9[061ob

06

b p M

NOTICE OF INTENT TO FILE A PETITION

FOR EXTENDED INVOLUNTARY TREATMENT
AND EXPLANATION OF RIGHTS

This notice is to inform you thac

1.

intends to file an application with the

E OF PETITIONING FACILITVI

on Pleas to extend your involuntary treatment for up to 20 more days.

2.

The court will consider this petition within 24 hours after it is filed. YOU will be
informed of the time and place of the wnference as soon as it is set

3.

You will be given a copy of the petition when it is filed. It will detail the specific
which will be considered by the
~ n d u c tarid iiicdicz.1 d i ~ o s j s~i ysur exmining
wurt

4.

You have the right to be represented by a lawyer at the conference. If you

to hire a lawyer, the wurt will appoint a lawyer for you

5.

You will be permitted to attend the conference. You and your lawyer will have the right
to question your examining doctor and any other witnesses and to present information on
your behalf.

6.

If your conference is before a Mental Health Review Officer and if you are not satisfied
with the results of your conference, you have the right to ask for a hearing before a
judge of the court The court will hold a conference, review all the evidence presented.
and make its own decision as to whether you should be dischafged or receive further
treatment

7.

In addition to the above rights, you continue to have the rights described in the patient's
bill of rights. If you have lost or misplaced your copy. ask for another copy.

If you have any questions regarding your rights under these procedures you may ask

;.Trd

(NAME OF MENTAL HEALTH WORKER)

[SIGNATURE OF EXAMINING DOCTOR OR MEMBER OF TREATMENT TEAM)

@
APPLICATION FOR EXTENDED INVOLUNTARY TREATMENT
MENTAL HEATLH PROCEDURES ACT OF 1976
(SECTION 303)
lThe

)NAME OF PATIENT

LAST

may be
FIRST

& d l A ~ ! d ' NAME OF BSU

,

NAME OF COUNTY PROGRAM

AME OF FACILITY

blanks below

completed following admission1

AGE

MIDDLE

SEX

ri

,+7
Y

BSU NO.

AOMISSION NO.

1. Part I must be completed by the petitioner. The petitioner wilt generally be the
director, act*
director, or appropriate designated staff within the facility where the
patient is being treated
2.

Part I1 is to be completed by persons authorized. by the director of the facility to

explain rights to the patients.

3.

Part 111 is to be completed by a physician who has personally examined the patient

4. Part IV is to be completed by a judge or a Mental Health Review Officer.

5. If additional sheets are needed at any point, note on this form the number of pages
which are attached

6. Attach a copy of the treatment plan and the 302 form prior to its delivery to thc
court.
7. The patient should receive a copy of MH 784-A, a copy of this petition, and a copy
of Part I or the 302 form when this 303 form is filed with the court.

8.

If the patient is subject to criminal proceedings/detention, briefly describe below.

IMPORTANT NOTICE
ANY PERSON WHO PROVIDES ANY FALSE INFORMATION ON
PURPOSE WHEN COMPLEnNG THIS FORM MAY BE SUBJECT
TO CRIMINAL PROSECUTION AND MAY FACE CRIMINAL
PENALTIES INCLUDING CONVICTION OF A MISDEMEANOR.

PAGE 1 OF 4

MH 7 M

- 5F)2

PART I
REQUICT FOR CERTIFICATION

has acted in s w h manner as to cause a responsible

INAWE OF PATIENT)

party to believe that helshe is severely mentally disabled as specified in the attached 302 form. He/
she was admitted to

for involuntary emergency examination

I W M E OF FACILITY)

and treatment on

under Section 302. Helshe was examined by

at

WATfl

(EXACT

TIM4

and was found to be in need of continued

(IIUIE OF P W S K U N I

treatment.

I respectfully request, therefore. that

heishe

be certified by the court

for extended

involuntary emergency treatment under Section 303.

ISIGNATUAE OF PETlTlONERl

(DATE)

PART I1
THE PATIENTS RIGHTS
I affirm that I have informed the patient of the actions I am taking and have explained to the
patient these procedures and histher rights as described in Form MH 784-A. I believe that
he/she&nderstands.
[7 does not understand these rights.

%@ 6
ATE

ISIGNATURE
OF

P ~ R S O NC I V ~ N CR~GHTQI

PART 113
PHYSICIAN'S EXAMINATION
I hereby affirm that I have examined

@/&A?d

2
(4-

on

[NAME OF PATIENTI

to determine if helshs continued to be severely mentally ill and in need of

<IDATE)

treatment.

RESULTS OF EXAMINATION
FINDINGS: (Describe your findings in detail. Use additional sheets if necessary.)

MH 7 8 4

017948
ICONTIUUED ON NEXT PAGE1

PAGE 2 OF 4

- 5192

TREATMENT NEEDED: (Describe the treatment needed by the patient. Continue on additional
sheets if necessary.)

In my opinion: (Check A or B.)

ehT@

A.

B.

patient co~ltinuasto be severely mentally disabled and in need of trcntmcnt.

(The patient

is not severely mentally disabled and in need of involuntary treatment.

PART IV
CERTIFICATION BY THE COURT FOR EXTENDED INVOLUNTARY
EMERGENCY TREATMENT-SECTION 303
In the court of

County

of

term. 19
In re:

No.

Certification for Extended Treatment

This
day of
, 19
after hearing and consideration of
(Details of findings. Include details as to what type and why treatment is needed. Attach
reports, testimony, etc.)

01794C

,,..

ICONTINUED ON NEXT PAGE1

MH 784

- 5/92

The court finds that the patient [O is

is not
severely mentally disabled and in need of
treatment Accordingly, the court orders that: (Check A or B below)

*. 0

n outpatient,

receive:

0partial

I W E Of PATlENn

hospitalization,

0inpatient

treatment

which is the least restrictive treatment setting appropriate for the patient at
INME

as a severely mentally disabled person pursuant

OF FACILIM

to the provisions of section 303 of the Mental Health Procedures Act of

1976 for a period of
M O T TO EXCEED 20 DAYS)

B.

0 The person is not subject

to involuntary treatment

I have explained to the patient that if hislher conference was before a Mental Health Review
Officcr helshc may petition the court for a rcvicw of any decisions reached at this conference.

(Check appropriate block)

n The patient was represented by

a The patient declined representation

for the court

(NAME OF ATTORNEVI

-rn-ud-vo
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rrt

L U N C P I U ~ HI W W

W u L l L b

UEP

ST27341

APPLICATION M R
INVOLUNTARY BMEaCllNCY BXAMINATION

AND TnMtMBNT

Mabtal Health Pracsdurac k t ar 1976

Section 302

INSraUCTIONS

1.

