HomeMy WebLinkAboutMIA ZARATE - MMZ, ET. AL VS. CITY OF SANTA ANA - 2016INSURANCE NOT RE-001'Rto
WC)1' X ! PROGEM
CLt i'ii'' OF COUPICIL.
OATP it -117° J•v+ v
"ViV SETTLEMENT AGREEMENT AND RELEASE
This Settlement Agreement and Release (the "Settlement Agreement") is made and
entered into this eJd day of October, 2016, by and among:
"Plaintiff" Mia Zarate, by and through her guardian ad litern Jasmine Zarate
"Defendant" City of Santa Amt
RECITALS
A. Plaintiff Mia Zarate filed a complaint against City of Santa Ana and its police
offiicors, in the United States District Court, Central District of California, entitled NINIZ, etc„ et
al. v. City of'Santa Ana, et al„ which bears case number SACV 15-0$51 JLS (DFMx) (hereinafter
"Action"), This Action arose out of the events surrounding the shooting of Ernesto Canepa on
February 27, 2015 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 February 27, 2015, which allegedly resulted in
the death of Decedent Ernesto Canepa and related personal injuries to Plaitniff Mia Zarate,
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:
LO RELEASE AND DISCHARGE
IA In consideration of the payments set forth in Section 2, which has a current cost of
four hundred and sixty-five thousand dollars and no cents ($465,000.00), 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
and Officer Christopher Shynn from any and all past, present or future claims, demands,
obligations, actions, causes of action, wrongful death claims, rights, damages, costs, losses of
servi6es, 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. It
is agreed that Plaintiffs and Defendants will each respectively bear their own attorneys' fees and
eosts.
IlPage
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 Christopher Shynn,
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 Christopher Shynn.
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 2.1 and 2.2 below:
2.1 Payments due at the time of settlement as follows:
$157,307,96 shall be in the form of a check made payable to "Guizar Henderson
& Carrazco LLP"
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: Mia Melanie Zarate
$2,500,00
Payable monthly, guaranteed for 84 payments only, commencing
10/16/2030 (age 18) through and including 9/16/2037
$50,000.00
Guaranteed lump sum, payable on 10/16/2037 (age 25);
$75,000.00
Guaranteed lump sum, payable on 10/16/2042 (age 30);
$100,000.00
Guaranteed lump sum, payable 10/16/2047 (age 35); and,
2 1 P a g e
$275,000,00 Guaranteed lump sum, payable 10/16/2052 (age 40).
The periodic payment obligation set forth above will be funded by a payment for at a cost of] of
$307,692.04 in a check made payable to BHG Structured Settlements, Inc.
The Parties agree that the Defendant may make a qualified assignment as defined in
section 130(c) of the Internal Revenue Code to BHG Structured Settlements, Inc. (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, (ii) 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
be 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 and
full execution of the Qualified Assignment and Release document.
2.3 The Defendant or Assignee reserves the right to provide for the periodic payments
set forth in section 2,2 of this agreement by purchasing an annuity policy from Berkshire
Hathaway Life Insurance Company of Nebraska ("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.
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 hisurer's Assignee. The designation must be in a form acceptable
to the Insurer or the Insurer's Assignee before such payments are made,
31Page
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 CObIPREHENSION 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:
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.
4]Page
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 fines 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 become effective immediately following execution by
each of the parties.
Dated:
Jasmin a a guardian ad [item for
Plamti M' arat
//
Dated: I0It it (0
...b�...w.. , ..may„
Attorney for Plaintiff Mia
Defendant City of Santa Ana
Dated: By:
David Cavazos,
Title:_ City Manager
ATTES%
'Al
MARIA C. HUIZAR
CLERK OF THE COUNCIL
S1Page
Qualified Assignment and Release Agreement
In Accordance With
Internal Revenue Code Section 930
"ciahnant(s)", Jazmin Zarate, individually
Mia Melanie Zarate, a minor, by and through her Guardian ad Litem, Jazmin Zarate
City of Santa Ana
"Assignor": __
"Settlement Agreement": _
[Exact title of Settlement Agreement or Order] _
"Governing Law":
"Assignee":_ sats STRUCTURED SKVHJ"MENT.'�NC.
"Annuity Issuer": BERKSHIRE HATHAWAY LIFE INSURANCE COMPANY OF NEBRASKA
"Effective Date";
"Payee(S)": As_,hown in Addendum No. 1, Descripi:.i.on of Perf.odic Payments _.._.
