The URL can be used to link to this page

Home My WebLink AboutResolution_66-03/04_09/16/2004 RESOLUTION NO. 66-03/04 A RESOLUTION OF THE VILLAGE COUNCIL, OF THE VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, APPROPRIATING $105,000.00 IN THE GENERAL FUND, ACCOUNT # 001-160-524.101, WORKER'S COMPENSATION CLAIMS FROM DESIGNATED FUND BALANCE TO FUND RAYMOND SMALL'S WORKER'S COMPENSATION SETTLEMENT CLAIM PAYMENT • WHEREAS, this payment is a final settlement on account of an accident on July 28, 1995, and WHEREAS, the Village of Tequesta has accounted for this as a Long Term Debt, claims payable, in it's Financial Statements (Attached Schedule A), and WHEREAS, the Village of Tequesta was required to pay out this claim per the approved Settlement Agreement (Attached Schedule B), and WHEREAS, the Village needs to appropriate funds in Budget Year 2004, of $105,000.00 to fund the Settlement payment. NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AS FOLLOWS: Section 1. THE FOREGOING RESOLUTION WAS OFFERED by Councilmember Humpage, who moved its adoption. The motion was seconded by Councilmember Resnik, and upon being put to a vote, the vote was a follows: FOR ADOPTION AGAINST ADOPTION Pat Watkins Geraldine A. Genco Russell J. von Frank Edward D. Resnik Jim Humyaae • • The Mayor thereupon declared the Resolution duly passed and adopted this 16th day of September, 2004 A.D. P~ ~, Pat Watkins Mayor of Tequesta ATTEST: i ~~ ~ r ~,. ~.~~, -Y "~ ~ ~ L ~~'L.-~ Ewen E. Carlisle Village Clerk C7 VILLAGE OF TEQUESTA, FLORIDA ' NOTES TO BASIC FINANCIAL STATEMENTS ~, (Continued) ~~ NOTE 9. LONG-TERM DEBT (Continued) 4~ Note Payable (Continued) Debt service requirements to maturity are as follows: Year ended September 30: 2004 Changes in Long-Term Debt S C ire ~ VK Q Principal Interest Payments $ 13,827 $ 197 $ 14,024 The following is a summary of long-term debt for the year ended September 30, 2003: Governmental activities: Revenue bonds - 1994 '. Note payable Capital leases Claims payable I~ Compensated absences Business-type activities: Revenue bonds - 1998 ~ ~ Unamortized bond discount ~~ ~ '. ~ Note payable. p, Compensated absences Balance Balance Due September 30, September 30, Within 2002 Additions Deletions 2003 One Year $ 790,000 $ - $ (95,000) $ 695,000 $100,000 5,000,000 - (161,648) 4,838,352 168,704 162,856 397,922 (207,142) 353,636 46,720 105,000 - - 105,000 340,132 26,762 - 366,894 18,763 $ 6,397,988 $ 424,684 $ (463,790) $ 6,358,882 $ 334,187 $ 7,495,000 $ - $ (] 50,000) $ 7,345,000 $160,000 (101,655) - 3,910 (97,745) - 7,393,345 - (l 46,090) 7,247,255 160,000 22,896 - (.9,069) 13,827 13,827 93,423 12,545 - 105,968 - $ 7,509,664 $ 12,545 $ (155,159) $ 7,367,050 $173,827 Defeasance of Long-Term Debt In a prior year, the Village defeased the 1978 Series $3,915,000 Water Revenue Refunding Bonds bx placing the proceeds of new bonds in an irrevocable trust to provide for all future debt service payments on the old bonds. Accordingly, the trust account's assets and the liability for the defeased bonds are not included in the Village's financial statements. At September 30, 2003, $2,040,000 was still outstanding. • -41- VILLAGE OF TEQUESTA, FLORIDA NOTES TO BASIC FINANCIAL STATEMENTS ~~~ (Continued) NOTE 9. LONG-TERM DEB')" (Continued) ,. Governmental Activities (Continued) Claims Payable i~ The Village's workers' compensation insurance company notified the Village that it had insufficient assets to meet its ultimate claims liabilities. Therefore, each member of the trust must fund its own individual costs, which would include claims administration and payments of indemnity and medical expenses of injured employees for any claims prior to July 1, 1998. Each member will be billed for actual costs. As of September 30, 2003, the Village had incurred and paid expenses of $17,220. The Village has two open claims for which there could be substantial settlements.