HomeMy WebLinkAboutNUNLEY, TIFFANY, A GUARDIAN AD LITEM FOR PLAINTIFF HAILLEY HALLSTROMAPR -5 -20316 92:21P PROM:NUNLEY BUSINESS 7148843846 T0:1562624117B
SETTLEMENT AGREEMENT AND RELEASE
This Settlement Agreement and Release (the "Settlement Agreement ") is made and
entered into this Sa day of NWch, 2016 by and among:
0,0 Rt 1 0.s
"Plaintiff' Hailley Hallstrom, by and through her guardian ad litem Tiffany Nunley
"Defendant" City of Santa Ana
RECITALS
A. Plaintiff Hailley Hallstrom filed a complaint against City of Santa Ana and its
police officers, in the United States District Court, Central District of California, entitled Tiffany
Nunley, etc. v. City of Santa Ana, etal , which bears case number SACV 14 -0766 CAS (FFMx)
(hereinafter "Action "). This Action arose out of the shooting, and subsequent incarceration and
hospitalization, of Jason Hallstrom on March 15, 2013 and alleged civil rights violations and
various state torts and negligent acts or omissions by the City and its police officers. In the
Action, Plaintiff sought to recover monetary damages as a result of that certain occurrence on
March 15, 2013, which allegedly resulted in physical injuries and personal injuries to Plaintiff
and Decedent Jason Hallstrom.
A- 2015 -305
F.I.
B. The parties desire to enter into this Settlement Agreement in order to provide for
certain payments in full settlement and discharge of all claims which are, or might have been, the
subject matter of the Complaint, upon the terms and conditions set forth below.
AGREEMENT
The parties agree as follows;
1.0 RELEASE AND DISCHARGE
IA In consideration of the payments set forth in Section 2, which has a current cost of
one mullion six hundred thousand dollars and no cents ($1,600,000.00), including up -front cash
and the promise of future periodic payments, Plaintiff hereby completely releases and forever
discharges any named defendant in the Action, including but not limited to the City of Santa
Ana, Officer John Rodriguez and Officer Peter Picone from any and all past, present or future
claims, demands, obligations, actions, causes of action, wrongful death claims, rights, damages,
costs, losses of services, expenses and compensation of any nature whatsoever, whether based on
a tort, contract or other theory of recovery, which the Plaintiff now has, or which may hereafter
accrue or otherwise be acquired, on account of, or may in any way grow out of, or which are the
subject of the Action including, without limitation, any and all known or unknown claims for
bodily and personal injuries to Plaintiff, or any future wrongful death claim of Plaintiff's
representatives or heirs, which have resulted or may result from the alleged acts or omissions of
the Defendant.
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1.2 This release and discharge shall apply to the past, present and future officers,
directors, stockholders, attorneys, agents, servants, representatives, employees, subsidiaries,
affiliates, partners, predecessors and successors in interest, and assigns and all other persons,
firms or corporations with whom any of the former have been, are now, or may hereafter be
affiliated of the City of Santa Ana, including but not limited to Officer John Rodriguez and
Officer Peter Picone.
1.3 This release, on the part of the Plaintiff, shall be a fully binding and complete
settlement among the Plaintiff and the Defendant, and their heirs, assigns and successors and
employees, including, but not limited to Officer John Rodriguez and Officer Peter Picone.
1.4 The Plaintiff acknowledges and agrees that the release and discharge set forth
above is a general release. Plaintiff expressly waives and assumes the risk of any and all claims
for damages which exist as of this date, but of which the Plaintiff does not know or suspect to
exist, whether through ignorance, oversight, error, negligence, or otherwise, and which, if
known, would materially affect Plaintiff's decision to enter into this Settlement Agreement. The
Plaintiff further agrees that Plaintiff has accepted payment of the sums specified herein as a
complete compromise of matters involving disputed issues of law and fact. Plaintiff assumes the
risk that the facts or law may be other than Plaintiff believes. It is understood and agreed to by
the parties that this settlement is a compromise of a doubtful and disputed claim, and the
payments are not to be construed as an admission of liability on the part of the Defendant, by
whom liability is expressly denied.
2.0 PAYMENTS
In consideration of the release set forth above, the Defendant agrees to pay the payments
outlined in Sections 21 and 2.2 below:
2.1 Payments due at the time of settlement as follows:
$778,505.00 shall be in the form of a check made payable to
''() ut' p jt /_.,.. Jt �'iNlf�� /l�x�'%i'✓�i F4cc' -.+'i
2.2 The Periodic Payments which constitutes damages (other than punitive damages)
received on account of Plaintiff's alleged personal physical injuries or sickness within the
meaning of section 104(a)(2) of the Internal Revenue Code of 1986, will be paid as follows:
Payee: Tiffany Nunley, as the mother of and guardian ad litem for Hailley Hallstrom
$7,500.00 Payable semi- annually for four years, all guaranteed, beginning August 1,
2017, with the final guaranteed payment made on February 1, 2021.
Payee: Hailley Hallstrom
$50,000.00 Guaranteed lump sum, payable on April 22,2020;
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$2,500.00 Payable monthly for 11 years, all guaranteed, beginning April 22, 2021,
with the final guaranteed payment on March 22, 2032;
$75,000.00 Guaranteed lump sum, payable April 22, 2021;
$25,000.00 Payable semi - annually for five years, all guaranteed, beginning August 1,
2021, with a final guaranteed payment on February 1, 2026;
$75,000,00 Guaranteed lump sum, payable August 1, 2026;
$217,096.41 Guaranteed lump sum, payable April 22, 2032.
The periodic payment obligation set forth above will be funded with the present value of
$821,495.00 in a check made payable to Mutual of Omaha Structured Settlement Company.
The Parties agree that the Defendant may make a qualified assignment as defined in
section 130(c) of the Internal Revenue Code to Mutual of Omaha Structured Settlement
Company (MOSSCO) (the "Assignee ") of the Defendant's liability to make the periodic
payments set forth in section 2.2. Any such assignment, if made, shall be accepted by either
Plaintiff without right of rejection and shall completely release and discharge the Defendant from
the liability that is assigned to the Assignee. Plaintiff recognizes that, in the event of such an
assignment, the Assignee shall be the sole obligor with respect to the liability assigned, and that
all other releases of the Defendant shall thereupon become final, irrevocable and absolute.