Annuity Contract No:
This Qualified Assignment and Release
Agreement ("Agreement') is made and entered
into as of the Effective Date by and among the
undersigned parties with reference to the
following facts:
A. Claimant(s) and Assignor are parties to or
are otherwise subject to the above -
referenced Settlement Agreement under
which Assignor has liability to make certain
periodic payments to the designated
Payee(s) as specified in Addendum No. 1 of
this Agreement (the "Periodic Payments").
Where no Payees) other than Claimant(s)
are shown in Addendum No. 1, it is
understood that any references herein to
Payee(s) shall apply to Claimant(s).
B. Assignor and Assignee wish to effect a
"qualified assignment" within the meaning
and subject to the conditions of Section
130(c) of the Internal Revenue Code of
1986, as amended (the "Code').
C. This Agreement will be effective contingent
upon Assignee's receipt of the full premium
to fund the Periodic Payments contained
herein.
Now, therefore, in consideration of the
foregoing and for other good and valuable
consideration, the parties agree as follows:
1. Assignment and Assumption; Release of
Assignor, Assignor hereby assigns to
Assignee, and Assignee hereby accepts and
assumes, all of Assignor's liability to make
the Periodic Payments. Each Claimant
hereby accepts and consents to such
assignment by Assignor and assumption by
Assignee. Effective on the Effective Date,
each Claimant hereby releases and
discharges Assignor from all liability to make
the Periodic Payments, including the failure
of Assignee to make any of the Periodic
Payments and/or Annuity Issuer to fund any
of the Periodic Payments for any reason
whatsoever.
2. Nature of Periodic Payments. The Periodic
Payments constitute:
i. damages (other than punitive damages),
whether by suit or agreement, or
li. compensation under a workers'
compensation act,
on account of personal injury or sickness In
a case involving physical Injury or physical
sickness, within the meaning of Sections
130(c) and 104(a) of the Code.
3. Extent of Assignee's Liability. Assignee's
liability to make the Periodic Payments shall
be. no greater than the liability of Assignor as
3S-1000 (1212013) (5) Page 1 of 6
4.
5,
of the Effective Date. Assignee is not
required to set aside specific assets to
secure the Periodic Payments. Claimant(s),
Payee(s) and Successor Payee(s) have no
rights against Assignee greater than those
of a general creditor. Assignee assumes no
liability other than the liability to make the
Periodic Payments. Assignee's liability to
make the Periodic Payments shall be
unaffected by any bankruptcy, insolvency,
liquidation or rehabilitation of Assignor.
Qualified Funding Asset. Assignee will
fund the Periodic Payments by purchasing
from Annuity Issuer a "qualified funding
asset," as defined in Section 130(d) of the
Code, in the form of an annuity contract (the
"Annuity") issued by Annuity Issuer and
providing for payments corresponding to the
Periodic Payments. Assignee shah be
designated as the owner of the Annuity. All
rights of legal ownership and control of the
Annuity shall (subject to paragraph a of this
Agreement) be and remain vested
exclusively in Assignee; provided; however,
that the Annuity shall be used by Assignee
to fund the Periodic Payments and shall at
all times be designated by Assignee on its
records as being taker into account, under
Section 130 of the Code, with respect to this
Agreement. Notwithstanding anything to the
contrary contained In this Agreement,
neither any Claimant, any Payee, nor any
Successor Payee (as defined in paragraph 8
of this Agreement) shall have any rights with
respect to the Annuity or the payments
thereunder that would cause any amount
attributable to the Annuity to be currently
includable in the recipient's income or would
otherwise affect the determination of when
any recipient is treated as having received
any payment for income tax purposes, or
would otherwise prevent this Agreement
from satisfying all of the conditions for a
"qualified assignment" within the meaning of
Section 130(c) of the Code.
Delivery of Payments. Assignee may
instruct Annuity Issuer to send payrrrents
directly to Payee or Successor Payee, or to
deliver payments by electronic funds
transfer ("EFT') to an FDIC -insured
depository institution in the United States for
credit (directly or indirectly) to an insured
account in the name of such Payee or
Successor Payee. Such direction of
payments under the Annuity shall not be
deemed to afford Claimant, Payee or any
Successor Payee any rights of ownership or
control of the Annuity.