- As of September 30, 2003, the settlement amounts are estimated to be $105,000. rr ~ Business-type Activities , Water Revenue Bonds - 1998 The Village issued Water Revenue Bonds, Series 1998, in the amount of $7,915,000 with a ~~ varying interest rate of 3.8% to 5.125% dated March 1, 1998 and a maturity date of March i 2028. Pursuant to the Bond Resolution, 7-97/98, the Village is obligated to establish and maintain required reserves as noted in Note 10 -Required Reserves. At September 30, 2003, the outstanding balance was $7,345,000. Debt service requirements to maturity are as follows: • Principal Interest Payments Year ending September 30: 2004 $ 160,000 $ 363,325 $ 523,325 2005 165,000 356,255 521,255 2006 170,000 348,885 518,885 2007 180,000 341,185 , 521,185 2008 185,000 333,015 518,0]5 2009-2013 1,075,000 ],548,050 2,623,050 2014-2018 1,380,000 ],251,975 2,631,975 ~ 2019-2023 1,765,000 862,744 2,627,744 ~ 2024-2028 2,265,000 359,775 2,624,775 r Total 7,345,000 5,765,209 13,110,209 . Less unamortiZed discount (97,745) - (97,745) $ 7,247,255 $ 5,765,209 $13,012,464 ®, Note Payable On April 9, 1999, the Village entered into a note payable agreement to finance the cost of a new ® utility billing system. The Village financed $108,000 over a term of 48 months at an interest ® rate of 4.75%. As of September 30, 2003, the principal balance of the note was $13,827. ~ . ,. u~~r loI t.r~rl~ 1C1: D4 /!5y/15 HAVES SCHLOSS ALCOCE HAVES, SCHLOSS ~ ALCOCER, P.A. ATTORNEYS AT LAW 4365 NORTHLAKE BOULEVARD PALM 6EACM GARDENS, FL 3341D-6253 tS,~3_._ '~~. ALCOCER ~'a! ~.IaAYES ~nNE F. McGILL GARY M. SCHLO55 vaC-~~L£ L- WILL' •ALSb ADMITI'&D TO PRACTICE IN WISCONSIN August 18, 2004 *V~A FACSIMILE* ~TOdi Forsythe .?~ccounti.ng Village of Tequesta 250 Tequesta Drive, #304 Tequesta, FL 33469 Re: Raymond Small v. SS#: 261 49-4595 D/A: 7/28/95 Dear Ms. Forsythe: Village of Tequesta PAGE 02 ~ GSA u-c~. ,~ TELEPHONE (861) 775-1770 FAX: (561) 775.9775 Enclosed please find the Settlement Agreement and Release of Claims/Voluntary Resignation with regard to the above- referenced workeral compensation case. As the Judge of Compensation Claims has approved the Motion for Approval of Attorney's FeeE; and Allocation of Child support Arrearagea for Settlements under F.S.440.20 {11)(c)(d)(e) on August 12, 2004 (this Order hae been date stamped as opposed to the Judge manually signing the Ox'der), this matter is considered settled. We are mailing the original Settlement Agreement and Release of CJ.aime to you under separate cover. zt was a pleasure assisting you in the handling of this case. If yvu have any questions or concerns regarding the above, please do not hesitate to contact me. 5i ce e , For the Firm G~iS : az cc: Daniel J. Gallagher, Village of TequeSta rr~~rr~ HAYES SCHLOSS ALCOCE STATE OF FLORYI7A DzVZSION OF ADMrNISTRATIVE HEARINGS OFFICE OF TFIE JUDGES OF COMPENSATION CLAIMS OLTCC#: 95-01386SWP8 ~TL`~GE : gASQUILL EMPLOYEE/CLAIMANT: Raymond Small Fost Office Box 14fl1 ,7upiter, Florida 33408 EMPLOYER/SERVICING AGENT: Village of Tequesta 250 Tequesta Drive,.#304 Tequesta, FL 33469 D/A: 7/28/95 VENUE ; PALM HFACH COUN'T'Y REPRESENTED BY: Daniel S. Vecchione, Esq. 1620 N. Dixie I~ighway West Palm Beach, Florida 33407 PAGE 03 REPRESENTED HY: Gary M. Schloss, Esq. Hayes,~Schloss & Alcocer, P.A. 4365 Northlake Boulevard Palm Beach Gardena, FL 33410 SETTLEMENT AGREEMENT & RELEASE PURSUANT TO F.S.440.Z0(].1) (G),2003 The parties to this Release, to wit: Raymond Small (Date of Birth 1/22/58)(hereinafter oollectively referred to as the "Releasor") and the village of Tequesta (hereinafter referred to as the "Releaaee") hereby agree as follows: WHEREAS, Releasor was an employee of the Village of Tequesta on July 28, 1995. WHEREAS, Releasor voluntarily resigned their employment with the Village of Tequesta previous to entering into this settlement agreement. WHEREAS, Releasor sustained an injury arising out of his. employment with the Village of Tequesta and has filed a workers' compensation claim or is otherwise claiming workers' ~ ~ ~ ~~. 