3.

Put I must be omplotod by the puson who beiicvor tb dent b ln need of

trsotmmt. II lhh proo ,isnot a physichi, p~llcsoffics, the
unp Admlnbtratar or
bir 401qat6, be or #he must rrqunl ruhrlzatlon or r m r n t through ths County

AQalni~tr&tor.

i.

when th. pr

t L Wen Ib tlM aminatlon fadlity. the r3&u d w i b d ia Farm MH

783-A =not ~ q l a i w d Pm
.
N h u l d bo nrgud by me w o n who =PI& tlm

M~mhptfttA
-

4.

..

6.

Fur V b O b'
%tor oi

0M by
lrunty Adminkator (or rapriumtntlvc) or by the
~8tp;1Y
bt repr-trwd u p onid
paat
mutry.
01

at

If d d l d o d rbma are required rr any point la cum I a u tU8 form, note on thin
fOm The numW of rddfticmrl lhab whlrh -6

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I W P

P U L I C E DEP

8727341

P.@Z

IMPORTANT NOTICE

r
ANY PERSON WRQ PROVIDES ANY
P A W INPORMATION ON PURPOSE
WITEN BE
TEilS poRM

MAY BE SUBJEf3 M CRIMINAL

~ O S ~ OANDN MAY FAC8

CRIMINAL PENALTIES INCLUDING
CONVICI'ION OF A MWDZMEANOE

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and ibU W L twouble eobabllity h i mh mnduct will bs re tt8. A clsu a d
QW

3 ~ ~ ~ d h r m o o o l l l a r w k ~ r r l l 4 d ~ m f i % f s t t ~ * p s r r 0 in b u
nud., t h w U of
hPr committdd IOO to. irrrthcnna of the Usat rs oornmlt
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would ba wbIr..
M ~ Ii m n d ~ S P P ~ ~ m b r u v o f o ~ ~ s , i . u l r , h: W
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thc .=ma b

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larlou psbd drbpiiadoa rDulQ orinto wimkr SO &yx vnlcoa raegU.0 truImant
w ~ p o.
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~od~r~o rtr; a

lfic pmw hrr awpkd ruielda md thrr them II rewarble pobrbiiiw 01 luMdr

unlca rdoqwtc trnlmant h affotM WI W act Pot tho p u p 8 of 0dr

m q bt damwrtnted by Qr prod that Do
I S I ~ $ L~ ,
MII pwt
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turtheruao of Uu that tb

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l h ~ U / h ~ u l ~f h r t a ~ y lmi!
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m.ultllrtkm d o 3 Ldqur(a Watmnt b .(forded W w Ih(r ML Par Ih. purpQau.
of mtr ~~Rwction.
r clar md prtmt
shall bd ssubUsd
proof +Jut
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U S : ~ LPl'l

LUNESTUCI?

TWP

POLICE

DEP

8727341

P . 03

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On 4-3-06 at 0715 h o w Mr. Caterbone entered a local restaurvlt and store. He walked
through the store and in to the dining room area and threatened six people that he wa

going to rob and then kill them and their children. This was unprovoked.
It is the opinion of this officer t h a t ' k Caterbone may suffer a mental illness. 1 have

learned that he had two family membas commit suicide because of mental
May suffer from bipolar and has been very delusional over the last 30 days.

C \ W * 54
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PI1

CuNESTOGA

T W P

P O L I C E DEP

8727341

P . 04

and explained that people can

tire a gun n their property as long &they are a minimum of 150 yards away from a
residarc&r. Caterbone became agitated
shouting at Sgt B v l u Sgt Bwer
asked him 10 leave, but he continued
then grabbed Mr. Caterbonc by
the arm and escorted out of the Police Station. As he was escorted out of the building,

Chief Fiorill was coming in. Mr. Caterbone began shouting at him.

On 3-21-06at 0716 hows Mr. Caterbone sent an mil address to Chief Fiorill and Chief
of County Detectives, Mike Landis. The mail alleged that Sgt. Buser had choked him
when being escorted from thc Police Station. The mail funha allegwl that Chief Fiorill
had alcohol on his breath,
\bg

,
r
-26-06at 0900 hours Pam Pflumm called the police after receivh telephone &om
Mr. Caterbone. She r e e d that hc waa accushg her son of traPass&d
firing a gun at
v
him on that date at 0730 hours.
> j ~~ ~ l ~ ~ l ,j $ t ' i
3-26-06at 2200 bum Mr. Caterbone came in to the Police Station to file a report of
!s fired. He allegad fbat
on that date at 0030 hours he heard 5-6 quick shots that ma
*
have come &om th ' @way in fiont ofhis home. His body language during this report
I
was mnfimntationa&wa
clenchii his fists and giving M mgy slue. HCthen p o l i t e l y 3
I
&
himself
i fromthe building.
, A. ,
* ~ t0: ;/ &fl

&i,

&

&

60.

27-06 at 0142 hours Mr. Caterbone sent an ernail to Chief Fiorill. The email was
" $1000,00 is missing %ommy bank account. The mail then only relating that he

--a&-

1:

C!'

On 3-31-06 at I000 hours I receivcd a call om Harrisburg International Airport. They

were inquiring&mut Mr Catchone. He wm at HIA

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Fin~c.iz&&wag:

surpicioush/ He d a h d
that he was thdusiness manager for sinner Chew1
he was thcre to pick L I G
her up. HIA hdf no record of Crow arriving and when they attempted to question Mr.
Caterbone fudher barricaded himselfin his vehicle. He ihen left HIA property, but
barricade h i i l f again in his vehicle.
-78
returned later
$E ,L e?"d4.&
On 4-2-06 at 1710 hours Mr. Caterbone approached two women out
e t h e and then argued with them over daylight saving
that there no such thing as daylight savings time.
This cunhntation lasted
in which he approached and harass them 5
times, This was unprovoked by t&? two women, and !vfr. Caterbonc is being cited with a
summary citation for harasstnent. .j j 9 i L! IP ,&$$ &
>- &

.-

RPR-03-06

83:47

PPl

CONESTOGR

TWP

POLICE

PA.

DEP

P. 09

8727341

VI

PHk'SICfAN'S EXAMINATION
r d v d at

~ taclllty at

,
:

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1..1.