If the liability to make the periodic payments is assigned, then Plaintiff understands and
agrees that (i) the periodic payments set forth in section 2.2 cannot be accelerated, deferred,
increased or decreased by the recipient of such payments, (il) the Assignee's obligation on
account of the periodic payments set forth in section 2.2 is no greater than the obligation of the
Defendant or insurer of the Defendant that are assigning the liability, and (iii) the rights of
Plaintiff against the Assignee are solely the rights of a secured creditor of the Assignee. The
Defendant and /or the Assignee shall not segregate or set aside any assets to fund the periodic
payments set forth in section 2.2. Execution by the Parties of the assignment will absolutely and
completely discharge Defendant from any further payment obligation. If the Assignee, and/or
Annuity Issuer of the contract purchased by Assignee to make the payment obligation specified
in section 2.2, fails to make payments or becomes insolvent or bankrupt, the sole remedy of
Plaintiff or her beneficiary, heirs or representatives to enforce payment obligations assigned shall
he against Assignee, guarantor and/or responsible party other than Defendant. Defendant will
have no further obligations upon payment to the designated Assignee and/or Annuity Issuer.
F section 2,2 of this agreement by purchasing an annuity policy from United of Omaha Life
Insurance Company (the "Annuity Issuer "). The Assignee shall be the owner of any such
annuity policy. Neither the Plaintiff nor any payee set forth in this agreement shall have any
incidents of ownership of that annuity. The Assignee may, for its convenience, direct the annuity
issuer to mail periodic payments directly to the Plaintiff. While the periodic payments are being
made, the Plaintiff shall provide to and maintain for the Assignee a, current mailing address.
31Pag4
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2.4. Plaintiff's Beneficiary. During the period of minority, Plaintiff's estate shall be
the sole beneficiary. At the age of majority, Plaintiff may designate, in writing, her beneficiary.
Neither such designation, nor any revocation thereof, shall be effective unless it is in writing and
delivered to the Insurer or the Insurer's Assignee, The designation must be in a form acceptable
to the Insurer or the Insurer's Assignee before such payments are made.
2.5 Discharge of Liability. The obligation assumed by the Assignee to make each
Periodic Payment shall be fully discharged upon the mailing of a valid check or electronic funds
transfer in the amount of such payment on or before the due date to the last address on record for
the Payee or Beneficiary with the Annuity Issuer. If the Payee or Beneficiary notifies the
Assignee that any check or electronic funds transfer was not received, the Assignee shall direct
the Annuity Issuer to initiate a stop payment action and, upon confirmation that such check was
not previously negotiated or electronic funds transfer deposited, shall have the Annuity Issuer
process a replacement payment.
3.0 DELIVERY OF STIPULATION TO DISMISS
Concurrent with the execution of this Settlement Agreement, counsel for the Plaintiff
shall deliver to counsel. for the Defendant an executed Stipulation to Dismiss. Plaintiff hereby
authorizes counsel for the Defendant to file said Stipulation with the Court and enter it as a
matter of record.
4,0 REPRESENTATION OF COMPREHENSION OF DOCUMENT
In entering into this Settlement Agreement, the Plaintiff represents that Plaintiff has
relied upon the advice of her attorneys, who are the attorneys of their own choice, concerning the
legal and income tax consequences of this Settlement Agreement; that the terms of this
Settlement Agreement have been completely read and explained to Plaintiff by her attorneys; and
that the terms of this Settlement Agreement are fully understood and voluntarily accepted by
Plaintiff.
5.0 WARRANTY OF CAPACITY TO EXECUTE AGREEMENT
Plaintiff represents and warrants that no other person or entity has, or has had, any
interest in the claims demands, obligations, or causes of action referred to in this Settlement
Agreement, except as otherwise set forth herein; that Plaintiff has the sole right and exclusive
authority to execute this Settlement Agreement and receive the sums specified in it; and that
Plaintiff has not sold, assigned, transferred, conveyed or otherwise disposed of any of the claims,
demands, obligations or causes of action referred to in this Settlement Agreement,
6.0 GOVERNING LAW
This Settlement Agreement shall be construed and interpreted in accordance with the
laws of the State of California. In executing this release Plaintiff does hereby waive all rights
and benefits, which she has or in the future may have under and by virtue of the terms of section
1542 of the Civil Code of the State of California, which section reads as follows:
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RPR -5 -2016 02:24P FRON:NUNLEY BUSINESS 7148843846 TO:15626241178 P.5
A general release does not extend to the claims which the creditor
does not know or suspect to exist in his favor at the time of executing
the release, which if known by him must have materially affected his
settlement with the debtor.
Plaintiff is hereby advised that for her protection, California law requires the following to
appear on this form, pursuant to California Insurance Code section 1871.2:
Any person who knowingly presents false or fraudulent claim for the
payment of a loss is guilty of a crime and may be subject to flues and
confinement in state prison.
7.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST
This Settlement Agreement contains the entire agreement between the Plaintiff and the
Defendant with regard to the matters set forth in it and shall be binding upon and inure to the
benefit of the executors, administrators, personal representatives, heirs, successors and assigns of
each.
8.0 EFFECTIVENESS
This Settlement Agreement shall be p a effective immediately following execution by
each of the parties.
Dated: Q--) L--1 C J J _ AU
fanjw unley, guardian d litem for
Plaintiff Ha: y Hallstro
L E+ �
Dated: -2elr.
Aiex'VGalindo, Esq.,
Attorney for Plaintiff Hailley Hallstrom
Defendant City of Santa Ana
APR 2 7 2016
By: I '"-I-..
Title: DaJia CaJ4Zes}CLk) ` cm. er
ATT5ST 51Vage
NI RIAD. HUIZAR
CLERK OF THE COUNCIL
cxx
' AAA BJ,L E Y HAA/ S L'RLFI,Yi.
