HomeMy WebLinkAboutDocumentation_Regular_Tab 06L_09/16/2004 � �
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RESOLUTION NO. 66-03/04
A RESOLUTION QF THE VII,LAGE GOUNCIL QF THE VILLAC'iE OF
TEQUESTA, PALM BEACH CC.3UNTY, FLORIDA, APPROPRIATING
$105,00Q.00 IN THE GENERAL FtIND, ACCOUNT # OQI-160-524.141,
W4RKER'S COMPEN5I�TION CLAINfS FROM DESIGNATEB FUNI3
BALANCE TO FUND RAYMI�ND SMALL'S WORKER'S -
COMPENSATIUN �ETTI.�EMENT CLAIM PAYN�NT
WHEREAS, this payment is a fznat settlement on account nf an aecident on .Tuty 28,
1995, a,nd
WHEREAS, the Viliage of Tequesta has accounted for this as a Long Term Deb�, claims
payable, in it's Financial Statements (Attached Schedule A), and
WHEF.EAS, the Village of Tequesta. was required to pay aut this ciaim per the approved
Settlement Agreement (Attached Schedule B}, and
WHEREAS, the Village needs ta appropriate funds in �udget Year �U04, of $105,0�0.Op
to fund the Settlement payment.
NOW, THEREFORE, BE IT RESOLVED B� THE VII.LAGE t�F TEQUESTA, PALM
BEACH COUNTY FLQRIDA, AS FOLLOWS:
Section Z.
THE FOREGOING RESOLUTI(JN WAS OFFERED by Councilmember ,
who moved its adoption. The rnotion was secanded by Councilmember , and
upon being put to a vote, the vote ��ras a follows:
FOR ADOPTION AGAINST ADOPTION
. �
The Mayor thereupon declared the Resolution duly passed and adopted this day
of , A.D.
Pat Watkins, Mayor
ATTEST:
Gwen E. Carlisle
Vil�age Clerk
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I� S L i�n u LK. �
1
i VILLAGE OF TEQUESTA, FLORIDA
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� NOTES TO BASIC FINANCIAL STATEMENTS
I (Continued)
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� NOTE 9. LONG-TERM DEBT (Continued)
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� Note Payable (Continued)
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Debt service requirements to maturity are as follows:
, Principal Interest Pavments
Year ended September 30:
, 2 � $13,827 $ 197 $ ]4,024
Changes in Long-Term Debt
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�,
The foliowing is a summary of long-term debt for the year ended September �0, 2003:
i
�= Balance Balance Due
�P September 30, Septernber 30, Within
, �j 2002 Additions Deletions 2003 One Year
I � Governmental activities:
!r'
Revenue bonds - 1994 $ 790,000 $ - $ (95,000) $ 695,000 $100,000
�� Note payable 5,000,000 - (161,648) 4,838,352 168,704
;� Capitalleases 16Z,856 397,922 (207,142) 353,636 46,720
�I, Claims payable 105,000 - - 105,000 _
I�� Compensated absences 340,132 26,762 - 366,894 18,763
I li� $ 6,397,988 $ 424,684 $(463,79p) $ 6,358,882 $ 334,187
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�
;I,
`I� Business-type activities:
, I �
Revenue bonds - 1998 $ 7,49� $ � - $ (I50,000) $ 7,345,000 $160,000
I,� Unamortized bond discount (101;655) - 3,9]0 (97,?45) _
� �' ` 7,393,345 - (146,090) 7,247,255 160,000
; �'j
; � Note payable 22,896 - (9,069) 13,827 I 3,827
� ��f Compensated absences 93,423 12,545 - 105,968 _
, �! $ 7,509,664 $ 12�545 $ (155,159} $ 7,367,050 $ l 73,82'I
�',i �
r� Defeasance of Long-Term Debt
��,
Ili'
In a prior year, the Vilfage defeased the 1978 Series $3,9]S,OQO Water Revenue Refunding
�� i� � Bonds b� 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
�� ]iability for the defeased bonds are not included in the Village's financial statements. At
� September 30, 2043, $2,040,000 was stil] outstanding.
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� -41 _
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f . �
VILLAGE OF TEQUESTA, FLORIDA
�
i NOTES TO BAS1C FINANCIAL STATEMENTS
� (Cootinued)
�
�
�;
- NOTE 9. LONG-TERM DEB'�' (Continued) ¢
� �_
Governmental Activities (Continued)
� Claims Payable
�
� The Village's workers' compensation insurance company notified the Viltage that it had
� insufficient assets to meet its ultimate ctaims 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 eosts. As of September 30, 2003, the Village had
� incurred and paid expenses of $17,220. Thg Village has two open claims for which there
could be substaniial settlements.- As vf Sep[ember 30, 2003, the settlement amounts� are
� estimated to be $105,OOQ. �
� Business-type Activities ,
'' Water ReveRUe Bonds —1998
The Villaae 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 Mazch
�028. Pursuant to the Bond Resolution, 7-97/98, the Village is obligated to establish and
mainEain 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: �
� Princinal Interest P�ments
Year er�ding September 30:
2004 $ 160,000 $ 363,325 $ 523,325
2005 165,000 356,255 521,255
2006 , 170,OQ0 348,885 518,885 .