Each Claimant, Payee and any Successor
Payee shall at all times keep Annuity issuer
apprised of such Claimant's, Payee's or
Successor Payee's current mailing address
and telephone number and, if Payee or
Successor Payee receives payments by
EFT, the name, address, ABA routing
number and telephone number of the
applicable U.S. financial institution and the
account name and account number to which
the payments are to be credited. Such
notices shall be in a form provided by
Annuity Issuer and must be received at least
thirty (30) days prior to the date payment is
due,
G. Discharge of Liability. Assignee's liability
to make each Periodic Payment to any
Payee or Successor Payee designated to
receive such payment shall be fully
discharged upon:
L the mailing of a valid check on or before
lire due date for such payment to the
address of record specified by Payee or
Successor Payee; or
It. the initiation of an EFT payment on or
before the due date for such payment to
the United Sates financial Institution
account designated by Payee or
Successor Payee
If Payee or Successor Payee does not
receive a scheduled payment by check,
Payee or Successor Payee shall notify
Assignee. Upon receipt of such notification,
Assignee shall initiate a stop payment action
for such check and upon confirmation that
such check was not previously negotiated
shall promptly mail a replacement check; or
If Payee or Successor Payee does not
receive a scheduled EFT payment, Payee or
Successor Payee shall notify Assignee.
Upon receipt of such notification, Assignee
shall initiate a trace for such payment and
upon confirmation that such payment was
not credited to the account shall promptly
issue a replacement EFT payment.
7, Acceleration, Transfer of Payment
Rights. None of the Periodic Payments and
no rights to or interest in any of the Periodic
Payments (all of the foregoing being
hereinafter collectively referred to as
"Payment Rights") can be
1. Accelerated, deferred, increased or
decreased by any recipient of any of the
Periodic Payments; or
1L Sold, assigned, pledged, hypothecated
or otherwise transferred or encumbered,
either directly or indirectly, unless such
sale, assignment, pledge, hypothecation
or other transfer or encumbrance (any
SS -1000 (12/2013) IS] Page 2 of 6
such transaction being hereinafter
referred to as a "Transfor") has been
approved in advance In a "Qualified
Order" as defined in Section 5891(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, Payee or Successor Payee
shall have the power to effect any Transfer
of Payment Rights except as provided in
sub -paragraph (it) above, and any other
purported Transfer of Payment Rights shall
be wholly void, Invalid and unenforceable. If
Payment Rights under this Agreement
become the subject of a Transfer approved
in accordance with subparagraph (11) above
the rights of any direct or Indirect transferee
of such Transfer shall be subject to the
terms of this Agreement and any defense or
claim in recoupment arising hereunder.
8. Contingent Beneficiaries, Any Periodic
Payments to be made atter the death of any
Claimant, Payee or Successor Payee shall
be made to such party as shall have been
designated in, or In accordance with, the
Settlement Agreement or, If.the Settlement
Agreement does not provide for such
designation, then to the party designated in
conformity with this paragraph 8. Any party
so designated is referred to in this
Agreement as a "Contingent Beneficiary." If
no Contingent Beneficiary is living at the
time of the death of a Claimant, Payee or
Successor Payee, payment shall be made to
the decedent's estate unless otherwise
provided to the Settlement Agreement. As
used in this Agreement the term "Successor
Payee" refers to a Contingent Beneficiary or
an estate that has become entitled to
receive Periodic Payments following the
death of a Claimant, Payee or a Successor
Payee. Except where a designation has
been made in the Settlement Agreement, no
designation or change of designation of a
Contingent Beneficiary shall be effective
unless such designation or change (1) Is
requested in a written request submitted to
Assignee In accordance with Assignee's
customary procedures for processing such
requests; and gl) is confirmed by Assignee.
hlowever, Assignee will not be liable for any
payment made prior to receipt of the request
or so soon thereafter that payment could not
reasonably be stopped. Except for a
designation that is expressly identified in the
Settlement Agreement as irrevocable, any
designation of a Contingent Beneficiary shall
be deemed to be revocable; and no party
that is designated as a Contingent
Beneficiary (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. Termination of Settlement Agreement 1
Failure to Satisfy Section 130(e). if at any
time prior to completion of the Periodic
Payments, the Settlement Agreement Is
declared laminated in a final, non -
appealable order of a court of competent
jurisdiction (or in the case of a workers'
compensation settlement, a final order of the
applicable workers' compensation authority)
or if it is determined in any final order or
ruling that the requirements of Section
130(c) of the Code have not been satisfied
in connection with this Agreement: (i) the
assignment by Assignor to Assignee of the
liability to make the Periodic Payments and
Assignee's acceptance of such assignment
shall be of no force or effect; (fi) Assignee
shall be conclusively deemed to be acting as
the agent of Assignor; (iii) the Annuity shall
be owned by Assignor; (iv) in the event the
Settlement Agreement Is not terminated,
Assignor shall retain the liability to make the
Periodic Payments; (v) Assignee shall have
no liability to maks any Periodic Payments;
and (vi) the parties hereto agree to
cooperate in taking such actions as may be
necessary or appropriate to implement the
foregoing.