2riit~.a1 HAVES SCHLOSS ALCOCE PAGE 04 compensation benefits against Releasee as the result of a .work related accident which occurred on July 28, 1995 and said claim i~.subject to the provisions of Chapter 440, Florida Statutes, or otherwise alleged to be covered by Chapter X40, Florida Statutes.. WHEREAS, Releasee has paid benefits to .Releasor pursuant to. Chapter 4g0. WHEREAS, the parties wish to cornpxomise. and settle all claims Releasor may have against the Releasee as a result of or arising out of any work related accident including those referenced herein. NOW, THEREFORE, the parties agree as follows: 1. Releasor, for and on behalf of each and all of their respective present, .former, and future successors, heirs, executors, administrators, guarantors, attorneys, representatives, insurers and assigns (a11 of whom are also hereinafter collectively referred to as the "Releasor"), for and in consideration of the lump sum of ONE HUNDRED FIVE THOIISAND DOLLARS ($105,000.00) ("the Lump Sum") 'and other good and valuable consideration, to be paid to Re~.easor does hereby release, acquit, and forevex discharge Releasee, and if Releasee is a corporation, all of its respective present, dormer and future officers, directors, stockholders, trustees, nominees, at~Ox'neyS, agents, employees, consultants, insurers, brokers, p t~ ~ .~ In~t~.al uor c/ Lr~C14. 1G: ~4 ~l5y!!5 HAVES SCHLOSS ALCOCE PAGE 05 personal. finders, heizs, executors, administratozs, managers, predecessors, successors, representatives, representatives and assigns (all of wham are also hereinafter collectively xeferzed to as the "Releasee(s)") of and from any and all claims, demands, actions, suits, causes of action, controversies, coats, expenses, damages, judgments, losses and liabilities of whatever kind or nature, in law, er~uity, statutozy or otherwise, whether known or unknown, which against them, or any of them, Releasox' nvw has, had, may have had, ox' can, shall ox may have for ox by reason of any matter, cause or thing whatsoever to and including the date hereof, which were or might have ox' could have been asserted in connection with, • arising out of, or in any way relating to any injuries resulting ~ from or claimed to be the result of any work-related accident including those referred herein, including but without in any respect limiting the generality of the f oregoing, any and all claims for or rights to past, present and future benefits under Chapter 440, Florida Statutes including any claims for attorney`s fees and attorney fee liens. The settlement amount referred tv herein sha11 be allocated as follows: a} past & Future Compensatio~x Benefits $ 60,000.00 b) Future Medical Benefits of the type typica].Iy covered by r[ed~.care $ 10, 000.00 c) Future Medical Benefits of the type NOT typically covered by Medicare $ 35,000.00 TOTAL: $ 105,000.00 j ~ ~-~ Izzitial _.__ ='^-%-a!te~n4 tn:54 7759775 HAVES SCHLOSS ALCOCE PAGE 06 2. It is the intent of the undersigned Releasor that tha.s is a complete, full, comprehensive and final release of any and all liability of the parties released herein arising from or relaying to any and all injuries arising out of any work related .accident including the accident referenced herein., including any and all liability of Releases for any act performed or omitted by, or on behalf of the patties released herein prior to the date herecf relating to any and all injuries arising out of any wdx'k related accident including the accident referenced herein. The Releasor agrees that this settlement shall constitute an election of remedies by the Releasor with respect to the Releases herein. 