DJ O.3:: 04/22/2002 (Age: 13:9)
Normal LiBe E%pectancy 71.8 Yom
PACKAGE A
Payuteut Descriptio f
U`TMAj � ! ANY N`C. NLL'Y AS CUSTODIAN
PRIVATE HIGH SCHOOL VI UN17
$7,500.00 payable se diµenuually, beginning
08/01/2017 (Age 15..3) Fov 4 years oortaua only. Last;
guaranteed psyramitis duo 02/01 /2021,
CAR/GRADUATION 1 UND
$50,000.00 on 0+4/22/2020 (Age 15.0).
LMNG EXPENSES TO AGE 30
$2,500:00 payable monthly, beginning 04/22/2021.
(Ago 19.0) Cdr, 11 years corttdu only. Last guaranteed
payment 1:s due 03/2'2'/2'032.
{175;000.00 on 04/22/2021 (Age 19.0),
COLLEGE FUND
$25,000.00 payable sem.1- annually, beginning
-
08/01/2021 (Age 193) for 5 years certaaln only. Last
guaranteed payment is three, 02101/2026.
COLLEGE GRADUA"11O /BUSfN'l ",S8 DEVELO11MENT
$75;000.00 on 08/01/2026 (Age 243),
Guaranteed Expected
Costs Payout Payout
$98,505,00 $98;505.00 $98,505.00
$60,000,00 $60,000.00
$50,,000.00 $50,000.00
$330,000.00 $330,000.00
$75,0M00 $75,000.00
$250,000,00 $250,000.00
$75;000.00 $75,000.00
HOME DOWN PA.Yai!a15,tNTIG tAD ATE, $CHOOL
$217,096,41. orx04/'22/2037(Age.35.0). $821,495;00 $217,096.41 $217,096.41
THENUMT3ERS CAON'TA1NEU 11171 EIN ARE COMIN.(:rl's[ T UPON VE11114C:ATION OF DATES OF BIRTH
800.326.1078
M1014,AL1, J. 1 IC1KETT, CSSC
SUMMIT SETTLEMENTS picke *ttstructuresra,hotmail.,o
ff • HAILLEY HALLSTROM Page 2
> D.O.B.: 04/22/2002 (Age: 13.9)
Normal Life Expectancy 71.8 Years
Payment Description
PACKAGE A
Guaranteed
Costs Payout
Expected
Payout
Totals: $920,000.00 $1,155,601.41 $1,155,601.41
Home office approval required before acceptance. Quoted through United of Omaha Life Insurance Company, rated
A+ Superior by AM Best and A+ Strong by S &P rating services. Assumes funding on or before 05/02/16.
THE NUMBERS CONTAINED HEREIN ARE CONTINGENT UPON VERIFICATION OF DATES OF BIRTH
800.326.1078
MICHAEL J. PICKETT, CSSC
SUMMIT SETTLEMENTS pickettstractures a7hotmail.c
Form W'9
Request for Taxpayer
Give Form tot he
(Rev. August 2018)
Identification Number and Certification
requester. Do
=Department of the Treasury
send to the IRS.
IRS.
ends Service
Name (as shown on your Income tax return)
Curd, Galindo & Smith, LLP
Business name /disregarded entity name, If different from above
N
m
Exempliom (see Instmotlons):
Check appropriate box for federal tax classification:
❑ Individual /sole proprietor ❑ C Corporellon ❑ $ Corporation ❑✓ Partnership ❑ Trust/estate,
c
Exempt payee code (It any)
F
❑ Limited liability company. Enter the tax classification (C.0 corporation, S.8 eorporetlon, P =partnership) ►
Exemption from FATCA reporting
code (if any)
U
❑ Cther (sae Instmotions)►
u
Address (number, street, end apt. or suite no.)
Requester's name and address (optional)
OM
301 E. Ocean Blvd Ste 1700
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City, state, and ZIP code
Lon Beach, CA 96601
List account numbers) here (optional)
Tax aver Identification Number IN
Enter your TIN In the appropriate box, The TIN provided must match the name given art the "Name" this I Social security number
avoid backup withholding, Far Individuals, this is your social security number However, for e
sole or disregarded entity, sea the Bart I Instructions on n page 3. Fo r ether
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resident alien, proprietor,
re
entities. It is your eolover identification number (EINI. If you do not have a number, see He to pet e
m
TIN an page -3.
Note. If the account Is In more than one name, see the chart on page 4 for guidelines on whose I Employer ldenufication number
number to enter. 3 3 - Fo 78 F6 To77 7 F6
Under penalties of perjury, I certify that:
1. The number shown on this form Is my correct taxpayer Identification number (or I am waiting for a number to be issued to me), and
2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding, and
3, 1 am a U.S. citizen or other U.S. person (defined below), and
4. The FATCA code(s) entered on this form (If any) indicating that I am exempt from FATCA reporting Is correct.
Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all 11 Brest and dividends on your tax ratyon. For real estate transactions, Item 2 does not apply, For mortgage
Interest paid, acquisition or aband� ant of secure operty, canoallat , h of debt, contributions to an Individual retirement arrangement (IRA), and
generally, payments other than ins , st and divide a, ou are not rsg)a red to sign the certification, but you must provide your correct TIN. See the
Vad" Signature of
Here I W.S. person 0' _ Date 0-
General Instruction
Section refermoas are to the Interns Revenue Cade unless otherwise noted.
Future developments. The IRS has created a page on IRS.gov for Information
about Form W -9, at www.Os.gov /w9. Information about any future developments
affecting Form W -9 (such as legislation enacted afterwa release tt) will be panted
on that page.
Purpose of Form
A person who Is requhed to file an Information return with the IRS must obtain your
correct taxpayer Identification number (YIN) to report, for example, Income paid to
you, payments made to you in settlement of payment card and third parry network
transactions, real estate transactlons, mortgage Interest you paid, acquisition or
abandonment of secured property, cancellation of debt, or contributions you made
to an IRA.
