf t!) ISD . CO ~ ,'<<:::===. ,,',lUSTeD VAf.UE r;;JUCTlIlI.E ; 1/.~!l.b5 ~ 500.0U- '" '!' ('l)m,UTED V,\L;JE $ 9~'.l,&:' "':;': =:= = =-=:: ::=_":.: .:.=-:::.===::=.: ===:-::::::=::==.':;:-::-:::- =::::=;:::.:.: =='::===::::.::= :::;.:.::.=;.: :.:!::::=====':'=== ro: l:! ,"i'~":I:.: TH1:; 'rOTAI. W::iS E'IAI.lIATI.ON ~IA:; ~F.;I.N Pfl~P^RJ;O Il'( cc..,lfllTl,1( iN , '...,JIW~.Nl)l; WI I'll Till:: PENNSYLVANIA Ai'l-%US!\L f,;'W MHl 1:; AN M,-;I'o,G1i II!::'!'"J L 'll' '11-: ,',PPRuPR (A n: E!IlTrI.l!iS l.I~ TI!I:: r;u lUl:: 6IJC:r.S IN t;~'H;c:r ',1,/ TI1~: IJI','I :,;, l)f (, O$~, .. Clr .,r- ,.v. IIlC -<" >~ -<r f1'l;.. 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(Iti.... .0: 31-illl'0\; C...j tied Prafil. 10: :6 2B 13 SIAIE FAR" "UTUAL IHSURANCE liS LmKILH ROAD HEW CllliBERLI,Hll PA !ibiD (711) 111-9021 FOR ANY QUESIIOHS REGARDING THIS ESTIMAtE FLEASE CONlnCI THE INDICAtED CLAI"S HANDLER ................................... O...~e A.le.l.d By: RAY BOND 3001731 Tyr. ef Lal.: Cotllllen (SF'~) O.Ie ef LeI': 03/18/95 Oedu,libl.: 5&O.GO In.ur.d: "ARIOH FORIEH!AUGH Addrel.: 211 B S SIAIE F.OAD ~ARYSVILLE PA li053 He.. Ph.n.: (717i 957.3520 "11,h.11 Seroi,.: 91\IB6 O..,rlptlon: ISIB CHEVROLEI SFAINI 40 HlI VIH: JGIIIR6158JK700643 LI,enle: 653,458 PA lll1to,.: 100,416 OEli/AlT: A Se.r,h C:d.: CUNBER Option.: CASSEIIE, SEARCH/SEEK, POUER IRA'-ES, ELECIRIC DEFOGGER 1 SIERED RADIO. All RADIO, FII F.ADID. 4.DOOR HAICHBACK, 3 CYLlIim mINE, FF.OliT VHEEL DRIVE,S SPEfP IIAlIlJAl 1RAHSII1SSIOII. Ll n. Entry L.bor Li n. I tel iln llil!Iw: h:a. Doe..tlen De...ioticn 900500 100Y 'IEliO\'E/F.EFLACE 'FRT BODY BECI REFIH REFINISH/REPAIR FRT BODY SECT L IliE nAF.KUP m .GO SECIlCN AS NEEOEO 100011 REFlN REFlIilBH L QllARTEF. fAllEL OUTSIDE 6 \26150 BODY P.E~OVE/REfLACE L COftBINATIOH lANF ASSEr-SLY LINE MARKUP 125,00 'LEFI QIR PANEL APPEARANCE ALLeVANCE SCRAPE RP. BUliPER PAlMI MlERIALS Port Type/ Dolt.. L.bor P.rl N".ber ft!wL !!ill.. QUAL RECYCLED FARI 600.00' 10.0' 1,0- 150.00 1.9 QUAL RECYCLED FART 50.00- 0.5 12.;0 4.0' 15.00. 76.10- 2 3 I 5 1 B 9 10 II AUlD 931079 BODY REF AlP. 936011 AUD'L COST ADD'L CDS I . JudS...rr! He: ~ ]-A ~.F FARtS LOCAIED AI !U~ILLERS ~ESI AS~ FOR BILL 1'100.521..151 DA~GE IS NORE SEVERE ESTINAIE CCNfiF.r-S TOTAL LOSS I. L.ber S,ttel.l. Bod/ Refiniln I1nlli ~ 1\,5 :0.00 5,3 26,"0 L.