3. On account of the accident of July 28, 1995, the Releases may have a cause of action against a third party tortfeasor(s). The Re~.easor is aware of the Employer/Servicing Agent's lien rights in any recovery against arty third party tortfeasar(s) for workers' compensation benefits paid as authorised under Florida Statute440.39. .The Releasor understands that the Employer/Servicing Agent retains its lien rights in any such recovery notwithstanding the settlement and this Release. The Releasor shall protect the Employer/servicing Agent's lien rights and notify the Employer/Servicing Agent in i ,~ S' ,~~ ~Ijn-i-t~i a~. -' -" -'" ' '"' ~~ ' ' ~" r =' HAYES SCHLOSS ALCOCE PAGE 07 writing of any recovery from, or the filing of a complaint against, any alleged third party tortfeasor(s). ~. The undersigned Releasor hereby expressly warrants, represents and covenants to the parties released herein that Releasor is presently the legal owner and holder of the claims or causes of action released hereby, and that it has not heretofore expressly or impliedly assigned, transferred, pledged ox otherwise disposed of any such rights, claims, demands, ox causes of action being described herein and released hereby. 5. The Releasor has been repzesentied by Daniel S. Vecchione, Esq., in connection with this matter who is entitled to a fee to be paid by the Releasor for legal services rendered. The Releasor shall pay $11,250.00 and Releasor'g attorney agrees that said fee is a reasonable fee for such services, resolves all claims for attorney's fees that Releasor's at~corney may have against the Releasee(s), and i.s within the guidelines for the determination ofi a reasonable fee as set forth in Florida Statute 4~k0.34 (].) . In addition thereto, the Re~.easor shall also reimburse the attorney $3,750.00 for costs. The Releasor has also been represented by Lewen Reich & Mancini in connection with this matter who has filed a lien for attorney's fees. Subject to the approval of the Judge, the Releasor is to pay Lewen Reich & Mancini $2,000.00 in satisfaction of all attorneys fees and costa that are being claimed by the law firm ~~ . Ynit~.al I HAYES SCHLOSS ALCOCE PAGE 08 of Lewen Reich & Mancini. The Releasor and/or his attorney are also responsible for any fees and costs payable to Rosenkranz & Gilhool fox any all services tendered in this matter including but not limited to the Medicare-set aside, Notwithstanding the provisions of Florida Statute 440.34, the Releasor and not the Releasee(s} is/are responsible for the payment of Releasor's vwn attorney's fees, and all claims for attorney` s fens and costs to any part are hereby satisfied a.nd released. Releasor also agrees that there are no other claims or liens for tees filed by any other attorney, and if a claim or lien is or has been made, the Releasor agrees to resolve said claim ox lien, and the Releasor agrees. to hold the Releases harmless if a claim for fees arises. The. Releasor and their attorney agree that this settlement agreement and release discharges the Releases fz'om any liability for fees for services rendered on their behalf. The fees and costs sha]:1 be paid from the settlement proceeds thereby making the net settlement amount $88,000.00. The Releasor understands that this does not include any and all sums which are payable to the Clerk of Court Support Department. for outstanding child support arrearages pursuant to section six of this release. 6. In reaching thzs agreement the parties have, pursuant to Section ~40.20(ll)(d) Florida Statutes, as amended 2001, Initial _~oi 1~' ~r~r,~ 1G:_~4. r r5y r r5 HAYES SCHLOSS ALCOCE PAGE 09 considered the issue~of child support arrearages. The Releasor warrants as follows (mark as appropriate): a. There are no arrearages owed by Releasor for ch~,ld support : ____. b. There are arrearages owed by Releasor for child support, in the total amount of .$70,901.63 and $3,780.39. if outstanding child support a.s shown above, the Releasor has allocated $25,922:12 and $3,780.39 of the lump sum to be paid by Releasor towards the payment of such arrearages. Counsel far Releasor shaJ,l be responsible for ensuring such child support allocation is paid to the proper agency toward Releasor's arrearage. 