QPR-05-86

W 3 : 4 8

PM

CONESTOGfi

T W P

POLICE

DEP

8727341

EXPLANATION OF RIQHTS UNDER INVOLUNTARY EMERQENCY

TREATMENT

a rrrp0ncblr P r m ku Obwrvud vwr conduct and fool^ thrt you p r a m r clear anger
10 6thW psople WMn two hewn from now you wlll be w m l n r d by r
physlCb W ms dacW flndr tM you do not nwd trrrtmsnt, you will b. r r t v M d w
vhtwn pace you d d r a wrYlin roaoon It ylr doctor agrsor hlt you err menblly Ill urd
cmrly in dm* of hrrnlng yaurolf or Mrnaone el-, you MII tu admlttsd to a fKilky
dad&
by mr %ty
Admlnlstrator for n parbd of treatment o t up to 110 hwrr
WNIb you nr* mar ullYnlmtion or In trrrtment you krvr the followb rlghta

to yOwWlf w

1. You must bm told apdflc#lly w h y yov w r r brbpht ham +or otnrrgancy

rx~rnlno~an
2. You m y r W # up to 9 cwnplotbd pnonv cdlr I m ~ w y .

4. YOU

*rd

my p k to tho iacilily thr

tSy d aontw(

(hsm

m a 8

nd

of 3 pmple whom you want osntrctmd,

k r p thorn intormad of

vow propa## whllr

hu.

b Ti?# Covm/ Mbntal Hbrltn Administrator muat taka ru@onrblb atop6 to mours
that wNle you r o drtdnsd, tho 1~11th md e~tetynoado of my of yaw
, d e p d W w r nut wd that yov psrronal proparty md your prrmlrsr whorr
you lkm u@ looked aftqr.
(I.

You wlll b r provldd Irutmenl whlck I8 nocwaay to darl with tha emsrgoncy
r, acr to protact yow Wlth and ufety ond ihrt of other o d d k i d trwtmrnt
may

pr0vld.d wlth your con8rnt

7. When you r r no kngw In nwd of (nrtmmt or in 120 howa, vvhichvsr

Fomr8 toanrr, you will ha dhohargad unlt~syou rgrma to ruwln at the
1r.atclg fdlKy volw~t~~rlly
w unlrla mr director of tlrr fadlity ankl (h. court
to extend your trratment for Ilonger period of tlrna.

r bn#r mar* d.WW vrrrion of B~wrtmtrnof Publle Wblfua R~guhtlon8on rlgh

wlihin

72

hour# ahw

ywr

NIOI Mmr-

eomrnlQnent
~IRAL~YWOW

If

you do not underrt~nd them

wlll ba pleanod ta oxplrln h m

COMMONWEALTH OF PENNSYLVANIA
COMMON PLEAS COURT
LANCASTERCOUNTY

COMPLAINT

il

b 6 k lk

Qd*,
%US-

Mch

Fa07
Go &( 2;

.3

1. Libel: On several occasions officers did willfully and knowingly commit

acts of libel by verbally communicating and alleging plaintiff suffers from
mental disorders without merit and with malice with intent to cause harm
to plaintiffs reputation; cause plaintiff stress; cause harm to business
affairs and to obstruct plaintiffs federal civil litigation.
2. Slander: Police Department did slander plaintiff and his business.
3. Harassment: Officers did harass plaintiff at plaintiffs home on several
occasions.
4. Police Brutalitv: On several occasions officers did ~hvsicallv
abuse plaintiff
. .
without just cause and with malice.
5. Undo influence: Police Department is causing plaintiff problems and is
obstructing plaintiffs right to due process regarding his Federal Civil Action
05-2288 currently in the United States Eastern District Court of
Philadelphia Pennsylvania.

COMMONWEALTH OF PENNSYLVANIA
COMMON PLEAS COURT
LANCASTER COUNTY

CERTIFICATE OF SERVICE

Stanley J. Caterbone represented by Stanley J. Caterbone

220 Stone Hill Road PROSE
Conestoga, PA 19516
Schedule F
Addendum to Add Creditors to Schedule
Service To:

Southern Regional Police Department

Chief John A. Fiorill
Officer8 0 s ~ ~
Officer Fedora
Officer Burger
Southern Regional Police Department
3284 Main Street
Conestoga, PA 17516

L=-..->

Certif~catesof Service were sent by United Stat s 1" Class Mail on April 5, 2006

EY?
Stanley J. Caterbone, Pro Se

Stanley J. Caterbone. Debtor

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Advanced Media Group

220 Stone Hill Road
Conestoga, PA 17516
April 5, 2006

Southern Regional Police Department

3284 Main Street
Conestoga, PA 17516

Re: Police Reports

I am formally and officially requesting a copy of all reports and incidents that I have reported to
your precinct since I have been living at the above address.

I am citing the Freedom of Information Act as my Right To Know these items and your obligation
under current Federal and State rules, regulations, and statutes to comply with my request.

Cc: Senator Gibson Armstrong

www.am~~lobalentertainmentaroup.com

infor@amaa~oba~entertainmentarou~.c~m
717.431.8184799.5915 Phone
717.427-1621 Fax

I ~ ~ ~ G E N E R ~ v _I

HOSP~~AL-

COLDREN MD,SEAN
DOCTOR U N K N O W

PATIENT BELONGING LIST

1IIIIIIl!IIII 111111I lulIII1111

M . & ~ r ~ h M m u -

S+a,,~Iev Cdterb~e

Name

eight
Temp.
~ ~ " d o C U m e n t eSECTION
dt
I1 #I,

PSY

Room #
Pulse

C ~ 1O
Resp.

fa

completed by:
BIP
Date

PATIENT ORIENTATION
Primary Nurse
CI Consent for Tx

Physical Layout
Smoking Policy
N/Phones
Call System

Visitation Policy
Med. procedures
Meals

07/15/1958

. .

1.

CATERBONE ,STANLEY

I.D. Band
St. ClothesIActs.
Prog. Schedule
Independence
Expectation

:<Billof Rights
0 l~rievanceproc.
0 72 Hour Notice
O Press-Ganey Explained

D Orientation deferred (state reason):

s I O ~

-.

PATIENT BELONGING LIST

2.

P = with Pt

..

C = Pt. Closet

Cane
CigareRes
Contacts
Credit Cards

asses

S = Safe

H = Sent Home

6
?
'

item

Amount

Nail File
Purse
Radio
1f
1/*%<
'
Razor
Suitcase
Toiletries
Tweezers
Walker

JJFAJ

M
&
h
s
&
f
i
k
u
C
&
&
r

Misc.

R.Responsibiltiy (No list)

Location

k!?l
~ e ~ t
Blouse
Dresses
Sweaters
Socks
Night GownlPJs
Bras
Misc.