~cr Sublot,j Liller tJA ~ 6.\!O~ l3~cr SUlIf.:3ry 'otJI~ :0.; 101011 3i7.IjC 153.\0 530,\0 31.22 It. Fori ;..pl.c...nt Su...ry h..ble For!. Part! Mj".t.ent 5.1.. I.. t S.CD: iut.1 Fcp!a:...nt /,rL. Iooun\: Aacunt SSG.OO 162.51) 46.;'5 OoU5 r.... .... ...f,..~, lSliMl, mllLl NW,eER: 03121/95 09:51:30 lB.lIlt'OIl Kitchell 0.\. ~er.ian: KAi.S5.'1 COP/113M <Ci ISSO. Kilcl..1l h,lwI.'\IOo.1 , '0:-,'- ....~'- ...,A'. . ~-~'{ .- , I I, L ,- Q::- -<, " , ~.: ::: " ~ ~;~ ;::::: '" :L ~~ ~ > ~: ~- <~ m::: @ ~ ~ , '. ~~ To ~. ~. ;.. i::~ E ~: ~~ ~~ :.:.,: ;.:, ~~ ~.~ ;.:. .- ;:: ~~ 0" .:" - . ':(- )10< !r.=7 ~ :~ "1':': ?~ .: .:~ 2" -;; z ;;:,,: " f,:- ~.' -,' ~'.. I.: ,J;,1. JS 'JJ;~i A,~, E.li.... ID: l8.7111'Oll Co..ill.d P,ofil. ID: :5 :9 II III. Addll!on.1 Co.t. TJ,.Jb1e Co.t. t.l,. I.. I 6,001 rol.1 Additlo..1 CO.I.: ~.[lunt 76.70 UO 91.10 I. Total l.bo,: Ii. Tol.1 R.pl.c....1 P.,I.: III, Tol.1 Ajdilion,1 Co,I,: 562,22 861.:5 81.30 ~ ~, - , E !:' I: ;: "CO! fotol: 11504.77 C..lo.., AIlowanc.: 75.00 Poi.1 of l,paCl: 15 TDTAL LOSS Body Shop: UHKNO~H C..lc..r R..po..lbility: Insp.ctio. SiI.: FJELO . 500.00' /lei Totol: 1,073,77 ~ III CO"PLI(~E WITH SECTION 1821 OF ACT 6 OF 1990: ANY PERSOlf I/HO KNOWINGLY AND ~IlH INTENT 10 INJURE OR OlFRAUO ANY INSURER FILES AH AFPLICAIION OR CLRln CONTAININe ANY FALSE, INCOftPLETE OR nlSLEADING INFORnATION SHALL, UPCN CONVICTION, BE SUBJECT TO IftFRISOHftENT FOR UP TO SEVEN YEAPS AHO PAlnENT OF A FINE OF UP TO 115,000. t, 'Jl '" z ,. -, ~, ... CAUlIO" ... FAILIHG TO PRESENT TNIS ESllnAlE TO THE REPAIR IllS GAlAGE BEFORE REFAIR ftAY RESULT IN AOOIIICNAL EXP~SE TO YOU. ANY SUPPtE~ENr TO THIS ESTI"AIE nuST IE AUIHORIZEO BY A SlATE FAR" ADJUSTER. HOllCE: REFAIRS TO II11S VEHICLE nAY REQUIRE SPECIFIC UELDllro EQUm,ENI AS RECOIIIIEH!)EO BY IHE ~AAIRAC1URER. LKQ PARIS LOCAIEO AT: ,......,.....,.........,................... PHONE I: ...._...................... PRICES REFLECT A 251 "ARKUP. 1,,- !'. > m= -< >' , <II" -<. >~ ".. m- or:': ~ ;:~ lie;, ("):--:- ~i f~ ;C:.; !2,,: ;;;;": 'I'~ '.1'. Z' -1-: ~-~ <~ rr.... , > r.; .. 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