7. Releasor and Releasee(e) adknowledge(s) that whereas Section 440.20{11),(d), as amended 2001, also requires that the nudge of Compensata.on Claims consider whether the settlement allocation provides for tk~.e appropriate recovery of child support. arrearages. It is the intent of the parties that this settlement . agreement and release shall not be valid and enfox'ceable and that Releases shall not be required to disburse settlement proceeds until the settlement agreement and release is executed by Releases and Releasor, and all Court approvals as to attorney's fees and child support allocations are obtained. Therefore, Releasor and Releases agree that the statutory 14 day period will ~_'Y~ ~--..~ Initial ~~/l~s/LF7J4 1b: 54 7759775 HAYES SCHLOSS ALCOCE PAGE 10 begin to run from the date of the mailing of the Court Order approving the fee and allocation for the recovery of child suppoxt arrearages, or receipt by Releasee(s) o~ a signed Settlement Agreement, whichever occur last. However, the parties agree that earlier payment shall satisfy the applicable statutory period and the Releasor's attorney agrees to hold the settlement proceeds in escrow until all conditions are met, including' the satisfaction of all liens for attorney fees. If these conditions are not met, Releasor'e attorney shall noti disburse any funds, but will immediately return to Releasee(s) those funds being held in escrow. 8. The Releasor represents that no services, medicines, medical appliances, or x-rays of any kind were received by the Releasor from any Veterans Hospital, Naval or military hospital, ar any other medical institution maintained by the united States Government, as a result of the acczdent and injuries described herein. The Releasor further represents that no medical. bills or services have been paid to Releasor or on Releasor's behalf by medicaid or Medicare as a result of any injuries arising out of and during the course and scope of Releasor's employment with the Releases herea.n. If Releasor has received any benefits as a result of their woxk related injuries from any state of Federal Insurance or benefits program, such as Medicaid or Medicare, the ~-~ Initial uv,io,cuuw 1G:~4 !!5y!/5 HAVES SCHLOSS ALCOCE PAGE 11 . Re~.easor understands that it is the~,r responsibility to reimburse them for any payment they may have made. 9. The Releasor has considered that many common medical expenses are not paid ox reimbursable undez certain group health policies of the Federal Medicare Program. The Releasor also. understands that he is, oz may in the future be entitled to Medicare benefits. The Releasor understands that it is not the intent of this settlement to shift the responsibility for the Releasor's future medical care to the Federal Government and the 'Releasor agrees that the sum of $10.000.00 from the lump~sztm settlement shall be allocated for payment of .those medical costs which are covered under Medicare which are related to the industrial injuries. This allocation is based on the workers' compensation fee schedule. The Releasox understands that. all payments to providers are to be adjusted accordingly, and any monies paid in excess of the fee schedule will not count towards the allocation. The $7.0,000.00 allocation is to be for the next 30 years into the future, representing the Releasor's l~.fe expectancy given Releasor's actual age of 46 years (~oB: 1/22/58). The Releasor understands that before any bills can be submitted to Medicare fox payment that this amount must be spent on expenses covered by Medicare and related to the industrial injury and that the Releasor must keep record of these expenses that have been paid. The Releasor understands that the Federal • ~~ ~~ Yn~,t1a1 i :JO/ 1 O( LGG4 1lJ: ',]4 / /~j9J~7~j HAYES SCHLOSS ALCOCE PAGE 12 • Government has the authority