2007 18Q, 000 341, l 85 , 52 ],185
r 2008 1$5,000 333,OI5 ' S18,015
2009-2013 1,075,000 1,548,050 2,623,050
2014-2018 I,380,000 1,251,975 2,631,975
2019-2023 1,765,000 862,744 2,627,744
� 2024-20�8 2,265,000 359,775 2,624,775
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
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� Note Payable
' On Aprit 9, 1999, the Village entered into a note payable agreement to �nance the cost of a new
! u[ility billing system. The Villa�e financed $108,000 over a term of 48 months at an in[erest
� rate of 4.75%. As of September 30, 2003, the Rrincipal balance of the note was $13,827.
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___ _ l�i �r�, r�4 . ln: 54 /759775 HAYES SCHLO� � ALCOCE Pl�GE 02
HAY�S, S�HLOSS � .ALCOCER, P.A. �G��Q�-t�- �
ATTORN�YS AT LAW `
4365 NORTHLAKE �OULEVARD
PALM BEACM GARDENS, F� 334'10-6253
_ �`� _'� fi. AD_cR
� ^.=�_�_ v., ��COCER TELERHONE
�'��� :. HAYES �
(S61) 775-17�0
JANE E. McGII,L
FAX: (561) 775-9775
GA??v M. SCHL055
y::CH�L£ L. wILL'
'ALSD ADMITT&D TO PRACTICE �N WISCONSIN
August 18, 200�
*V�A FACSIMI.LE*
�.jodi Forsythe
;�ccount�ng Village of Tequesta
2�0 Teques�a Dx�ive, �304
Tequesta, FL 33469
Fte: Raymond Sma�l-v. villag� of T�questa
SS# : 261--49-4595 '
D/A: 7/28/95
Dear M�. Forsythe:
En.closed plea5e find the Se�tlement A�reemen.� �nd Rel�ase Qf
Claima/Vr�lu�.tary Reaigna��.on with regard to the above-
re��renced workera� compen�ation case.
As the Judge of Compensation Claims has apprQV�d the Motion
for App�oval of Attorney's Feea and Allocation �f Child
Suppor� Arrearagea for Settlements under F.S.�40.20
(11) (c) (d} (e) on August �2, 2U04 (this Order ha� b�en date
stamped as oppdsed t� the Judge manualXy signin.g the Oxder),
this matter is considered aettled. We axe mailx�g �he
original S�ttY�ment Agreemen� and Releaee af C�aima �o you
under aeparat� cover.
It was a pleaeure assieting you in the handling of thYS ca�e,
Zf you have any questions ar concerns acegarding the above,
pleas� do nat hesitate to eontact me.
Si ce e ,
,�_ ,� � �� `�- � �CC
. �� � -
Far the F�rm
G�lS:az
cc� Dani�l J. Gallagher, Village of TequE5�3
O/1G/LGG4 in:�4 i�Sy�Ib HAYES SCHLOSS ALCOCE PAGE 03
.. � -�� �- � _ . . �
, A . •
STATL� QF FLORYnA �
� D�VZSION OF ADMYN�S'I'RA�IV� HEAR�NGS
oFFICE OF TIiE JUDGE3 O'�' COMPEI�TSATION CLAIM�
OJCC�: 95-01386SWP8 D/A: 7/28/9b �
�T : HASQUII+L V'ENCTE : PALM BFACT� COU�T'I'Y
EM7�'LOY',EE/GLAIMAN'r: RE�'RESENTED F�Y: ' .
it�ymond Small Daniel S. Vecchior��, E�q. �
� Post Office Box 1401 7.620 N. Dix�� H�.ghway �
�..Jupit�r, F7.orida 334�8 West Palm Beach, Flora.iia 33407
EMPI,OYER/SERV�CIN� AGENT: REPRE5ENT�D BY: . �
village of Tequ�sta Gary M. SChlo�s, �sq.
250 Tec�uesta Dxive�,� #304 Hayes, �Schloss & Alcdcer, P.A.
Tequesta, FL 33�69 4365 Northlake Boulevard
Palm BEach. Garden.e, FL 33�k10
SETTLFyMEN'r AGREEMENT & RELTP,SE PURS'UAN'� �O
F.S.4�0.20 (1.�) (G) .2003 '
The parties tv �his Release, to wit: Raymond Sma11 (Date of
�irth 1/22/58�(here�nafter col.lec�ive�y referred to as the �_
"Releasor" � and the vil].age of Ter�uesta (h�rein�ftex r��erred to
as the "Releaaee�� ) h�reby agr�� as fc�llows :
wHEREAS, R�leasor was an employee of �h� Vill.age of
Tequesta on Ju�.� 28 , ].995 .
WF�EkEAS, Releasor volt.�ntarily resigned theix employment
with the Village of Tequ�sta previoua ta entiering int4 ehis
set�l�ment agr�eme�t.
wHEREAS, Releasox austaix�ed an injury ari5ing out of his.
emp�oyment with the Village af Tequesta and has filed a workers'
compensa�ion claim ox is atherwise claim�ng workers`
.� � � -�-��--
Ynita.al
n�/1�/1bb4 7759775 HAYES SCHLOSS ALCOCE PAGE 04
compenaat�on ben�fx�s against Releasee as the �esult of �.wozk
. re��ted accide�t whxch occurr�d on Ju�y 28� 1995 and said c�a�m
i � ������ �o �he provisions af Chapter 440, �lorida Statute�;
or otherwis� a�leged �o be covered b� �haptier �40, Florida
S�atutes.. .