Use Form W -9 only If you are a U,S, person (including a resident alien), to
provide your comsat TIN to the parson requesting it (the requester) and, when
applicable, to:
1. Certify that the TIN you are giving Is correct (or you are waiting for a number
to be Issuod),
2. Certify that you are not subject to backup withholding, or
8. Claim exemption from backup withholding If you are a U.S, exempt payee. If
If I t i U9 allocable share of
withholding tax on foreign partners' share of aITactively connected Income, and
4. Certify that FATCA cadets) entered on this form (If any) indicating that you are
exempt from the FATCA raponing, la correct,
Note. If you are a U.B. person and a requester gives you a form other than Form
W -9 to request your TIN, you must use the requester a fomr it It is substantlally
similar to this Form W -9,
Definition of a U.S. person. For federal tax purposes, you are considered a U.S.
person If you are
• An Individual who Is a U.S. citizen or U.S, resident alien,
• A partnership, corporation, company, or association created or organlzed In the
United States or under the laws of the United States,
• An estate (other than a foreign estate), or
• Adomestic trust (as defined In Regulations section 301.7701 -7).
Special rules for partnerships, partnerships that conduct a trade or business In
the United States are generally required to pay a withholding tax under section
1446 on any forolgn partners'share of effectively connected taxable Income from
such business. Further, in certain cases where a Form W -9 has not been resolved,
the rules under section 1446 require a partnership to presume that a partner Is a
foreign person, and pay the section 1446 withholding tax. Therefore, If you are a
U.S, person that is a partner In a partnership conducting a trade or buslness In the
United States, provide Form W -9 to the partnership to establish your U.S. status
and avoid section 1446 withholding on your share of partnership Income,
applloabla, you are a so sort y ng 1 Is a$ a . person, your
any partnership Income from a U.& trade or business Is not subject to the
Cat. No. 10231 X Form W-9 (Rev. 8 -2013)
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Request for Taxpayer
(ftnv: E7Wamm6ar 014)
L Identification Number and Certification
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li%ampt payaP Soda pf nay) G
t1qCa. Far asnnyyla•,pWmmaWPi„LU that to dlWratlafdod, do not check 1101 Clinch Ilia- dpprometd box In thalhei above for
Varoptlan from FATCA reporting
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flmtaxoteaa,Ilcatlon othhe aingIwmamborawnar.
code (if any) _
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6 Ad toss numhar street, and apt aradila no,) Fl. eque9lettiLYmaand.a dresa (apilaliag
8800 mutual or Omaha plaza .,. .
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Omaha, NEC 60178
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tlSSptTYer darlti cWltitan 3tiumber
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Wer yourTIK In trip appropriate box, Tho7IN prnvlded must match the name giveline,[ an to avold
sa aI saaudryn"uan or _
dualse for a
gaakupwlftimS (page0hlaoroth,l'
lu,poarindWt
ntIor6ganality, seathePalsocurkynumbar
real'cfpnt dl(an, seta proprietor; ordistogardad aritlty, ass the pad 'I lnatn,ol(ana MI page 1, Far o'tYiaP
eni9dsa, ttla your omPloyer ldanklribattan number (Glt�. IP you da net have a numbor, ere blow W.gata
VN on pegs S.
Mato, If the wootnitin In more than one name, we the Instructions for line f and the ohart on page 4 for
guldelinaa on whaae number to enter.
'I. The number shown on this Parrs Is my aameat taxpayer ldengftcntlon nurnber (or I am waiting tar a number to be Issued tome):; and
2, .I ant notsubleat to backup wlthholding.baaau ia; fay I amexernpt fwm backup Withholding, or tbl i naive not been mongod b the Informal Revenue
Service (IP18) that I ern subjeut(o backup wlthhalding as a result of a failure to report all Interest or dividends, or (o) the IN$ has notified. me :that I am
ndlomquir subject tobabkup' Withholding: and
-
9, 1 Am a With slice" or other Us, person Idellhsd be"; end
-A, The FATCA codes) entered on fire form -(it any) tnddeling that I -am exempt from FATCA reporting Is Garrott:
- Centifloatfon Inatrumthma. You must oress out -Item 2 above It you have been nollffed by the IRS thatyou are currently, wbjeotto.bebkup withholding
booaase you haveiailed to report ail interest and dividends on your tax return, For real estate trallgagtiana, ham 2,toes not apply, Par Mortgage
Interest paid, sgquis)tion or abandgrlmentofassured property, can, callettlort at :debt, mntdbt,)lloba to an Individual retirement amengemant 0RA7, and
generally, payn anb other than Interest and dividends, you am not Wegpirod to alga ilia corRlltcadon, but you must provide your Correct TIN. Son the
General Instruotions
Section:rniorancma arm to the informal navende coda unto" olhorwiso:noted,
Fur Oro dnv&lapmMWt trfapllmlahaboliEdaVeruptYNtlnlU 01actlag I-ann W-9 Inch
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Purpose of Farm:
An Individual or Pntity aFonn'N,9 requester), who ($ acquired to Ilia oil Nqui.nQon
return Willi 1110 IRS Met obtainy nurgpfregt tax dgar lilanllfloatlan numbor (TIN)
Writplt mayhdynurp0alal aWOa,ily paml7Pr 9aNl,,(ndtvid
m pal laxpayar ldenllgnatinn
etier (ITINI deopllohCrapaypr.ldantip6ailop numisnr(A71N), or employer
Idmntifaatlan number (EMi, to report an an Information return the amount paid to
Yam = orother amount ioporlab'ie on an Information return, ExamPla6 of Ihfarmallon
returns include, nut are ucttimitedto, the Tolluwfng;
• Form 1009 -INT (mfe est earned Or pale)
•.Form Ia9o•CIV (drvldarde,. Inoluding those, from stocks or mutual tundej
• Pore 1,09- 14*0tvorious]yposof Income, prize$. awards, orgronprappeds)
*.PennI00Y n (stock ormutual fund Palos end certain other tommulldnaby
Molars)
• Form .Imf gds (Prumvearfrom coal estate manaaotfona)
• Porm 1099 -K (movahant: card :"Ind rthird parW nPWJalk.tYanS3a9dnbj
= Form Ines (home mortgaga Intamsf), 10SA -E (a mdom men Interest), lam•T
(1011(x)
Form 1e99- 0 :(canomadtlabt)
• Form 1(rp8 -a (aaqulollion orebdndonm9nt otencumd,properly)
use Porn)Vyo andY If� YYou area U. phreon(imeludina e maidentatiam,,.to
pravtde,yaar: correct TIN,
Ifyog do flat mmm Fbart W-9 to the requeGterwttc a IIN, You might be subject
to backup wrl uY60ag. San yVhni 19 hookup w11001*39 to paga2,
sySigning too flilad -out form, your
L sentry that the TN you are giving Isaarraot(or you are waltlag for a number
to he hotrod),
2. Certify that you as notsubiect le haakup withholding, Or
a, Clatm oxatllptlan iral'n baakuP VrllhhaidinBBttyau run n ll,a, axemptpayoa, it
applluahla ymvro also oarfffyinl' that as a tl 6, femP , your altoaable sham of
anyy ppannatshlp'Ingoma from a: tlJoadoor �ptln na6a 18 flak auateahto1h0
wlthhalding. tax on lfr ign.panneral clues of nilnolIvuly Pomaded Inoamo ,and
A. CndIty thatrATOA aerials entered an mrs form(il say) Indicadm that you ere
o%ampt front the FAVA rppart ego Is carroot, See:Wnat Is PATCA roparring2 on
Pape 2 fur further In(Orma11Ion.