.P

.&@L

Item
-

.d.~1..r,

Location

slacks
Slippers
Shoes
Underwear
Robe
Hats

fl

i?3iz*AJ
I

T&+

lRdYJe
c

CGSc

d,.X/~,&w

I P.PAbr

12-

Not Responsible (actual count) -including checking pockets

Coats

8
.?3

Amount

'5

Amount

!aZ&!m

'gJT5

.-

N = Nursing Station

(to be completed on A U patients)

Location

Hearing Aid WL
Dentures u/L
Keys (label)
Money

B = Belonging Box

i E T TIiE UaTITED STATES DISTRICT COURT

FOR THE EASTERN D I S T R I C T OF PENNSYLVWIA

STANLEY it. CATERBONE

C I V I L ACTION

v.
LAWCASTER COUNTY PRISON, 9

NO. 0 5 - 2 2 8 8
ORDER

-AND NOW, this 5th day of ~axlu*.

--

consideration of the plaintiff's December 17,

2r06,

upon-

2005 letter to

the

Court requesting to amend the complaint and for a hearing, whereas

the camplaint was filed and summons

were issued to the Pro se

plaintiff on May 16, 2005, and whereas the plaintiff has not served
)

the summons and complaint within 120 days after filing the
-

complaint, as required by Rule 4 ( m ) of the Federal Rules of Civil

Procedure. IT IS HEREBY ORDERED that the plaintiff shall serve the

summons and complaint on or before January 2 5 , 2006.

If the

plaintiff does not do so, the c o u r t w j l l t t h complaint

without prejudice.

.-.
, J

The Court will consider the plaintiff's requesL

zmiind !ilr c a n i p l a i n t and for a hearing after the summons and

complaint are served.

IT IS FURTXER ORDERED that the plalntlff's mocion co

-file the complaint under seal

{Docket No. 2) is DENIED.

A document

in a c i v i L action may be filed under seal only if the a c t i o n is

brought pursuant Lo

f e d e l d l scatUte tb,at prescribes the s e a l i n g

of the record, or where good cause is established.

*M;n " - E D

5.1.5 ( a ) (11 of the

,3-0

Local Rules of Civil Procedure;

h -

23 F . 3 d 772, 786 (3d Cir. 19941.

The party seeking

confidentiality may establish good cause by showing that disclosure

will work a "clearly defined and serious injury" to that party;
"broad allegations of harm, unsubstantiated by specific examples or

articulated reasoning," are insufficient.

Even when judged by

se

the less stringent standards by which courts judge

pleadings, the plaintiff has not brought suit under a statute that

-- -- -cause
- .for doing
requires t h e s e a l i n g l o f the-record, or shown
-- good
---so. The plaintiff alleges that several threats have been made on
-

his life, but does not provide any facts to support this

allegation, or explain how these alleged threats relate to his

complaint.

BY THE COURT:

OFFICE O F THE CLERK

U N I T E D STATES DISTRICT COURT
PHILADELPHIA. PA 18106.1797
O I I l C l A L BUSINESS

SUMMONS IN A CIVIL ACTION

r U N T E D STATES DIsTNcT COURT FOR THE EASTERN DISTRICT OF P E N N s Y L v m u

JTANLEY I. CATERBONE

CIVIL ACTION NO. 05-2288

W C A S T E R COUNTY PKISQ&MANHEIM TOWNSHIP TO: (NAME AND ADDRESS OF

DEFENDANT)
POLICE DEPARTMENT; STONE HARBOR POLICE
DEPARTMENT; AVALON POLICE DEPARTMENT,
COMMONWEALTH NATIONAL BANK (i.e. MELLON
RANK); SOUI'HEKN KE(;IONAL POLICE DEPARI'MEN'I';
L ~ A + ~ T O U N T Y SHERIFFS DEPARTMEW+

YOU ARE HEREBY SUMMONED and required to serve upon

Plaintiff's Attorney (Name and Address)

Stanley J. Caterbone (Pro Se)
220 Stone Hill Road
Conestoga, PA 17516
an answer to the complaint which is herewith served upon you, within 20 days after service of this summons upon
you, exclusive of the day of service. If you fail to do so, judgment by default will be taken against you for the relief
demanded in the complaint.

Michael E. Kunz, C1

(By) Deputy Clerk

Date: 5/16/05

,
Stan J. Caterbone
.20 Stone Hill Road
Conestoga, PA 17516
FiorillJ@nolice.co.lancaster.oa.us
Chief J. Fiorill
Southern Regional Police Department . .
Main Street
Conestoga, PA 17516
Re: Recent Police Reports & Status of Ongoing
. . Investigatiolls

1. Break-In reported on June 12, 2005: As reported Lo the officer, "Adams"? who
came to take my report, I left my home at approximately 2:30pm, with all doors
locked. At approximately 9:15pm. I entered through my garage door and found
my back door wide open. I also rcported a Honda file missing, which I have since
located.
2. I an1 requesting the status of the complaint thal I reported to OTlicer Berger on
June 10 concerning the sexual harassment by Mr. Tllomas Grasssel on the same
date.
3. During my visit by the officer on June 12, I again asked if anyone in the
department had questioned Mr. David Pflurnm regarding access to my home. As
I have stated in just about everj; cornplai~itabout a break-in o\-cr the past six
months, On Thanksgiving day, 2004, Mr. David Pflumm, his son Keagen, and
daughter Lizzy, approached my hoii~e. I wanted NO personal cont:~ctwith them,
and made sure my doors were closed and loclted. After sevcl-al minutes of
knockins on my back door, I wunt.down to the basement hopill: they would
leave. They instead went to my f i ~ ndoor
t
and basement door an(! kept knocking.
I was located in the rear of lny b:!sement, waitill2 for them to !c:::e. Suddenly,
Lizzy and Keagan appeared in nly basement asking why I did ::at answer the
door. 1 quickly asked them how tliey got into my house. First thc:.~said the door
was opened, then they said l<eag:ui used a credit card to open !ny back door.
They said Dave was upstairs in lily kitchcil. M'e walked upstair; and I quickly
~ ,responded "We have li.!s of keys".
asked Dave how they got into my I I O U She
Now with all of the reports of people breaking illto my house, ai:tl !he fact that I
first reported the above event to Or(icer Berzer ill December with ii'c report of my
missing remote cun~rol.,I will. a ~ a i nask you why your depart!: ,:nt ref~lsedto
question the Pflumm's regarding, l i ~ y to
s my house?
4. During my interview last evening I showed the officer the letter : . . ~ m
Mr. David
Pflumm dated Julie 2, 2005, which was served to me by a Pennsy!...!nia. Constable
fi-orn District Jilstice Leo Eckel-tshi.fite at appro::imaiely 9:30 am : I .lune 10"' on
Stone I-Ill1 road infront of my maiiilox. The ofl7cel. said "we ha\ :I copy of lliat
~

letter, and are aware of that". I requested the officer to take t l : ~letter and tlly
response, sent via facsimile to P1!~1mmContractors on June lii . to you. The
officer refused to take the letter. i asked him lo take my stateme::! regarding the
same, and he refused. I asked hi111why he would not take my s:::telnent, if you
have a copy of the complaint fi-oil1 Mr. David Piluinm? He s::lii "I am going
home". I called hiin corrupt and said that the whole department \\:I.; comrpt.