WxEREAS, Releasee has paid ben�tits to .Releasor pursuant �o_
Chapter 440. �
wHER�AS, the part�ea wish to compxom�se. and se�tle ��1
claims ReleasoZ may have aga�nst t�� Releasee aa a reault of or
arising out vf an� work related accid�nt including tho�e
referenced herein. �
NOW, THER�FORE, th� partie� agree as follows:�
l. Releasor, �oz arid ori behalf of each �nd al� of their
�
respective present, former, and fu�ure successors, , heirs,
executor�, �administrato�s, guarantoxs, attorneys,
xepresen�atives, insurers and assigns (all of whom are also
hexeinafter collective�y referred to as the "Relea�or"), for and �
in consi.deration of the lum� sum of oNE HUNDRED FIVE THOUSA�m
DoLLARS ($�05,000.00) ("the Lump �um") �and other gaod and
valuable consic�eration, ta be paid to Rel�asor does hereby
release, acquit, and fvrevex discharge Re7�easee, az�d if Re3.easee
is a corporation, all of it� respective present, �ormer and
future ofticers, directo�s, stockholders, trustees, nominees,
atCOx'neY'9, agents, employees, coneultants, insurers, brokers,
P � = � .�
Initial
"'�/"�/1bb4 1�►:54 7759775 HAYES SC :LOSS ALCOCE PAGE 05
, °
� index's ,
heixs �xecutors, admin�strator�, personal.
� predecesso��, successors,
� x-epresentatives, managera,
xs�re�enta�ives a�d aseigns (all. of wham are a�so hereinafter
co1.�,ectively �ef��red ta a� the "Rel�asee (�) ") of and f�om any .
�nd a11. cla�ms, demand�, a�tion�� �uita, causes of action,
con��oversies, coat�, �xp�nses, damagea, judgm�nts, lasses and
liabiliti�s of urhat�v�� k�nd or na�u�e, i.n law, ec�uity,
statutoxy or othe�wise, whether known or unknown, wh�ch agair��t
them, or ar�y of them, Releasox' n.vw has, had, may have had, ox
can. shall ox may have �or ax by reasQn of any mat�er, c�uae or
thing wha�soever to and incXuding �he da�e hereof, which were ar
might have ox� could have been ass�rted in. connection with,
arzsing out of, or in any way relating to an�r in�uries resulting
f
fxom or Gl�imed to be the resul� of �ny wark-rel�ted accident
including thvse referred h�rein, including but wa.thout �n any .
respect lzmiting the generality of the fQregoing, any and all
c�.aims �oz or rights to pas�, pre�ent and future benefits un.de�
Chap�ex 4�0, Florida Starutes includ�ng any claims for
a�torney's �c�es and attorney fee liens.
Th� settlement �mount referred to herein shall be a7�locat�d
as fol�ows:
a) Past &�'uture Compensa�ion B�nefits $ 60,000.00
b) Future Medical B�:nefa.�e of the
type typica].Iy covered by Medica�� $ 10,000.00
c) F'utuze Medica]. Bez�efits of the .
type NOT tYpicaiiy covered by Medicare $ 35,000.00
TO�'AL: $ 105,000.00
� � �
Initial
�8;''Q/20a4 10:54 �759775 HAYES SCHLOSS ALCOCE PAGE 06
_4._.. .- , -•- .
2. It is the intent of the undexsign�d Releasor tha� th�s is
� a complete, fu11, compxehensive and final xetiease of any a�d alL
i�abil��y of the part�e� xeleased herain arising from or
re?a�ing to any and al� injuries arising out o� any work related
.accident including the ac�ident rsfexe�ced herei�, inc�uding any
� and all liabil��y of Re�easee for a�y act performed or omitted
by, ar an behal�� o� the paxties rel�ased herein pria� �o �h�
dat� hereof zel.ating �o any and all in�uxie� arising out of any
work related accident including �he accident ref�renccd herein.
'rhe RE].ea5ox agrees that this settlement sha�l consti�ute an
election of �emedi�s by th� Rele�sor wi�h �re�pect to th�
R�leasee l�erea.z�z. .
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3. On aCCOUn.t of the acciden� of Jul.y 28, 1995, the
� Releasee may have a�ause af action ag�inst a thixd par�y
tortfeagor (s) . Th,e Releasor is aware of �he Employ'Er/Se�v�.cing
Ag�nt'e li�n rights in any recavexy again�� a�y third party
tortEeasor(s) for worltera' compensation b�nef�.ts paid as
autho�ized under Flo�ida Statute �40.39. The Re�easor
�wnderetande that the Emplayer/Serva.cing Agent retain,� its liex�
rights in any �uch recovez�y notwith�tanding �h.e setrlem�nt and
thi� Release. The Rel.easor shall protect the Employer/servicing
Agen�'s lien rights and natify the �mp].oyer/Servicing Agent a�n
� J .��
Initia�.
uo/io/���4 1� :�4 �i5y��5 HAYES SCHLOSS ALCOCE PAGE 07
... ._ ;
writing af any recovexy �rom,� or �he fi].i.ng af a complaint
aga�nst, any alleged thi.rd pa��y tortfeasor(s).