.__.,�..���. root. No, tagatx Form W +S (hbv. tic -2gtA)
Nof Pied Assignment and Release Agreement
-to A fcord ttce With I tertrtrl Reverraae 0040 Seetlota 130
< I.aluadnt(a } "; Hailley qalistrom by and through her Guardian ad Lltem 'Wary Nunlery,
J
"Assignor"t
City af'garttaArta
"Settlement Agreement ",
[Data and title ofsetilcmentagrcomcnt,: order or other document embodying the
Assignor's Obligation to make the agreed periodic payments]
"Assignee": Mutual of omaha Structured Settlement company ( "MOSSCO-)
"Anmuity issuer ": lJoited of Omaha Life Insurance Company ("Ytnitad")
"Effective Date "''.
This Qualified Assignment and Release Agreement is made and catered into as of the Effective Bate by and
among the undersigned parties with Micro= to the following, facts.
A Claimants) and Assignor tae parties to or are otherwise subject to ar entitled to receive payments under the
above - referenced Settlement Agreement, under which Assignor has liability to make certain_ periodic payments
to or for the benefit of'Claiment(s) as specified or referred to in paragraph 12 of this Agreement (the "Periodic
Payments "'), and I
13 Assignor and MOSSC;0 wish to ethot a "qualified ,.asviguateuer within the naonning and subject to lire
conditions of Section 00(c) of the Internal kevenue Cock itf IoSFi, as amended '(the "f ride" %
Nosy, therefore, 14 t onsideradon of the foregriing and for other good and valuable consideration, the parties agree as
follows:
I. Assignment and Amamptionq Release Of Assignor, Assignor hereby assigns, to MOBSCO, and MJSSCO
hereby accepts and assumes, alt of Assigitor's liability, to make the Periodic Payments, Eagh Claimant hereby
accepts and consents to such assignment by Assignor and assumption by MO$SCf3, Iitfectiva nit the Effective
Date, each claimant herbytelca*and. discharges Assignor from all IiAjity to make the Peri"at Payments.
2. Nature of Periodic Pa) 'Rents. The Periodic Faymenty .constitute
i, damages (other thaw i punitive th mages); whether by suitor agreement, or
ii. compensation andep a workers' compensation act,
on account of personal Mary or sickness In a case involving physieai injury or physical sickness, within the
meaning of Sections 130(c) and 104(a) of the Code,
3. Extent of MOSSCtp's Liability. MOSSCo's liability to make the Periodic Payments shall be no greater than
the liability of Assignor, immediately prior to the Pffective Date. MOSSCO assume$ ntr liability other than the
liability to make the Periodi0ayments. MOSSCO's liability to make the Periodic Payments shall be unaffected
by any bankruptcy or insolvency of Assignor.
4, Qualified Funding Asset. M05SC0 will fund the Periodic Payments by purchasing from United a "qualified
funding assct," as defined in Section 130(4) of the Code, in the form of an annuity contract (the "Annuity ")
issued by United and providing for payments corresponding .to the :Periodic Payments. MQSSCO shall be
IiPD957 Page 1 rf4 0711
1
I
designated as the owner of the Annuity. All rights of legal ownership and genital of the Annuity shall (subject
to paragraph 9 of this'Agreetnent) be and remain vested exclusively in MosSCo; providcd,.howover, that tie:
Annuity shall be used by MOSSCO to fund the Periodic Payments and sball et all times be designated by
MOSSCO on its iths�rds as being taken into account, under Section 130 of the Code, with respect to this,
Agreement. Nnewritlisf uding anything to the contrary contained in this Agreement, neither any Claimant ttor
any Successor Payee shall have any rights with respect m the Annuity or the payments thereunder that would
Cause any amount Attributable to the Annuity to be currently includible in the recipient "s income or would
otherwise. affect thq drttcrmitlgtion of whenany recipient is treated as having received any payment for iocomo
tax purposes, or woui otherwise Prevent this Agreement front satisfying fill of the conditions for a"qualified
assignment° within it meaning of Section 136(c) of the Code.
S, Delivery of Payintai . MOSSCO may have United send payments directly to a Claimant, or, if applicable, to' at
Successor Payee (as 4 fried in paragraph s of this Agreement), or deliver payments by electronic funds: transfer
to an FDIC- insured dository institution in the United States for credit (directly or indirectly) to an insured
account in tite name o such Claimant or Successor Payee. Such direction of payments under the Annuity shall
not be deemed to afford the Claimant or any Successor Payee any rights of ownership or control of the Annuity,
Each Claimant and an Successor Payee Shall at all times keep United apprised of such Claimant's or Successor
Payee's current street address and telephone number and, if such Claimant or Successor Payee receives
payments by electroQ finds transfer, are name, address, bank identifier number (SIN) and telephime, number
of the applicable depository institution and the account number of the account to which the payments are to be
credited.
G. (Discharge of Liabllity, MOSSCO's liability to make each Periodic Payment; to the Claimant or Successor
Payee designated to repeive such payment shall be discharged automatically at such time as a corresponding
Payment is made to such Claimant or Successor Payee by United.