I attest to the above statements as the t r ~ i t iand

~ request a copy of all of ::iy complai~lts,
reports, and calls to your department;as.tIefined and a~iiliorizedunder \:.I: Freedom Of
Information Act, and according to the laws governing the same by the C(-~:::monwealth
of
the same.
Pennsylvania and the federal rules gove~~iiljilg
Attest,
Stanley J. Caterbone

. .

Customize Leaflet

Olanzapine (oh LAN

peen)

U.S. Brand Names ZyprexaB; ZyprexaB ZydisB

Pharmacologic Category Antipsychotic Agent, Atypical

Reasons not to take this medicine
If you have an allergy to olanzapine or any other part of this medicine.
Tell healthcare provider if you are allergic to any medicine. Make sure to tell about the
allergy and how it affected you. This includes telling about rash; hives; itching; shortness
of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other
symptoms involved.
If you are breast-feeding.
What is this medicine used
This medicine is used
This medicine is used

It may take 6 weeks to see the full effect.

How does it work?

Olanzapine helps clear your thinking.
It works on improving social interactions, mood, expression of mood, as well as,
delusions, paranoia, and appearance.
It is a mood stabilizer.
How i s it best taken?
Take this medicine with or without food. Take with food if it causes an upset stomach.
Drink plenty of noncaffeine-containing liquid unless told to drink less liquid by healthcare
provider.
Oral-disintegrating tablet: Place on tongue and let dissolve. Water is not needed. Do not
swallow whole. Do not chew, break, or crush.
This medicine is given as a shot into a muscle.
Follow diet and exercise plan as recommended by healthcare provider.
What do I do if Imiss a dose? (does not apply to patients in the hospital)
Take a missed dose as soon as possible.
If it is almost time for the next dose, skip the missed dose and return to your regular
schedule.
Do not take a double dose or extra doses.
Do not change dose or stop medicine. Talk with healthcare provider.
What are the precautions when taking this medicine?
If you are 65 or older, use this medicine with caution. You could have more side effects.
If you have PKU, talk with healthcare provider. Some products do contain phenylalanine.
If you have diabetes, talk with healthcare provider. This medicine can increase blood
sugar.
If you have a family history of diabetes, talk with healthcare provider.

Olanzapi'

'i
,!

'

If you are overweight, talk with healthcare provider.

Check medicines with healthcare provider. This medicine may not mix well with other
medicines.
You may not be alert. Avoid driving, doing other tasks or activities until you see how this
medicine affects you.
Avoid alcohol (includes wine, beer, and liquor) or other medicines and natural products
that slow your actions and reactions. These include sedatives, tranquilizers, mood
stabilizers, antihistamines, and other pain medicine.
You can get sunburned more easily. Avoid sun, sunlamps, and tanning beds. Use
sunscreen; wear protective clothing and eyewear.
Be careful in hot weather. Drink plenty of fluids to prevent dehydration.
Tell healthcare provider if you are pregnant or plan on getting pregnant.

What are some possible side effects of this medicine?

Feeling lightheaded, sleepy, having blurred vision, or a change in thinking clearly. Avoid
driving, doing other tasks or activities that require you to be alert or have clear vision until
you see how this medicine affects you.
Feeling dizzy. Rise slowly over several minutes from sitting or lying position. Be careful
climbing.
Nervous and excitable.
Hostility.
Headache.
Constipation. More liquids, regular exercise, or a fiber-containing diet may help. Talk with
healthcare provider about a stool softener or laxative.
Dry mouth. Frequent mouth care, sucking hard, sugar-free candy, or chewing sugar-free
gum may help.
Weight gain.
High blood sugar. Usually reverses when stopped.
Inability to sleep.
What should I monitor?
Change in condition being treated. Is it better, worse, or about the same?
Check blood sugar as directed by healthcare provider.
Dry mouth may cause an increase in cavities. Take good care of your teeth. See a
dentist regularly.
Follow up with healthcare provider.
Reasons to call healthcare provider immediately
If you suspect an overdose, call your local poison control center immediately or dial 91 1
Signs of a life-threatening reaction. These include wheezing; chest tightness; fever;
itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat.
Severe dizziness or passing out.
Significant change in balance.
Shakiness, difficulty moving around, or stiffness.
Very nervous and excitable.
Feeling extremely tired or weak.
Increased trips to the bathroom, increased thirst, or weight loss.
Any rash.
No improvement in condition or feeling worse.
How should I store this medicine?
Store at room temperature.

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Protect from light.

Protect from moisture. Do not store in a bathroom or kitchen.
Iniection:
The injection will be given to you in a healthcare setting. You will not store it at home.

General statements
If you have a life-threatening allergy, wear allergy identification at all times.
Do not share your medicine with others and do not take anyone else's medicine.
Keep all medicine out of the reach of children and pets.
Keep a list of all your medicines (prescription, natural products, supplements, vitamins,
over-the-counter) with you. Give this list to healthcare provider (doctor, nurse, nurse
practitioner, pharmacist, physician assistant).
Talk with healthcare provider before starting any new medicine, including over-thecounter, natural products, or vitamins.
Disclaimer we .vam

yu_r I I ed :it c ~t 5 palen1 ease[ 5 a summan, of .scf. rfor-won 10 help yc..

yo^ tug<^ toe r, u,t ueoel I YUL
~ r c e r s l a n dan0 :are I safe y O:ner dcrn a l c l abo.1 in.$ me0 c ne may oe rnpcrorl far yoi, la r r o * Plcasc u l * a In g3.r nea lrczre provmer for

more ~nforrnationand your special health needs

LEXI-

Copyright 62 1978-2006 Lexi-Comp Inc. AN Rights Reserved

7
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Customize Leafla

Lorazepam (10,

,,,I

U.S. Brand Names AtivanB, Lorazepam Intensol@

Pharmacologic Category Benzodiazepine
Reasons not to take this medicine

If you have an allergy to lorazepam or any other part of this medicine.