to change this allocation and make -the Releasox spend more of this settlement on Medicate expenses related to his work-xelated injuries. The Releasor understands and acknowledges the freedom and ability to consult with specialists practicing in the area of Social Security and Medicare law and has chosen to settle the case either a,n lieu of dr after such consultation. The Medicare Set Aside funds in this case are to be self administered by the Releasor. The Releasor has been provided with directives issued by CMS regarding his rights and responsibilities in this regard. The Releasor undezstands .that until he becomes entitled to Medicare, the MSA funds must not be used to pay the Releasor's e~cpenses. The Releasor further understands that the MSA funds must be placed in an interest bearing account, and this account moat be separate fxom the Relaasor's personal savings and checking accounts. The funds in this account may only be used for payment of medical services related to the work injury that would normally be paid by Medicare. Medicare will not pay injury-related claims until these funds are restored to the MSA's account, and then properly exhausted. -The Releasor further understands that annual reporting must be prepared for submission to Medicare to include summaries of the transactions and status of the account. These summaries are to include the date of each ~se~vice,,the procedure Initial r HAYES SCHLOSS ALCOCE PAGE 13 • perfoxctted, diagnosis and paid receipt or cancelled ,check: C]~aimant will be reBponsibJ~e for keeping records of payments made from Medicare set aside account and providing annual accounting summaries of funds transactions along with the Status af~the account to the following Medicare contractor: ~Fixst Coast Service Options, Ync• Attn: MSF Manager P.O. Box 44179 Jacksonville, FL 3223].-4179 1fl. By receipt of the consideration set forth above, the, Releasor agrees that the terms of this settlement, including but; not limited to the amount of consideration paid herein, will not be discussed either directly or indirectly with any past or • present employees of the Employer yr any other persons. The Releasor specifically agrees to keep the terms of this settJ.emerlt strictly confidential. The Releasor acknowledges that any direct or indzrect communication of this type on the Releasor's behalf may result in a forfeiture of the consideration paid pursuant to this Release. . 11. The parties agree that this Settlement Agreement is valid and enforceable. If this Settlement Agreement and Release is ever found to be unenforceable for whatever reason,. the Releasor agrees that any payment made by the Releasee shall not be considered a gratuity and that the Releasee shall be entitled to full reimbursement of the lump sum paid to the Releasor and `~-~ ~' Initial ~. HAYES SCHLOSS ALCOCE PAGE 14 • to the e~ctent full reimbursemexlt ie not made, Releasee is entitled to a credit for any money paid to the Releasor in connection with the settlement against benefits owed or found to be-due, past or future without limitation on the type of benefit 'to which this offset would apply, nor as to the amount of offset to be taken as to any benefits. The Releasee shall have a. dollar for dollar offset fox the money paid under this. Settlement Agreement. The Releasee agrees to pay for authorized medical care for ~sexv'ices rendered up until the date of execution of this agreementi. 12. Releasor agrees that upon payment of the consideration referred to herein, all claims, petitions for workers' compensation benefits, actions for personal injuries ax'isi.ng out of the accidents referenced herein, and axly and all Claims or lawsuits against the Releasee axe voluntarily dismissed with. prejudice and Releasor shall file voluntary dismissals in all Couxts where claims. or actions are pending. 13. Releasor agrees that he shall not seek further employment with Releasee. 