� Q. The und�r�igned Releasor Yzereby ex�reasly wax
�epxesents and covenan�s ta �he parties released herein tha�
Releasor is pr�s�ntly the legal owner ara,d hold�r o� the claims
or caus�s of action zeleased hereby, and that it has not�
hexetoforE expressly or impliedly ass�gned, tran�fe�xed, pl.edged
. oz vth�rwise dispo�Ed c�f any such r�.ght�, cYaims, d�mands, ox .
causes of action being described her�in and re�,eased hereby.
� 5. The Releasor h�s been rEpxesentied by Daniel S. .
Vec�hione, E�q., �n connecta.vn with this matt�r who is Entitled
� to a fee td be pai.d by the R��easor for lega]. a�rv�.ces zend�r�d.
The Releasor sha11 pay $1�.,Z50.00 an.d R�l�asor'� attorney ag��es
�
that said fee is a reason.able fee for such ,��rvices, xesolves
��.1 cla�ms tor at�oxney' s fees tl�.at Rel�a�or' s at�orr�ey may have �
ag�in�t tihe Releasee(s), and �.� within th� guidE7:ines for the
c�etermination, ofi a reasonable �ee as set forth in Florida
Statute 4�0 . 34 (1.) . In additian thexeto, the Re�.�asor ghall also
r�imburse the attorne�' $3,750.�0 for costs. The Rel.easor has
also been represented by Lewex� R.eich & Mancina� in connection
with tihis matiter who ha� filed a Iien for a�torn�y's fees.
Subject to �he approva3. of the Judge, the Releasar i� '�o pay
L�wen Reich & Mancini $2,000.00 in eatisfactian, o� all
attorney�s fees and costa �hat are being claimed by the law firm
� �� .
rni��.al
_�S/28/2064 16:54 7759775 S SCHLOSS ALCOCE PAGE 08
of �ewen Reich & Mancini. The �eleasor and/or his attor�ey a��
ai�o xe�P��sibla �ar any fees and costs payab7.e to Roser�zanz &
Gilhoal fax any a11 servzce� zendered i.n th�s ma�.tez i.�acluding
but not limited to tih� MedicazE set aside,
Notwi�hstandin,g the p�ovisians o� Florida StaCute 440.�4,
the Re1e�.sor and not the Re].easee (s) is/are responsible ���' ��e
pa�men� of Relea�or' own attorn.ey's fees,� and all c�aims for
attorney's fe�s and costs to any paz�t are hereb�r satis�xed an.c�
�relea8ed. Re].easor aleo agrees that there are no orher claa.ms
ar l.i�n� foz �ees filed by any other at�4rney, and if a claim or
1�,en i.s or has been made, the Rel.easor agree� to resolve said
cla�.m ax li�n, and the R.�l�asor agrees. to hvld the Relea��ee
harm�.ess it a claim for fees a�isee. Th�. Re1Ea�or and their �
. attQrne� agree �that this settlemer�t agreemen� and rel.ease
discharges the Releasee ��'om any liabili�y for �ees for �ervices
rendered on their b�half. The fees and co�Gs sha]:1 b� paid from
th� s���lement proceede thereby making the net settlement amovn�
$88,000.00. The Releasor unders�ands �hat th�.s doES not
include any and all sums which are payable to tk�e Cl�rk of Cour�
Support Department. f�r outstanda.ng child support arrea�ages
pur�uan� to section six of this release,
6. In reaching thi� agr�emen� the paxtie� have, pursuant to
Sect�.on �440.,20 (1.1) (d) Florida Statu�es, a� amended 2D01,
� � �
Initial
'��;18(2004 10:54_ 7759775 HAYES SCHLOSS ALCOCE PAGE 09
. _ _ ___. ._.___ -.. . .
� � con�idered the issue�o��Ghild �upport arrearages. The Releasar
� warr�.nts a� follows (mark �� appropxiate): .
a.There ar� no arrea�agee owed by Releasor tor chi.ld
� suppoz't : �
b.�'here are ar�earages owed by Releasor for child
support, in the total amQUnt o� 570,901.63 and �
$3,790.39. .
St r,utstanding child su�porti zs ehowr� above, �he Relea�or� has
a7.locat�d $25, 922 : 1.2 and $3, 790 . 39 of th� lump sum ta be paid by
Releasor towards the payment of such arrearages. Counsel for
Releaaor ehal.l be respons�b7.e for �nsuring such child �upport :
a1l.ocation is paid to the prop�r agency toward Releasor'�
arrearage. �
. i
7. Releasa� and R.eleas�e(e} acknowledge(s) that where�s
SBCtIOn 4�0 .20 (11). (d) , as am�n,ded 2001, also r�quires �.hat the
sudge of Compensata.on C�aims conside�° whetk�er the se�tlement .
all.oca�ion p�ovide� for tJrie approp�iat� reco�tery af child suppvr� .