Tell healthcare provider if you are allergic to any medicine. Make sure to tell about the
allergy and how it affected you. This includes telling about rash; hives; itching; shortness
of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other
symptoms involved.
If you have any of the following conditions: Glaucoma or liver disease.
If you are pregnant or may be pregnant.
If you are breast-feeding.

vL

What is this medicine used

This medicine is used

This medicine is used
This medicine is used
This medicine is used

How does it work?

Lorazepam calms the

How is it best taken?

Take this medicine with or without food. Take with food if it causes an upset stomach.
A liquid (solution) is available if you cannot swallow pills. Mix with water, juice, or soft
food before drinking or eating.
Those who have feeding tubes can also use the liquid. Mix with water. Flush the feeding
tube before and after medicine is given.
What do I do if I miss a dose7 (does not apply to patients in the hospital)

Take a missed dose as soon as possible.

If it is almost time for the next dose, skip the missed dose and return to your regular
schedule.
Many times this medicine is taken on an as needed basis.
What are the precautions when taking this medicine?

This medicine may be habit-forming with long-term use.

If you have been taking this medicine on a regular basis for more than 10 days, talk with
healthcare provider before stopping. You may want to gradually withdraw this medicine.
If you are 65 or older, use this medicine with caution. You could have more side effects.
Check medicines with healthcare provider. This medicine may not mix well with other
medicines.
You may not be alert. Avoid driving, doing other tasks or activities until you see how this

*"la

126 East K~ngStreet

Lancaster, PA 17602-2893

1,1,111,,,111,1oat1ll,lllllIIIl
MR. STANLEY J. CATERBONE
220 STONE HILL ROAD
CONESTOGA, PA 17516

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BILL OF RIGHTS
WITH DIGNIN

TO BE TREATED
AM) RESPECT

YOU SHALL RETAIN ALL CIVIL R I G H l 3 THAT

H4VE NOT BEEN SPECIFICALLY CURTAILED 8 Y

You have the r@t to ureslricted ard p-ivae connxnication bside wd outside this fan%ty
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To peaceful assembly and to jom with other patients to organize a body of or

paticipate h patient government when patient government has been d e w to be
feasible by We fscirt.

I
s asassisted by any advocate of your choice h the assertion o f you rights and to
see a lawyer in private at any time.

To

To make conplaints sd to have your canplaints heard and adjudicated promptly

To receive visitors of p r own choice at reasonaWe hars udess your treatment
- ~ ~ n a s n , + n a - ~ r ~ - w e ~ t n y o u r o r
others ireatment or welfaa

T o r ~ a n d s m d u l p a l I ~ a - ~ J t o h . n o u t g o i n g ~

hDoningma7nlaybeexaT.liredforgooclraasonillyarpraerra oramirabald
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a threat to yorr health ad welfare

b n t d = d mears spefific property wiici-~&-Is

UtothehaspitafcolNnUq

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To have access to tekpbms designated for

You have the right to practice

patient use

the religion of y a s choice or to abstain from reiigious

Ycn~have the right to keep ad to use personal w,

d e s s it has been determined
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that specific paronal pr
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sellanypersonalatideyoumdreadkeep~prdfromitshale

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ct'wer's license a profas&md Coenss, maq%ga abtaiing a dvwcs ad writing a will

5.

YOU havs the right

6.

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You haw the rigM to recsivs treatment ill the least restncbvs setting within
necessxy to acconplIsh the trestment goals

7.

to pa-bCp& h the development md review of var twament pbn

You have the rigM to be & d u g &

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from

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as soon as you no lwger need w e

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If you have been inrduntsity camitted in xcadavs with civil oaat promdngs, md
you re not reoeiving l m a h m t
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can arvive safely n the commnty, yw have the rigM to be ctsWged fran the f d r t y .

10.

You h e a right to be paid for my wmk pu do uhkh M

i the operirtion md
maimmame af the fscilii in accordance with existing kdsral wage ad how regulations

SCHEDULE OF ARTICLES STOLEN, DAMAGED OR DESTROYED

,port As Of April 5 2006 Updated Apr 5,2006 1:25 pm

INSURED: Stanley Caterbone

CLAIM NUMBER: MO-

State law requires us to include the following statement -Any person who knowingly files a statement of claim containing any
frlse or misleading infortnation is subject to crimlnsl and clvil penalties.

TRANSACTION REPORT
APR-09-2006

RECEIVER
#

DATE

START

TM

SENDER

COM T I M E

PGS

SUN 0 9 : 2 8 A M

TYPE/NOTE
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OK

DEPT

I 4

INVESTIGATION

The CIA%No. 3 Has aFriend in the Spotlight

-

S LOGISTICS CHlER

S O U ~ W - ~ ~ I$525,000, w b i ~ h

at the CWs main

base near F&rt,

Wtlkes allegedly agreed to

came CIA executive

that Congresswas n&ed

sides attributedhis rise

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hand over in return for $6 million wortb ofgovernment contracts. W~lkeshas not been
chargedwithany wrongdoing,
and his lawyer declined to
comment. But lastweek a D.C.
businessman, Mitchell Wade,
ID'ed in Cunningham court
documents as "Co-conspirator
No. 2,"pleadedguilw to wrrupting both Cunningham and
unnamed Defense Department
05cials. So far, no p m f has
emerged that Wdkes, whose
companies did a lot of business with the Pentagon,also
did business with the CIA. A
source close to Foggo,declining to be ID'ed whiie talking
about the case, said Foggo had
no knowledge of the criminal
inqniw and had not been contacted by inveStigato13.Pad
Gimigliano, a CIA spokesman,
told NEWSWEEK: "It is standard procedure for the i e r
general to lookinto assertions
that mention agency officers.
That should in no way be seen
as lending nedibilib' to any
allegation." Gimigliano added
that Foggo had ''oversea
many oonaam: all of which
were "properlya w d e d and
administe~ed,~

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TREAi.UIENT NEEDED: (Describe the treatment needed by the patient. Continue on additional
sheets if necessary.)

In my opinion: (Check A or B.)

d p a t i m i continns to b; r v u e l y -17

B.

disabld ami in n m i of treatment

The patieat IS not sziiaidy meniaiiy &able-d and in need of involuntary treatment.

PART IV

CERTIFICATION BY THB COURT FOR EXTENDED INVOLUNTARY

EMERGENCY TREATMENT-SECIION 303
In the court of

County

of
term, 19

No.