7, Acceleration, Transfer of Payment Rights. Nonc of the Periodic Payments and no rights to fir iriierest iu any
of the Periodic Payments (all of the foregoing being hereinafter collectively referred to as "Payment (tights ")
can be
I, Accelerated, deferred , increased or decreased by any recipient orany of the Periodic Payments; or
ii.. Sold, assigned, pledged, hypothecated or otherwise transferred or encumbered, either directly or indirectly,
unless such sale assignment, pledge, hypothecation or other transfer or encumbrance (aoy'such transaction
being hereinafter referred to as a "Transfer") has been approved in advance in a "Qualified Order" as
defined in Section 1589 1(b)(2) of the Code (a "Qualified. Order") and Otherwise complies with, applicable
state law, including without limitation.any applicable state structured settlement protection statute,.
No Claimant or successor Payee shall have the power to effect any Tinanstlrrr. of Payment Right, except as:
provided in sub- paragsph (II) above, and MY Other purported Tt"ahafer of Payment Rights shall be wholly void.
If Payment.Iligtats urs r this Agreement become the sObject of a Tnnsror approved in accordance with sdb-
Patagraph (11) above th4 rights Of direct or Indirect transferee of such Transfer shall be subject to the terms
of this Agreement and any defense or claim ut recoupment arising hereunder_
Confittgent Hencfaciaries. Any Periodic Payments to be made after the death Qf any Claimant ur SucCCSsar'
Payee shall be made to such party as shall have. been designated in, or in accordance with, the Settlement
Agreement or, if the Settiemant Agreement does not provvide ibr such desit, tailed, then to the party designated
in conformity with this' and uplt g. Any party so designated is referred to in this Agreement as a "Contingent
Beneficiary." ffno Contingent lsoneticlary is living at the, time of the death of Claimant or Successor Payee,
payment shall be made io the dascedont's estate. As used in this Agreement the term "Successor Payee refers to
a Contingent Benaficiar or all estate that has become entitled to receive Periodic Payments following the death
of 'a Claimant or a Successor Payee. Except as otherwise provided In the Settlement Agreement, no designation
or change of designation of a Contingent Beneficiary shall be effective unless such change (i) is requested in a
written request submitted to MOSSCO (or its authorized agent) in accordance with MOSSCO's customary
procedures for Process such requests, and (ii) is confirmed by MOSSCO (or its authorized agent). Except
for a designation that is, expressly identified in the Settlement Agreement as irrevocable, any designation of a
Contingent Beneficiary shalt be, deetned tit be revocable; and no party that is designated as a Contingent
Benei'icioty (other than a party irrevocably designated as a Contingent Beneficiary in the Settlement
Agreement) shall, solely by virtue of its designation as a Contingent Beneficiary, be deemed to have any
cognizable interest in any Periodic Payments,
9. Failure to Satisfy Section 130(c). If at any time prior to completion of the Periodic Payments, the Settlement
Agreement is declared terminated in a final, non - appealable order of a court of competent jurisdiction (or lit the
case of a workers' Compensation settfcment a final order o('the applicable workers` compensation authority) or
1tPD957 Page 2 of 4 0%112
if it is determined in rv; such final order that tlt® requirements of'Secflon 130('x) ortho Cade have fret bee.
satFa cd, ih ao.neution h this Agreamofit; (I) the Assignment * Asargnor to MOS90o oPtho llefatitry to make
the T eriodio.l ayntanis OB CWN naneptanoo Qhsut lx asst me ?t nttd,.the ,ralaase by Cisimantjs) aPAssigranr's
liabdyty shaiF Fin ePno rce'Or c oot- ,.(if) i'�US&'W shaAi)le" conclusively daomad to ire' lticttng as•th6s agent or
satgnar (tip the nuity shall be eivad by Asslgnor,whiah shall retain the liapil(ry gtt N:hhiKe thq periedfc
Pit re; (iv) lt� 08 0 shall have nq 11'4bChty to Make any Pedodic Payments and'(v) thkpartlas ho rdto agree
tar CAo(iarafa i. taking nch,ACtians as tnAy'be ooeesAAty rsr appropriate to implement fhe �brsgaNgl�.
io t,Tos"ornin #Lis AisaYasureOf Certain Tax
NnParmaHuq ,.; lmding)Eifaet.
0 this Agree eat s all be governed by and lnierprctod lqr aceordancp with the 1ptaCual Incas or the State of
C4 widtout regard to the aanfiiets'eF lgYrys provisions of that or any other, state;
prtttvlliFawev� khat. anyTranstbroP 'PymentRightsundartli'isA teottien't'nia taesubject ta the laws
bPa different statelthan,designated ebovq,
This pgreoment a all be binding upon the pardea hereto snit t(reic'rcapdntiva stieeessors, heirs, oxooutom,„
administrators, an per.dited assigns, Including without IFmitatto. any pArty asserting; an, interest in
i aymcnt nights.,
11. Advice, .Comgarehans on of Agreement. in entering into this Agraonaem, each Clahnaat represents and
wan sacs that (i) sueb tlaiment has railed saloly upon die legal and tax advice or suctt Cluimant's own Attorneys
and other advisors, who Bra the attgttleys and advisors of such Claimant's choice, concerning tlta legal and,
income tax consnqupnges aP this Agrcomciet, and (it) the terms of this Agreement have been completely read by
and explained to such'Cl'aimant,and are fially'Understood and voluntarily accepted by such Ctaomanq,:
t2. DeaerMptien 6t' Lrariot¢l'c mymairM The periodic PAymcrits are as set ford, hr the Attached Addendum No. 1,
which is hereby, Fncorpomted in and Wdo a part olthis Agroeagent.
This Qualitind Asslgnmoolt and Retcaae Agreement is signed in one or mar ®couutcrparta as of the Effective hate.
by the reltowiogi
Asslpnq'ra ("1, e ofa na MutualoLCiorahaStraCtured,
Aesignew %iooment Callip[My
13y ay:
rtutlinnz�rti2epressutur...� �v�*. "..., ,. • �•------- """` "..,.."'•^- T..,"�..,... —"_,
�. Atldkorizad ltaprasAntatl've
Titla; — _..._. Title:
Claim taC
Hoilley Hallsleturl by,aild thmugh her
Guardian ad Lii'em, "1"ilfany Nunlay
Alaxio 0011 pdo, Flog,
i
igapmw s n POP d xinent °
'Claimant TClaimapl °'s Atkcir.ey -- �.. .,•.."