axreazages. zt i� the intent of the parti�s that this Settlemen�
agreemen� anrl release ahall no� b� vala�d and �n�orceab�.e and that
Rel..easee shall x�ot be required to da.�burse s���lement p�oceeds
untiJ. tihe settJ.ement agreement and releaas i� executed by
1�eleasee and Rel.easc�r, and a�.1 Court approva7.s as to at��orney' s
�ee� �nd Ghild support allocations are obtained. Therefore,
?teleaeor and Re�.easee agree tha� tk�e statutory 14 da� peri.od wiJ.l
�� � �
Initial
aS/18/2004 10:54 _ 7759775 HAYES SCHLOSS ALCOCE PAGE 10
beg�n to run from the date of the mailing vf the Co�rt Order
approving th� fee and a�location fo� th� recov�ry of chi��d
suppoxt arxearages, ar receipt by Releasee(s7 0� a signed
Set�lem�nt Agreement, whichever occux �ast. However, �he parties
agree �hat earlier paym�nt shall BatisfX the applic�ble s�atu�ory
period and the Releasor's attorney ag��e� to hold the �ettlement
proceeds in escxow until al� co�diti�na are me�, in�luding the
satisfaction of all lie�a £or attorney fee�. It �heae cnnditions
ar� not met, �eleasnr'a attorney aha�l no� disburse any tunds,
but wi�l immedia�elX return to Releasee(s) those funds being held
z� e9crow. .
8. The Releasor rep�esents that no services, medicines,
medical appliances, o� x-ray� of �ny kind wex� zeceived by the
�
Releasox from any Veterans Hospital, Naval or military hospital,
pr any ��her medical institution maintairzed by the uni�ed States
Government, as a reault of the acc�.de�� and �njuries described
herein. The R�leasor �u�ther represents that no medica]. }�ille
or �ervices have been paid to Releasor or on Releasor's behalf
by Medicaid ox� Medicar� as a r�auZt of ax�x injuries ariszng out
of and during the course and sco�e of Releasor' c�mp7.oyment wi�k�
thE Re�easee herei.n. If ReleasQr has rece�ved any benefits as a
re�ult of �heir woxk related injuries from any state of Federal
Znsurance or benefi�s pxo�ram, such as Medica�.d or MediCax'e �he
- � � � ��.
Ir�iti.al
^ o�1ta�1be4 F 10:54 __ 7759775 HAYES SCHLOSS ALCOCE PAGE 11
Re�ea�o� unde�stands that it �a �he�r responsibiXity to
� x�imburse �hem �or any paym�n� th�Y may have made.
. g. The Releasor �as considered �ha� many commQn med�ca� .
expenses are not paid or r�imbursable undex certain group health
poliC�es�of the F�deral Medica�e Program. The Releasor a1�o .
� understands that he is, oz may in the future be entitled td
' Medi�are benefits. �he Releaso� unde�stands that z� �s not �he �
intent af this se�tlement to shi£t the xesponsibility for the
Re�eaSOr' fuCUre medical care to the Federal Gavernmen� and the- �
Re�easor agr�es that �h� �um of $10,000_0o from the lump-sum
�e�t�ement shall ba alloca�ed for paym�nt of .�hose medical costa
which are cavered under Medicare which ar� relat�d to �he
industr�al injuries. This allocation is ba�e� on th� workers'
� � r
cornpensation f�e �chedul�. The Re�easo� und�rstands that.all
payment� ta providers are ta be adjusted accordingly, and any
� monie� paid in excess of the fe� schedule will not caun� towards
the a�loCation. Th� $��,000_�0 allacation �e to be for the ne�t
30_ y�ars into �the futu�e, re�resenting �he Relea�or'e l�fe
expectancy giv�n R�leasar's actual age o� 46 y�ars (�oB:.
1/22/58). T�e Releasor unde�stands that betore any bi11s can be
eubmitted to Medicare fox payment that �hi� amount must be spent
on �xpenses covered by Medicare and related to the induatrial
injury and tha� �he Releasor mu�t keep �ecord af these expenses
that have bee� paid. The Releasor understands that the �ederal
. �� `�---�_
Yn�.tlal
e�/18/2004 10:54 __7759775 HAYES SCHLOSS ALCOCE PAGE 12
' ' .
Gowernment has the autho�itY to change thi� a1loCation and make
�he Releasor sp�nd more of this S�tt�eme�t on Medi�are expenses
re�ated �o his work^xela�ed injuries. The Rel�aso� undeXStands
� �nd acknowledges thE tr�edorn and abili�y ta cansu�� with
spec�alists practicing zn �he area �o� Sdcial Security a�d
� Medica�� 1aw and has chosen �o se�Gle �he case e�ther �n �ieu ��
or a�tex such consultation.