10. Governing Law; Binding Effect
This Agreement shall be govemed by
and Interpreted in accordance with the
internal laws of the state identified as
Governing Law above; provided,
however, that any Transfer of Payment
Rights under this Agreement may be
subject to the laws of other states in
addition to the state designated above.
This Agreement shall be binding upon
the parties hereto and their respective
successors, heirs, executors,
administrators and permitted assigns,
including without limitation any party
asserting an Interest in Payment Rights,
11. Advice, Comprehension of Agreement. in
entering into this Agreement, each Claimant
warrants, represents and agrees that
Claimant is solely relying on the attorneys
and advisors of such Claimant's own
choosing, and not upon Assignor, Assignee
or their advisors, for advice regarding the
legal, government benefits and tax
88-100G(12/20-13) (S] Page 3 of 6
consequences of this Agreement. Each
Claimant further warrants, represents and
agrees that the terms of this Agreement
have been completely read by and
explained to such Claimant and are fully
understood and voluntarily accepted by such
Claimant. Furthermore, each Claimant
hereby releases and discharges Assignor,
Assignee, Annuity Issuer, their affiliates and
their respective employees and advisors
("Releasees") from any and all claims,
rights, damages, costs or expenses of any
nature whatsoever that such Claimant now
has or may have in the future against such
Releasees (I) with respect to the present
and future taxation of this Agreement or the
Periodic Payments; or (ii) the impact that,
this Agreement or the Periodic Payments'`
may have on Claimant's eligibility for, and .,
the quantum of, any governmental benefit
payments.
12. Future Cooperation. All parties agree to
cooperate fully and to execute any and all
supplementary documents and take all
additional actions, which are not inconsistent
with its terms, which may be necessary or
appropriate to give full force and effect to the
terms and intent of this Qualified
Assignment and Release Agreement.
Pursuant to its obligations under this
paragraph 12, and without limitation,
Assignor shall promptly provide Assignee
with copies of any,,?aquired court approval
with 'rre"spect tgl'tl70` underlying settlement
and executpd..�copies of all required
SS -1000 (12J2013) [SI Page 4 of 6
of Periodic Payments. The
ments are as set forth In
andum No. 1, which is hereby
in and made a part of this
In the event of any conflict between this Agreement and the Settlement Agreement with respect to
the Periodic Payments or the assignment made herein, the terms and conditions of this
Agreement shall prevail.
This Qualified Assignment and Release Agreement may be signed in one or more counterparts.
Assignor: City of Santa Ana
S
By:
David Cavazos,
Title: City Manager
Assignee:
BHG Structured Settlements, Inc.
By:
Authorized Representative
Clalmant(s) or Payeo(s):
By'�=
Jazmin Z !a, ini i wally
Mia Meta' Zarat �inor, by and Ihroueh har
Guardian ad Litem, zmin 'Carate
Attorney fo Claimant's
Approve '10 Fon Content
By: _._._._.__. --
Angel Car zco _
SS•1000 ('12/2013) (Sj Page 5 of 6
ATTEST.
`'-MpA RIA d. VIA d
MAHUILAW
CLERIC OF THE COUNCIL
Addendum No. 1
Description of Periodic Payments
Payee: Jazmin Zarate
$65,000.00 Guaranteed Lump Sum Payable 8/27/2023
$25,000,00 Guaranteed Lump Sum Payable 8/27/2028
$25,000.00 Guaranteed Lump Sum Payable 8/27/2033
$30,000,00 Guaranteed Lump Sum Payable 8/27/2038
Payee: Mia Melanie Zarate
$2,500,00 payable monthly, guaranteed for 84 payments only, beginning October 16,
2030; final guaranteed payment September 16, 2037
$ 50,000.00 Guaranteed Lump Sum Payable 10/16/2037
$ 75,000.00 Guaranteed Lump Sum Payable 10/16/2042
$100,000.00 Guaranteed Lump Sum Payable 10/16/2047
$275,000.00 Guaranteed Lump Sum Payable 10/16/2052
INITIALS
Assignor:
Assignee: _
Claimant or Payee: nn
Attorney for Claimant:
Ncl
SS -1000 (12/2013) ISI Page 6 of 6