WWI pAge 3 ON
07112
Guaranteed Payments
Payments payable to Tiffany
Period Certain Annuity - $7„
Payments through 211 /2021.
Payments Payable to Hailley
Guaranteed lump Sum -
Period Certain Annuity - $2,5(
payments through 3/22/2032.
Guaranteed Lump Sum
Period Certain Annuity - $24
Payments through 211/2026.
Guaranteed Lump Sum -
Guaranteed Lump Sum - $217
tmttiais
Maigmor;
MOSSCO:
Ctaimmeat:
Artormey(a) fur
Ctainaaatt
Addendum No.1
Description of P riodic paynne nt$
as mother of and guardian ad litem for Hailley Hanstrom.
semi- annually beginning 817 /2017. Payable for 48 months guaranteed. Guaranteed
lump sum payment on 4/2212020,
monthly beginning 4/22/2021. Payable for 132 months guaranteed. Guaranteed
lump sum Payment on 4/22/2021.
semi - annually beginning $1112021. Payable for 60 months guaranteed, Guaranteed
lump sum payment on 8/7/2026.
lump sum payment on 412212632.
' / (City of Santa Ana)
MffanyNunleg, GAS.)
(Aleut. Galindo, iiaq.)
PT?t1957 Page 4 of 4 07/12
RF.L,I SE� TI'S LJLL SE!, Frf EM]�IdIpL1 �lNI)p � . C'(1(�p�7�C)1o��g,
1. I, Raven Starr Shine, the undersigned, for and in consideration of
the sum of one million six luaadrecl thousand dollars (,$1,600,000.04), for
rrryself, my heirs, executors, administrators, and assigns do hereby remise,
release and forever discharge the City of Santa Ana, Chief Carlos Rojas,
Corporal Anthony Bertagna, Detective Leo Rodriguez, Officer John Rodriguez
and Officer Peter Pieone, their principals, employees, ofCcers, agents, claims
administrators„ attorneys and insurers [hereinafter referred to as "Releasees "],
from any and all claims and carises of ac Lion lay reason of any injury, damage
or civil rights violations, itwhuling any and ail attorney's fees and costs, which
I have sustained, or inay have sustained, as a. result of the events surrounding
the detention, shooting and subsequent hospitalization of Jason Hal'lstrom oil
March 15, 2013, as more fully described in the Second Amended Complaint
filed by me in the United. States District Court - -- Central District of California
in the matter entitled R.S, ct al. v. (7ity raf,5'antca Ana, et al„ and which bears
case number SACV14 -0589 CAS ('F.FM.,t).
21 it is expressly understood and agree([ that This release governs all
claims and. causes of action, including any alleged civil rights violations, and
state torts, and all injuriea and damages that arise out of the allegations in the
action entitled R.,S„ et al. v, City of Sanla Ana, et at, and which bears case
number SACV 1.4-0589 CAS (Fr-Mx) pending in the United States District
Court, Central ]district of California.
3, It is further understood and agreed that this settienaent is the
compromise of a doubtful and disputed claim, and that the payment herein
provided for is not to be construed as an admission of liability, which is
expressly denied.
4, As a further consideration and inducement for this compromised
settlement, tire following provisions of California Civil Code section 1542 are
hereby expressly waived:
A general ,release does not extend to claims which the
creditor does not lwow or suspect to exist in her favor at
the time of "executing of the release, which if known by
incur must have materially affected her settleaaaent with
the debtor.
5, 1 represent that 1. have not died any complaints or charges (other
than the Action referenced. above) against the Releasees with. any local, state or
federal agency or court; and that if any such agency or court assumes
Jurisdiction of any complaint or charge against the Releasees and/or their
predecessors, successors, heirs, or shareholders, officers, directors,, agents,
Police officers, attorneys, subsidiaries, or corporations or organizations,
whether previously or hereafter affiliated in any maalner, on behalf of myself,
whenever filed,l will t•ecluest such agency or court to withdraw and dismiss the
matter forthwith.
G. 1 acknowledge that r am responsible for any and all liens arising
from„ based upon, or relating to the Incident, incic.rdiug without limitation, any
and all MEDI -CAR1s and' 'or AIEDI -CAT, liens for iniw)- - related services paid
by the corresponding State programs, Talus any a.nd all other liens against me
related to my claims in this action.
7. 1 agree to indemnify road defend the Releasees, their officers,
Police officers, agents and employees, against, and will hold and save there and
each of them harmless from, any and all third party actions, suits, claims, liens,
damages to persons or property, losses, costs, penalties, obligations, or
liabilities, including any and all hcaltheare provider liens, that may be asserted
or claimed by any person, firm or entity against the settlement proceeds being
paid to the render this Release.
S. The undersigned does hereby affirm and acknowledge that she, has
read the foregoing release, or had it fully explained to her and fully understands
and appreciates the foregoing words, terms, and their effect, anal that this is a.