The M�di�ar� Set Aside �unds in �h�s case are to be self
administered by �he Releaga�. � T�e Releasor has been pro�aded .
with dixeCtives issued by CMS regazding his righ�� �nd
respons�bilities in this xegard. Th� Rel�a�or undezstande.�hat
un�i1 he becomes enti�led to Medicaxe, the MSA funds mus� not be
used to pay the Re�easor's expenses. The Re�ea�or fu�ther
r
unders�ands tha� �he MSA funds mu9t be p�aGed in an interes�
bearing account, and �his accau�t muQt be $eparate �xom the
ReXeasor�s p�rsonal saving� and checking accoun�s. The funds in
� thia accou�t may only be uaed for payment ot m�dical services
rela�ed to �he work �n7ury that would normally be paid by
Med�care. Medicare will not pay injury=relat�d �laims un�il
these furxds are resto�ed to the MSA`s accoun�, and then praperly
exhaus�ed. The Releasor furth�r understands �hat annual
reporting mus� be prepared �or submiasion tio Med�ca�e to include
summaries o� the trana�ct�ons and etatus of �he �ccount. These
summarie� are to include the da�e of each �ez procedure
�� �
Initlal
' y"1�/2?�4 10_54 _7759775 HAYES SCHLOSS ALC�)CE PAGE 13
, -
� perfa�med,� diagnosis and paid xecei.pt or �ancel�ed check:
� Clai.m�nt will be reeponsib�.e toz kee�z�-9 xecords of �aymen,�s �
made from Medicare s�t aside account and �providing annua� .
ac�ountir�,g summari�s of funds transa��iox�� along with the 5t.�tU3
of �the account to the following Medicare contrac�or: �
�First Coast Service Option�, rnc. .
Attn: MSF Manager
� �.0. Hox 44179
�7'acksonvill�, FL 3223].-�179 .
1o. By x�eceipt o� �he cor�sidera�.ioz�. set forth abave� �he .
� Releasor agreea that the �exms o� tha.s settle�ent, including btiC
nat li.mi�ed to the atnount af consideration pa%d her�in, will n.ot
��be discussed either directily o� i�.directly with any past or
pxesent employees of the EmpZoyer or any otY�er pe��ons. The
Releasar speaiEically ac�reee to ke�p the terms of this �.
sett�.ement strictly con�idential. The Releasor acknowledges
that any direc�G or indi.rect comm,�ni�ata�on of �this type ori th�
Rel�a�or's behal.f rnaX r�eul� in a �orfeitur� Qf the
consicieration paid �ursuant to �his Release. .
11. The parties agree that this Settlement Agreem�nt is
valid and �nfox�ceable. I� tihia Settlement Agreement and Release
� is ev�r fo�.nd to be unen.fo�ceable f or whatever reason,. the
Re7.�asor �grees that any payment made by the ReTeasee shall not
be con.sidered a gratuity.and tha� the Releasee �hall be entitled
to fu11 reimbursemen.t of th� lump sum paid �o �he Releasor and
� � �^
Initial
_ �o/to/Lnb4 ln:5q 7759775 HAYES SCHLOSS ��"�OCE PAGE 14
�
to �he e�tent fu7,l reimbursement iB not mad�, Releasee is
• ez�titled ��o a, cred�.� for any money paid to tihe Releasor a.n �
. conx�c�ction wi�h �he �ettlemant against benefits owed or taund �o
� be due, pa�t or future w�thout l�.mitation on �he type o� benefit
to wh�.ch th�.s o��a�t would app].yr nor as to the amount o� offset �
to be taken as to any benefits. The Releasee shall ha�re a.
c�ollar for doll.ar � of�set for the rrtoney� paid unde� this. �
� � Set��.ement Ag�e�ment�. � The Releasee agrees to pay far authoz�i.zed
� med�ca7. care for sex rendered up urztil the date . of
exec�xtion. of �h�s ag�'�ernen�. �
z2. Relea�or agxees that upon �aymen� of the cvn�ideration
referred �.o hexei�„ all claims, petiitiox�s� fox workers'
compensation bene�its� actions foz' pErsonal �njuriee ax'is�.ng out �
�
of the accid�nts re�e�enced here�n, and �ny and all Clairns ox
lawsui�s agains� �he ReleaBee �xe vo7.untarily dism,issed with.
prejud�ce and Rel.�asor sha11 fi].e vo�.ta.ntaxy dismissals in all
Couxts where claims. c�� act�.ons are pez�ding.
13. Releasor agrees that he shall not seek further emp�oyment
with Re�easee.
14. This a.gre�ment is not binding o� enforceable by parti.es
until approved by the Centers for Medicare and Medicaid S�rvice�
(CMS? . Upon' approv�l b� the CMS, thia agreem�nt will be de�m�d
rat�fied and w�ll become binding ar�d entorceable.
� �
`J �-�-�-- �
Initial
�_i�_=i�nn4 _in_b4� 7759775 HAYES SCHLOSS A�COCE PAGE 15
�5, �y signing this Settlement Agreement, R�leasor ac�nowledges�that
he has xea� the ��g�eement, has had xts terms ful�y explaXnefl to him by
his attorney, ha� been tully i�fo�med �nd undexstands: �
a, �he seCt�ement's e£fect on any rXghts the Releasor may have; _
b. his right� regaxding �he claim(s) sett�ed;
c. he �s giving up these ri�hts; .
and xs ent�ring inta this Sett�ement Agreement volunGari�y, and
withou� . any undu� influence, pressurE or coercion whatsoever.
rurther�.by signXng this settlement agreement, Releasor's attorney
agrees that he� has explained the settlemenr a�reement and that ,
�eYeasor does understand his rights and the effea� of thzs sett�emen�
on those r�ghts.