14. This agreement is not binding or enforceable by parties until approved by the Centers for Medicare and Medicaid Services {CMS). Upon approval by the CMS, this agreement will be deemed ratified and will become binding and enforceable. • . '!~ v~~ Initial I ~~+ ~ ~+ «~-~ iu. ~~+ r r~~ r is HAVES SCHLOSS ALCOCE PAGE 15 • 1.5. Sy signing this Settlement Agreement, Releasor acltnowledges that he has read the agreement, has had i.ts terms fully explained to him by his attorney, hae been fully informed and understands: a, the settlement's effect on any rights the Releasor may have; b. his rights regarding the claim(s) settXed; c. he is giving up these rights; and is entering into this Settlement Agreement voluntarily, .and without .any undue influence, pressure or coercion whatsoevez. ~~urther,by szgnxng this settlement agreement, geleasor's attorney agrees that he' has explained the settlement agreement and that Releasor does understand his rights and the effect of this settlement on those rights. ~... ~` 3~ p Ra and Sma11 Date Claimant/Releasoz BEFORE ME, the undersigned authority, personally appeared, ~ Raymond Small who, after being duly cautioned and swozn, depose(s) and says he has read the above release and that he has set his hazzd(s} and sea7.(s) thereto for the purposes therein expressed. ~~ foregoing instrument was acknowledged before me this ~_ day of i9 L. 2004 by Ra and small who is personall ~~sn~uw.~. to me or produces identification # ~W'~-~ZX~'~~~~Q~ fJ ,P CINTNYA L KA?~unn~^'''• ~,~{ COMM1551oN ~ ~ 023218 F~tPIRfeS: Felxua~Y 18,2006 , Biped Thru rlderr~i10 txa yly Commission Expires: t Name of No d Daniel S. Vecchione, Esq. Date Releasor's Attorney r ~ ~J Initial `'°." 1O~ `GG~+ 1~: ~4 ..._. r r5y r r5 HAYES SCHLOSS ALCOCE PAGE 16 RELEASE Ok' CLAIMS, VOLUN'~ARY RESYGNATION ANA • AGREEI~NT NOT TO SEER RE-EMPLOYMENT KNOW ALL MEN BY THESE PRESENTS, that Y; Raymond Sma1J~, in consideration of the sum of Ten ($lo•oo) Dollars and other good and valuable consideration, do hereby remise, release, and forever discharge the Village of Tequesta and/or any of the officers, agents, servants, employees, directors, successors, assigns and any other person or entity so connected to the Village of Tequesta, of and from any and all manner of actions, causes of action, suits, proceedings, debts, dues, contracts, judgments, damages, claims and demands whatsoever in law or in equity, including, but not' limited to, claims made pursuant to ~2 IT.S.C. ~~127.01-12~~-3 ("Americans with disabilities Act of 7.990"), claims of discrimination under .any federal or state law, claims of wrongful termination of employment, which I, Raymond 8ma11, ever had, now have, ox which my personal i representatives, heirs or assigns hereinafter Can, shall, or .may have against the Village of Tequesta and/or any of the officers, . agents, servants, ernploXees, directors, successors, assigns and any other person or entity so connected to the Village of Tequesta for or ,by reason of any matter, cause or thing whatsoever, from the beginning of the world through the date of these presents. AnY vested benefits I may have through the employer will .not be a~fected. FURTHERMORE, I, Raymond Small, do hereby voluntarily terminate my employment relationship with the village of Tequesta effective the last day I worked at the Village of Tequesta. FURTHERMORE, 1, Raymond Small, shall hereinafter neither seek • re-employment nor hold employment with the Village of Tequesta, Yf T should hereinafter become employed by the Village of Tequesta, ,then Page 1 of 3 bti/lti/Lbb4 1d: 54-- 7759775 HAVES SCHLOSS ALCOCE PAGE 17 • r shall tender a written voluntary resignation of said employment within three (3) days upon receipt of written x'equest from the Village of Tequesta. IN WYZ'NESS WF3EREOF, I have hereunto set my 2004. hand and seal. this ,,, _ day o~ ~~ Raymond Small State of FJ.orida ? County of Palm Beach ) Before me the undersa,gnerl