In re

Certification for Extended Treatment

after hea~mgand conrlderat~onof

T h
day of
19
(Dctalls of fmdmgs. Include deriuls as to wbat type and why treatment IS needed. Attach
reports, testimony, sic.)

01794C

MH 79.
lCOlTWYED O* E X T SArXl
PAGE 3 OF 1

5192

REGULAR

SUNDAY

Pleae Limit (2) Entree's Per Meal

P$mCircle Your Selections

BREAKFAST
Chilled Fruirs &Juices
Pineapple Juice
Qwge ~
..&,
iice
Grape ~uie2,

Apple Juice
Banana

Breakfast Cereals:
Oatmeal
Cream of Wheat
Shredded Wheat
Raisin Bran

Corn Flakes
Rice Krispies
Cheerios

Bagel
Beverams:
Decaf Coffee
y-0
Qegular Coffee i
Regular Tea

~7-

2% Milk
Skim Milk

. Sugar .-s---.u u e a r substitute2

Lemon
A.

PART I
REQUEST FOR CERTIFICATION

has acted in such manner as to cause a responsible

party to believe that

spccificd in the attached 302 form. He/

she was admitted

for involuntary emergency examination

Section 302. Heishe was examined by
and was found to be in need of continued

be certified

by the court

for extended

involuntary emergency treatment under Section 303.

PART I1
TEE PATIENTS RIG3'IS
I affirm tbat I have Informed the p a k n t of the acuons I am taking and have explamed to the
pahat these procedures m d &/her r~ghts as described m Form Mg 784-k I believe that
befsbe-b~.
0 does not understand these rights.

PART I11
BW!3ICIAlrPS EXAMINATION
I hereby affirm that 1 have examined*&/&/Q

IDATO

&
-R a M E

on
OF PATIENT)

to determine ii helshe continued to be severely mentally ill and in need of

trdment.

REULTS OF EXAMINATION
FINDINGS: (Describe your findmgs m detail. Use additional sheets if necessary.)

M H 784 - 5192

017848
ICONTIHUED 01 S X T PADR

PAGE 2 OF 4

APPLICATION FOR EXTENDED INVOLUNTARY TREATMENT

MENTAL HEATLH PROCEDURES ACT OF 1976
lSECTION 303)
lThe
~ A M EOF PATIENT

LAST

blanks below may b s completed following admission)

FIRST
M 1 DOLE

&d/Ald

NAME OF COUNTY PROGRAM

AGE

SEX

V-7
/ AME Of 6SU

BSU NO.

AWISSION NO.

INSTRUCTIONS
1. Part I must be completed by the petitioner. The petitioner will generally be the
director, acting director, or appropriate designated staff within the facility where the
patient is being trcatcd
2. Part I1 is to be completed by persons authorlzed by the dnector of

the facility to

explain rights to the patients.

3.

Part I11 is to be completed by a physician who has perso~dlyexamined the patient

4.

Part I V is to be completed by a judge or a Mental Health Review Officer.

5. If additional sheets are needed at any point, note on this form

which are attached

the nmber of pages

6. Attach a wpy of tbc treatment plan and the 302 form prior to i t s delivery to the
court.

7. The patient should receive a copy of MH 784-A, a copy of this petition, and a copy
of Part I or the 302 form when this 303 form is filed with the court

8. If the patient is subject to criminal p r ~ d ~ n g s / d e ~ t i ob nr i,d y describe below.

IMPORTANT NOTICE
ANY PERSON WHO PROVIDES ANY FALSE INFORMATION ON
PURPOSE WHEN COMPLETING THIS FORM MAY BE SUBJECT
TO CRIMINAL PROSECUTION AND MAY FACE CRIMINAL
PENALTIES INCLUDING CONVICTION OF A MISDEMEANOR

ri

--

NOTICE OF INTENT TO FILE A PETITION

FOR EXTENDED INVOLUNTARY TREATMENTAND EXPLANATION OF RIGHTS
003)

This notice is to inform you that

intends to file m application with the

1.
E @ PI!ftTlONING

FACIL17?>

on Pleas to extend your involuntary treatment for up to 20 more days.

2.

The court will consider this petition within 24 hours after it is filed. You will be
informed of the time and place of the wnference as soon as it is set

3.

You will be given a copy of the petition when it is filed. It will detail the specific
conduct and mgdical diqposis of yox examinkg doctor which ail! be considered by the

4.

You have the tight to be represented by a lawyer at the conference. If you cannot afford
to hire a lawyer, ihe court will appoint r lawyer for you

5.

You will be permitted to attend the conference. You nnd your lawyer will have the right
and my other witnand to pr-t
information on
your behalf.
to question your examining doctor

If you have my qustiom regard'-

your rights under these procedures you may ask

d.Tr4 h;
WAME OF MENTAL HEALTH WORLERL

4 6 w

ISIGNATURE OF EXAMlNlffi DOCTOR OR WEMeER OI TIEATWENT TEAM)

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Lancaster General
f i - h p i d

0542297
190418296
M
CATERBONE ,STANLEY

MHU DISCHARGE INFORMATION

Family
Physician:

07/15/1958
PSY

COLDREN MD, SEAN

DOCTOR UNKNOWN

IIIIIII
11111IIIIIIIIIIIIIII
IIIII
rIIIII 11 1111

Physician:

Batwdressing:

independent

Return to worWschooi
Returnto driving

other

immediate

immediate

other

other

Avoid alcohol and non-prescribeddrug use unless advised otherwise by

I

If you have a Mental Health Emergency call:

Case Manager
Psychiatrist
merapistlprogram

Fambly Dr

Crisis lnterventim 394-2631 or qo to Hospital Ememencv Room

RMrictionWSPeCiallnsvuaons

'

Status

StaMe

0Other

Safety Siatus
Computerized Medication information given to patient Dyes

O NA

Psydl~atnOpsychodynamlc:

Drug Allergies:

---

FOLLOW UP APPOINTMENTSTTESTS

!!

Phone
Datdirne
#

DoctorfLccation
.

,'
.

, 2.

.,
,

.,

..II~YJ /

Medim!:
Compliance:
Medioation changes:
Lab Data:
See Dictated RX Summary
Obtaiied Release of Information for outpatient RX providers
NA
Patient satisfaction survey/outcome survey complete
SafeNaluables claim slip: with patient
NA
Iv e i i that Ihave t a k n all my personal belongings. I have received and
understand this written statement regarding my dis.zharge instructions. If
Services have been m m e n d e d for me after my discharge. I have been
giwn a choica of service providers.