/... �� .
� ��Qo
Ra nd SmalJ. Date � � �
� C1a3mant/Releasor �
BEFORE ME, the undersign�d autharity, � persona].7.y appeared,
�
Ra�rmond Small who, after being duly cautioned and swox'n, depose (s) and .
� says he has read Che above Release and tha� he has se� his hand(s) and
seaJ.(s) there�o for the purposes therein expxessed.
' ��
foregoing instrum�nt was aCknowledged before me this � day
of i9L. , 2004 by Ra Qnd Small who is �ersanal.l ��� tio me
� pr produces identification # �W'�-��' �L�"� � �,J
CINTN�YA L KAy�NNIKOFf ,,,�,`,,
� � � �( CQMMlSSION � Od �3218 , w'
,�`' �XPIRES: f-eb+ua�Y ig. 20W
�� �,t�`�'r�n� �, '
. ��,,,..
�ly Commissior� Expires :
' zint Name of Nota
� �
;
Dana.el S. Vecchione, Esq. Date ,
Re].easor's Attorrtey '
Initial
"='•129a4 �10:54 7759775 HAYES SCHLOSS ALCOCE PAGE 16
� RELEASE Ok' CLA�MS, VOLUN'�AR.Y R�s2GNATION ANp
AGREEM�N'P N�T TO SEEK RE-EMpLOXNiENT
�10W ALL MEN BY THESE PRESENTS, that r; Raymdnd Sma1J., �n
consideration af the sum of T�n ($10.00) Dollars and othe� good and
valuablE consi.deratiox do hereby remisE, xelease, and farevex
dischaxge �he Village o� Tequesta an.d/or any of the of��.cers,
' a.g�1�.t5� servan'�s, employe��, directo�s, suCCessors, assign.s and any
� other person or entity so connec�ed to the Village o� Tequesta, of
and from any and al� mann�r af actions, caus�s o.� actioxi, auits,
proceedings, debts, du��, contract�, judgments, damag�s, clazrns and
cemand� what�oever in 1aw or in equity, i.ncluding, but not limi�ed
+�o, claims� made pursuan� to �42 TJ ��127.01 ("Americans wi�k�
aisabili�ties Ac� of 1990"), claims of discrimination under any
f�deraJ. or state law, claim� of wron,gful terminatian o� employmen�,
which I, Raymond Smal�, ever had, z�aw have, ox w�ich my� personaJ�
repxesentati�rea, hei.re or aesigns hereira.af��r Can,, �hal1, or . may '
have against the Village o� Teque�ta and/ox az�.y a� the officers,
. a�ente, servants, emploXees, directors, successars, assigns and any
other person ox entity so connected �o the Village of Tequ�s�a for
or xeason o� any matte�, cause ar �ha.ng whatsoezrer, frorn the
begir�ning of the world through eh� date c�f �hese presenta. Any
ves�ed benefits I ma� havE thzough th� emplayer wi1� .no�e be
a�f ec�ed .
FURTHERMOR�, �, Raymand Smal7�, do h�reb�r voluntarily texminate
my� emp�,oym�nt xe].atiorz�hip with the village of Tequesta eftec�ive
th� last day I worked at the Vi11ag� of Tequesta.
FURTHERMOR�, �, Raymond Small, shall hereinaf�er ncither seek
re-employment nor hold employmer�.t with the Village of Tequesta, Y� T
should hexeinafter become employed by the Vzllage of Tequesta, then
Page 1 of 3
8/18/2004 10:54__ 7759775 HAYES SCHLOSS ALCOCE PA6E 17
r shal� tender a wxitten vo�untary re�ignation of sa�d employme��
within three (3) days upon rece�pt o� written reques� f rom the
� Vil�age af Tequesta. XN WYTNESS W��R�OF I have h�xeunto set rny
day o� , 2004.
ha�d and seal �h�� �, � .
�� �
� � gaymond Small
Sta�e o� F�.orida �
County of Palm BeaCh ) � �
B�for� me the undersa.gned �authori�.y authoriaed to �dminister
oa�hs and �ake acknowledgments personally appeared Raymon.d 5malx who
is personally known �o me or wa� identified by drive��'s licen�e or
_�_--..-
other idEra.tificatioz� [indicate metHod of id�n�if�cation:
� ] ox� this day o�� , 2004. �
who upon being duly sworn, �ertifie� and affirms �hati:
1.. He has read the £oregQir�g RELEASE OF C�AIMS, VOLUNTAR.Y
RESIGNATION AND AGREEMENT NOT T� SE�K RE-EMPLOYMENT and�
that all. information contain�d therein is true and
corre�t;
2. H� agre�s the REL�ASE OF CL�AIMS, VOLUNTARY RESIGNATION AND
AGREEMEN'I' NOT �O SEEK RE�EMP�OYMENT was writt�n in
u�d�rstandable langu.a�e;
3. �Te under�tanda tha� the RE�EI�SE OF CLA�MS, VOLUNTARY
12ESIGNATION A�TD AGREEMENT NOT TO S�EK RE-EMPLOYMENT
in�ludes a re].eaBe of any and all claa.ms based on . the
,Am�r�eans w�.th Disabilities Act of 1990 agaiz7s� th�
Vi�lage of T�queeta.