full and final cornpmmise, release and settlement of all claims, demands,
ac.tians or causes of actions known or unknown, suspected and unsuspectcd•
9. This release extends and applies to all untmown, unsuspected and
unanticipated injuries and damages, as well a$ those which are now disclosed,
and the undersigned hereby aftirms that she has affixed her signature hereto
voluntarily and of her own free will and accord, T'his release contains the
entire agreement between the parties hereby grid the terms of this release are
contractual and not merely a recital,
10. Should any provision of this Release be declared or determined by
any court of eonnpetenCjurisrl.irtion to be klegal, invalid, or unenforceable, the
legality, validity, and enforceability of the rernainingparts, terms or provisions
-2-
shall not be affected thereby and said illegal, unenforceable or invalid part,
term, or provision shall be deemed not to be part of this Release,
DATED: 0
RAVEN STARR, SHINE - T;IiIntiff
Approved as to form and content:
DATED:") A-LIA.` t LAW OFFICE OF DALE K. GALIPO
By:
I K. Cr ipo' L,s/q./
al r
Job 0'attahi., Esq,
Attorneys for Plaintiff
-3-
RELEASE JAI FULL SET TLE1V ENT AND CO14f1'RC6'1V ISE
L 1, Phyllis Hallstrom, the undersigned, for and in consideration of
the sum of five hundred thousand dollars ($500,000.00), for myself, my heirs,
executors, administrators, and assigns do hereby remise, release and forever
discharge the City of Santa Ana, Chief Carlos Rojas, Corporal Anthony
Bertagna, Detective Leo Rodriguez, Officer John Rodriguez and Officer Peter
Picone, their principals, employees, officers, agents, claims administrators,
attorneys and insurers [hereinafter referred to as "Releasees "], from any and all
claims and causes of action by reason of any injury, damage or civil rights
violations, including any and all attorney's fees and costs, which 1 have
sustained, or may have sustained, as a result of the events surrounding the
detention, shooting and subsequent hospitalization of my son Jason Hallstrom
on March 15, 2013, as more fully described in the Second Amended Complaint
filed by me in the Unted States District Court -- Central District of California
in the matter entitled. R.S., et al. v. City of Santa Aria, et al,, and which bears
case number SACV14 -0589 CAS (FFMx),
2. It is expressly Gulderstood and agreed that this release governs all
clairns and causes of action, including any alleged civil rights violations, and
state torts, and all injuries and damages that arise out of the allegations in the
action entitled R.S., et cit. Y. City of Santa Ana, et ar /., and, which bears case
number SACV14 -05 89 CAS (FFMx) pending in the United States District
Court, Central District of California,
3, It is further understood and agreed that this settlement is the
compromise of a doubtful and disputed claim, and that the payment herein
provided for is not to be construed as an admission of liability, which is
expressly denied.
4. As a further consideration and inducement for this compromised
settlement, the following provisions of California Civil Code section 1542 are
hereby expressly waived:
A general release does not extend to claims which the
creditor does not know or suspect to exist in her favor at
the time of executing of the release, which if known by
him must have materially affected her settlement with
the debtor,
5. 1 represent that I have riot filed any complaints or charges (other
than the Action referenced above) against the Releasees with any local, state or
federal agency or court; and that if any such agency or court assumes
jurisdiction of any complaint or charge against the Releasees and/or their
predecessors, successors, heirs, or shareholders, officers, directors, agents,
police officers, attorneys, subsidiaries, or corporations or organizations,
whether previously or hereafter affiliated in any manner, on behalf of myself,
whenever filed, I will request such agency or court to withdraw and dismiss the
matter forthwith,
6. 1 acIciowledge that 'I am responsible for any and all liens arising
from, based upon, or relating to the Incident, including without limitation, any
and all hrI:Dl -CARE and/or M:EDI -CAI, liens for injury- related services paid
by the corresponding State programs, plus any and all other liens against me
related to my claims in this action.
7. 1 agree to indemnify and defend the Releasees, their officers,
police officers, agents and employees, against, and will hold and save them and
each of them harmless from, any and all third party actions, suits, claims, liens,
damages to persons or property, losses, costs, penalties, obligations, or
liabilities, including any and all healthcare provider liens, that may be asserted
or claimed by any person, firm or entity against the settlement proceeds being
paid to me under this Release.
S. The undersigned does hereby affirm and acknowledge that she has
read the foregoing release, or had it fully explained to her and frilly un. derstands
and appreciates the foregoing words, terms, and their effect, and that this is a
full and final compromise, release and settlement of all claims, demands,
actions or causes of actions known or unknown„ suspected and unsuspected.
9. IUs release extends and applies to all unknown, unsuspected and
unanticipated fiijuries and damages, as well as those which are now disclosed,
and the undersigned hereby affirms that she has affixed her signature hereto
voluntarily and of her own free will and accord. This release contains the
entire agreement between the parties hereby and the terns of this release are
contractual and not merely a recital.
10. Should any provision of this Release be declared or determined by
any court of competent jurisdiction to be illegal, invalid, or unenforceable, the
legality, validity, and enforceability of the remaining parts, terms or provisions
shall not be affected thereby and, said illegal, tmenforceable or invalid part,
term, or provision skull be deemed not to be part of this Release.
BATED:/ Ga J
P; Ti S HALLSTROM - Plaintiff
Approved as to form and content:
DATED: t,t —t(- LAW OFFICE OF DALE K. GALIPO
By
ale K. G ipo, Esq/
7 n , Zattabi, Esq.
Attorneys for Plaintiff
-3-
PARENTAL RELEASE AND INIDEA/MTY AGREEM NT
Tn consideration of the payments to Hailley Hallstrom [DOB: 4/22/02], a
minor, in the total amount of one million six hundred thousand dollars and no cents
($1,600,000.00), the undersigned parent and guardian ofHailley Hallstrom, a
minor, does hereby forever release, discharge and covenant to hold harmless and
indemnify the City of Santa Ana, Officer John Rodriguez and Officer PeterPicone,
their principals, employees, officers, agents, claims administrators, attorneys and
insurers, from any and all claims, injuries, demands, damages, costs, expenses, loss
of services, actions and causes of action of said minor or the undersigned arising
from the events surrounding the fatal shooting of Jason Hallstrom by Santa Ana
Police Department Officer John Rodriguez on March 15, 2013, as more frilly
described in the First Amended Complaint filed by me in the United States District
Court — Central District of California rn. the matter entitled 1 ally Nunleur ere, v..
City of Se nta Ana, et aL,l which bears case number SACV -14 -0766 CAS (%1{ NMx),
1, Tiffany Nunley, the undersigned, do hereby agree to be bound, as well as my
heirs, assigns, administrators and executors, to repay to the City of Santa, Ana, Officer
John Rodriguez and Officer Peter Picone, their principals, employees, officers,
agents, claims administrators, attorneys and insurers, any additional sum that they
may at any time hereafter be compelled to pay on account of the injuries to said minor
because of said incident.
I understand that the parties hereby released adinit no liability of any sort by
reason of said incident or events, and that said payment in compromise is made to
terminate further controversy respecting all claims for damages that said minor or the
11.11age
tmdersigned have heretofore asserted or might personally or through our personal
representatives hereafter assert because of said incident.
TIFF.
Approved as to form and content:
DATED: 2016
By:
Hallstrom
& SMiTH, L.L.P.
Alexis Galindo
Attorneys for Plaintiff
H.H.
2113age