PatiqnVResponslble Party Signature IPhone It:

For questions regardinp your dischaw or follow-up appoinbnents call

Adult Mental Health Unit a 544-5832.
RW. 4104

ORiGINAL Medical k m r d

.-r ',

,.

- j c j~,
/.jlj/L,phone

. ?6/7,>* /
)/(
id-&?,
J
?,.

NuneS Sinalye:
MIDDLE PVResp Party

Time,/

sgiTt;)M Phystclan

'>- .,

CATERBONE ,STANLEY

COLDREN MD,SEAN
DOCTOR UNKNOWN

07/15/1958
PSY

PATIENT BELONGING LIST

te\/' CLttPi\hc.le

Name

Room n
Pulse

Temp.

~ 9( 0
Resp.

C
*

Completed by:
BIP
Date

!5/O/O

PATIENT ORIENTATION
1.

Physical Layout
Smoking Policy
TVIPhones
Call System

Consent for Tx
Bill of Rights
Grievance proc.
72 Hour Notice
Press-Ganey Explained

Primary Nurse
Visitation Policy
Med. procedures
Meals

I.D. Band
St. ClothesIActs.
Prog. Schedule
Independence
Expectation

Orientation deferred (state reason):

PATIENT BELONGING LIST

P = with Pt

.-

2.

C = Pt. Closet

S = Safe

H = Sent Home

N = Nursing Statton

(to be completed on ALL pattents)

Location

Cane
Cigamttes
Contacts
Credit Cards
Glasses
Hearing Aid WL
Dentures U/L
Keys (label)
Money

B = Belonging Br;x

!lgm

Amount
~

nzz$.

Nail File
Purse
Radio
Razor
Suitcase
Toiletries
Tweezers
Walker

~~

V'w.

J7l&tLmi
M

Amount

Make up

W&TC
F

/ l ) h g N h j & b ~ ~ W c;&J,
~-

Misc.

IA+*ucs~z4

Pt.Responsibility (No list)

3.

Not Responsible [actual count) -including checking pockets

item
Belt
Blouse
Dresses
Sweaters
Socks
Night GownIPJs
Bras

Misc.

4
A

2 z=
T
P

2IEi

Slacks
Slippers
Shoes
Coats
Underwear
Robe
Hats

Location

THIS FACILITY CANNOTASSUME RESPONSIBILITY FOR ITEMS

RETAINED IN YOUR POSSESSION. PATIENT UNDERSTANDS
THAT BY SIGNING BELOW HUSHE IS AWARE OF THIS POLICY
AND VERIFIES THAT THE ITEMS LISTED BELOW AS INVENTORY ARE CORRECT AND THAT THE ENVELOPE HAS BEEN
SEALED IN HIS/HER PRESENCE.

--~

is Patient Conscious?
{yes;.;-- t\lo
., .-.,
Did Patient Witness the
Contents of this Envelope? ::-Yes
No
-

-'

190418296

- - - .

ROOM NCCATERBONE ,STANLEY

COLDREN MD, SEAN
PATIENT DOCTOR UNKNOWN

s s - #i

- -

11111111111111111111lIll1lll1
Il 11

DATE

: I

cuRREN;Y:

.
;

C *

.>

.,0

.. ,.
I. j

CHECKS:
VALUABLES (OESCRIPTIOY

I
HFS 7

I i

I
THE HOSPITAL

RETAINS THE RIGHT TO DISPOSE OF ANY PROPERTY NOT CLAIMED WITHIN 30 DAYS O F DISCHARGE
YELLOW i Remains Attached To Envelope
WHITE i Attach To Patients Chari

COMMONWEALTH
OF PENNSYLVANIA

JUDICIAL CONDUCTBOARD
PENNSYLVANIA
PLACE 301 CHESTNUT
STREET SUITE 403 HARRISBURG, PA

m.m-234-7911

March 27,2006
Stanley Caterbone
220 Stone Hill Road
Conestoga, PA 17516

RE: Judicial Conduct Board Complaint No. 05-256

(Magisterial District Judge Leo H. Eckert, Jr. - Lancaster County)
Dear Mr. Caterbone:
The Board is presently reviewing your complaint.
In your complaint, you state that you secured a court reporter to transcribe the
hearing on your citation for Harassment held on May 10,2005. As your complaint
claims that District Judge Eckert displayed improper demeanor toward you at that time,
the Board is requesting that you provide a copy of the transcript for review.
As you privately arranged for a reporler, the transcript is not a part of the official
district court file. Therefore, the Board cannot obtain it on its own. Since you did not
include a copy with your complaint, I am requesting that you provide it at this time.
Please provide the additional requested information to the Board within
thirty (30) days from the date of this letter.

I remind you the Pennsylvania Constitution provides that all proceedings of the
Board are confidential except when the subject of the investigation waives
confidentiality. Pa. Const. Art. V, 18(a)(8). The Board cannot provide status reports of
its investigation; however, you will be notified of the Board's decision on your complaint
following appropriate review.
verytruly yours,

FJP I1

Deputy Chief Counsel

IN T H E COURT OF COMMON PLEAS

O F LANCASTER COUNTY,PENNSYLVANIA

PROTHONOTARY
CIVIL COVER SHEET

..-

-,

DO NOT STAPLE THE COVER SHEET TO THE PLEADING

-.-.
-?

.
.

..
.-

:.

ADDRESS:

220

ADDRESS:

~ - 4 ~

320d /LEG
J-

TELEPHONE #:
SSN#

SSN#

TYPE O F ACTION:

J u r y Trial Demanded:

No

Arbitration:

Name of Firm and Filing Attorney OR Filing Party, Address, Telephone Number, AOPC Number

-.
t i

DEFENDANT 'S NAME

TELEPHONE #:

c-.

ZIP C O D E S A R E REQUIRED BINFORMATION MUST MATCH PLEADING

~,

.,, ,
-<....

PLEASE T Y P E OR PRINT LEGIBLY ALL INFORMATION REQUESTED.

PLEASE LIST NAMES, ADDRESSES AND SOCIAL SECURITY NUMBERS
OF ADDITIONAL PARTIES ON A SEPARATE S H E E T .

0,
" ,
",~

Nofr: C A O S C H E D U L I N G C O V E R S H E E T M U S T B E A T T A C H E D ,
ii A N E V E N T N E E D S T O B E S C H E D U L E D .

VS

r.2

Address:
City:
-

Stare.

Teieuhone Number:

E-mail:

Fax Nuillber:
Signature:

Z ~ Code:
D

fl7