� page 2 of 3
_a8/18/2604 10:54 _ 7759775 HAYES SCHLOSS ALCOCE PAGE 18
,.. • . .
4�, ge agre�s thaG a xeasonalaZ� pexiod ��f .tim� was pxovided
. �or h�.m � to de�,i.ber�te o�' consider �he REL�ASE OF GLA.YMS,
� ZIOLUNTARX RESIGNA.TION 1�TD AGR�EI`'�EN'r NQT '�O SE�K RE-
. . . EMPLQYMEN'T ;
S. He agrees that he was encaurag�d to consult with an
attori'�ey r�gardi.ng the REL�ASE O� CLAIMS, VOLLTNTARY I
RESIGNATION AND AGREEMEN'T NOT TO SEEK RE-EMPL03�MENT; and ,
6. H� agrees �ha�. he� received consideratiQn for the R�LEASE
OF CLAIMS, VOLUNTARY RESTGNATXON AND �GREEMENT NOT Td S�EK
� � RE-EMPLOYMENT to wh��h he was not otk�erwi,�e entitled.
" �.
� R�ymand Small
,� , , ,'�����Clt�ifHYA� K � DNt ��
,.- �'`' r �''�.,",� - MY GOMMISSIQN # D��'�
, � �,,, "; EXPIRES; February 1�, 2006
��, , ; ` s �� ' "'ti°�°ryP+� � _
NOTAR � C �
STATE O k'�ORYDA
( S EAL f
. ! .
. ,
. MY COMMISS�ON EX�rREB:
page 3 oP 3
�3/18/2004 10:54_ 7759775 HAYES SCNLOSS ALCOCE PAGE 19
• .
5'T.AT� OF FLORID,A. ���a�r���
DIVZS�ON Ok' ADMINTSTRATIV� H�ARrNGS
OFFZCE OF TFi� JUDGES OF COMP�NSA'TI(7N CLAZMSA�� � 3 Z��G �
OJGC# : 9 5- 013 8 6 5WPB p/A : 7/ 2 8/ 9 5 HAYES SChLOSS & SLCOCF �1 , P:A,
JUDGE :'�� VENU'� : PAT,M BEACI� COT.TNTX
EMPLOYEE/CTlA�MANT: REF�S�NTEA HY:. � �
Raymond Sma7.l � Daniel S. V�cchiane, Esq.
Post O�fice Box Z�k01 1620 N. Da.xie IIighway
Jupiter, �'lorida �33�68 West Pa].m Beach, FJ.Qra.da 33407 .
�MPLOXER/SERVTCING AGENT: R�QRESENTED BY:
Villag� of Tec.jues�a Gary M. SchZos�, Esq.
250 Teques�a Dxive, #30� Hayes, Schloes & Alcocex, P.A.
Tequesta, FL 33469 4365 Northl�.ke Bou�-e'vard �
Palm Beach Garclen,�, F�. 33�10
bRUER TJNDER SEGTZON 440 .20 (1�,) (e? , (d) , (e? , �
FLORZDA STATU'��S ( 2 4 0�, )
Pursuant ta Secti.on 440.20 (].7.) (c) , (d) , & (e} , Florida
� Statla,�es (200�? , th� parties have reach.ed a set�lement
.�
agreement. Af�er reviewir�g th� a�tached documentation, thE
uz�dersigned Judge tinds that:
1. The amount o;E attarney's fees a� eviden.ced in the
at�ached At�orx�ey� Fee Data Sheet and eupporeing documentatioan
m�ete �he requir�me�z�a of th� Workers' Compensation Law.
2. The ae��lemen� allocation providee �or the appropria�e
recovery of cha.ld support axrearages, if any exis�, as eviden.ced
by th� suppdr�i�.g documen�ation.
3. The attarn�y�� fees shal�. no� be subject to
modifzcation.
07CC# 95 -OZ3685�VPB
Pleeding# Order on Motion for Approval of Attorney's Fecs & Child Support Allocation
Page #1 of #2
_ _ 10_54_ _7759775 HAYES SCHLOSS ALCOCE PAGE 20
� It is ORDERED and ADJUDGED tha� the �ttarn�y's fee and
� , c�i�d support ar�earage allocation, it any, paid under �he
•� settlement agzeement is approved,
DONE and oRDExED,at West Pa1m �each, Palm Beach County,
Flor�da. �
Judg� of Compensation Claims �
Th�$ is to ce�tify that the above Order was en�ered by the
�udge of Comp�nsation Cla�ms and a copy was served by II. S. mail
on each party and counsel at the addresse� 1�.s�ed �bove on this
day of _ , 2004.
Assietant �o the �`udge o�
Com�ensation Cl.aims �
� � � GbhY : . ..
� � Q�i
-------�---- � � � NNC1 M�11��D
�'<« Z 2 2a�4
� u � � . JUf]IC1AL A�IBTAN7
. �� �
' (���� � ,IUDG� OD AAPFM&A CVtlh!$ .
OJCC# 95-013685VV�'B -- _- _— - _____
Pleading# ordcx on Mobon for A,pprovai of Attamey's �'ees & Cbild Sapport A.11ocadon
Page #2 of #2