authority authorized to administer oaths and take acknowledgments personally appeared Raymond SmalX who is personally known to me or was identified by dr_~vez''s license or • other identification [indicate method of identification: ] on this ~ day of 2004, ~ who upon being duly sworn, Certifies and affirms that: 1. He has read the foregoing RELEASE 0~' CLAIMS, VOLUNTARY RESIGNATION AND AGREEMENT NOT TO SEEK RE-EMPLOYMENT and' that all information contained therein is true and correct; 2. He agrees the RELEASE OF CLAIMS, VOLUNTARY RESIGNATION ANTS AGREEMENT NOT TO SEER REEMPLOYMENT was written in understandable language; 3. He understands that the RELEASE OF CLAIMS, VOLUNTARY RESIGNATION AND AGREEMENT NOT TO SEEK RE-EN[PLOYMENT includes a release of any and al]. claa.ms based on .the • ,Americans with Disabilities Act of 1990 against the Village of Tequesta. Page 2 of 3 -~ts~l~s/znn4 1b:54 _ 7759775 HAVES SCHLOSS ALCOCE PAGE 18 4. • He. agrees that a reasonable period ~of time was provided for him to deliberate or consider the RELEASE OF GLAYMS, VOLUNTARY RESIGNp,.TSON AND AGREEMEN'T' NOT TO SEEK RE- . EMPLOYMENT; S. He agrees that he was encouraged to consult with an attorney regarding the RELEASE OF CLAIMS, VOLUNTARY RESIGNATION AND AGREEMENT NOT TO SEEK RE-EMPLOYMENT; and 6. He agrees that he received consideration for the RELEASE OF CLAIMS, VOLUNTARY RESIGNATION AND AGREEMENT NOT TO SEEK RE-EMPLOYMENT to which he was not otherwise entitled. Raymond Small • OTAR ~ ~,'~~~4~•- MY~~MMISSION X16 ` "' *_' EXPIRES; Febn1~~1~~ ' s°"de°T~n'-~an -~a N + UB C / STATE O FLORIDA (S~ r MY COMMISSION EXPYRES: • Page 3 of 3 HAVES SCHLOSS ALCOCE PAGE 19 S STAT>; OF FLORIDA, f"-~~~~~IG~ . DZVZS70N Ob' ApMYNTSTRA~'IVE >slEp,,RYNGS Auk ,~ ~ 2~~~ OFFICE OF THE JUDGES OF COMPENSATION CLAIMS OJCC# : 9 5 - 0 Z3 8 6 5WPH D/A : 7 / 2 8 / 9 5 HAVES, SCHLOSS ~ ALCdCFR, P:A, JUDGE : .$~ VENUE ; PALM BEACI~ COUNTY EMPLOYEE/CLA2MANT: REFItESENTEA HY:. Raymond Small Daniel S. Vecchione, Esq. Post Office Bax Z~k01 1620 N. Daxie Highway Jupiter, Florida 33468 West Palm Beach, F],orida 33407 EMPLOYER/SERVICING AGENT: REQRE$ENTED HY: Village of Tequesta Gary M. Schloss, Esq. 250 Tequesta Dxive, #304 Hayes, Schloss & A1GOCex, P.A. Teq'uest8, FL 33469 4365 Northlake Boulevard Palm Beach Gardens, FL 33410 ORDER UNDER SECTION 440 .20 (17,) (C) , (d) , (e) ~ FLOR3:DA STATUTES ( 2 0 01. ) Pursuant to Section 440.20 (].7.) (c) , (d) , & (e) , Florida • Statutes (2002), the parties have reached a settlement agreement. After reviewing the attached documentation, the undersigned Judge finds that: 1. The amount of attorney's fees as' evidenced in the attached Attox'x~.ey Fee Data Sheet and supporting documentation meets the requireme7rxte of the Workers' Compensation Law. 2. The settlement allocation provides for the appropriate recovery of child support axrearages, if any exist, as evidenced by the supporting documentation. 3. The attorney's fees shah. not be subject to moll f ZGatiOTl . r~ ~J OJCC# 95-0~3685~TPB Pleadingl# Order an Motion fo: Approval of Attorr-ey's Pecs 8c Child Support Allocation Page #1 of #2 dti/lti/1l7f~4~ 1t~_54__ _7759775 HAYES SCHLOSS ALCOCE PAGE 20 zt is ORDERED and Ap,7UDGEp tklat the attorney's fee and cJnild support arrearage allocation, it any, paid under the settlement agreement is approved. DONE and oRDERED•at West Palm Beach, Palm Beach County, Florida. Judge of Compensation Claims Thl~e is to certify that the above Order was entered by the Judge of Compensation Claims and a copy was served by U.S. mail on each party and counsel at the addressee listed above on this day of _ 2004. • Assistant to the ~7udge of Compensation Claims Ct7pY :. , O~i1~INAL C~fiTIFIEp ~ ~' HNC1 MAILf;Ij v u~ ~~ . JUDICI~LASS187ANT ~~[/~J yl (~ JUbGE p'AMBHp~ID `I~' JUDGf; pF CDMPENSATIDN CWIHIB • i OJCC# 95-013685W~B P16~dirig# Order on Motion for Approval of Attamey's 1~ees & Child Support Allocation Page #2 of #2