Preview
Filing # 124231479 E-Filed 04/02/2021 10:19:39 AM
9935734 IN THE SMALL CLAIMS COURT OF THE NINTH
JUDICIAL CIRCUIT IN AND FOR ORANGE
COUNTY, FLORIDA
WATT FAMILY CHIROPRACTIC, LLC a/a/o CASE NO.:
NIKOLAS HAWLEY,
DIV. NO.:
Plaintiff,
vs.
SAFECO INSURANCE COMPANY OF ILLINOIS,
Defendant.
___________________________________/
COMPLAINT
WATT FAMILY CHIROPRACTIC, LLC, (hereinafter "Plaintiff"), as assignee of Nickolas
Hawley, (hereinafter "Insured"), sues the Defendant, SAFECO INSURANCE COMPANY OF
ILLINOIS, (hereinafter "Defendant"), pursuant to the Ninth Judicial Circuit Court Administrative
Order 2009-12-02 applies and alleges:
1. This is an action for damages in the amount range of $500.01 to $2,500.00 dollars
exclusive of interest, costs, and attorney’s fees.
2. At all times material hereto, Defendant was a corporation duly licensed to transact
insurance in the State of Florida and maintained agents for transaction of its customary business in
Orange County, Florida.
3. On or about August 29, 2019, the Insured was involved in a motor vehicle accident.
The Insured sustained personal injuries in, or as a result of, said accident.
4. As a direct and proximate result of the personal injuries the Insured sustained in
the accident, the Insured incurred reasonable expenses for related and necessary medical and
rehabilitative treatment and therapy, supplies, diagnostic testing, nursing and remedial care
performed or provided by the Plaintiff in the State of Florida.
5. Defendant issued an insurance policy that provided personal injury protection (PIP)
benefits required by law to comply with Section 627.730 - 627.7405, Florida Statutes, and/or
medical payment coverage. A copy of the policy is not available, but it is in the possession of the
Defendant. Plaintiff is not in possession of the policy and Defendant is not prejudiced by the
policy not being attached to this complaint.
6. The above described policy was in full force and effect on the date of the accident
and provided PIP and/or medical payment coverage for the Insured for bodily injuries sustained in
said accident.
7. Pursuant to all or a combination of the following, Plaintiff has standing to pursue
this action directly against the Defendant, and to collect all reasonable attorney's fees pursuant
to Sections 627.733 et seq., 627.736(4)(c), 627.736(8), and 627.428, Florida Statutes:
A. a written assignment of benefits wherein the Insured assigned to Plaintiff the
rights to any potential benefits under the PIP policy of insurance issued by the
Defendant (A copy of said assignment of benefits is contained in Exhibit "A");
B. an equitable or implied assignment (hereinafter "equitable assignment"), that
exists between the patient and Plaintiff wherein the patient assigned the rights to
any potential benefits under the PIP policy of insurance issued by the Defendant;
and/or
C. as the real party in interest as Plaintiff has a sufficient stake in the controversy
addressed in this count, will be effected by the outcome of this matter and is the
actual party that stands to lose or gain.
8. Defendant received notice of the covered losses.
9. Defendant failed to make proper payment of said PIP benefits within thirty (30)
days as required by Section 627.736(4)(b), Florida Statutes.
10. A demand for PIP and/or medical payment benefits was made for all reasonable
charges that were for necessary medical and rehabilitative treatment and therapy, supplies,
diagnostic testing, nursing, and remedial care related to the subject accident. (The medical bills,
charges, and items that are the subject of this claim are attached hereto as Exhibit “A”).
11. The Plaintiff has performed all conditions precedent to entitle Plaintiff to recover PIP
and medical payment benefits for reasonable, related and necessary medical and rehabilitative
treatment and therapy, supplies, diagnostic testing, nursing and remedial treatment regarding the
above-described policy, or those conditions have been waived.
12. Despite the fact that Defendant had no reasonable proof to establish that it was not
responsible for the payment, Defendant has failed to pay Plaintiff for covered losses.
13. Due to Defendant’s failure to pay PIP benefits in accordance with Florida law,
Plaintiff has been required to retain the undersigned law firm for the prosecution of this lawsuit.
The Plaintiff has agreed to pay, and the attorneys have agreed to accept, any Court-awarded
attorneys’ fee.
14. Defendant has failed to pay the applicable statutory interest, postage, penalties,
and the statutory attorney fees required by law.
15. The determination of the reasonableness of charges is subject to Section,
627.736(5), Florida Statutes and Defendant’s policy language. To the extent Defendant has
made a legally sufficient election allowing it limit payment pursuant to the schedule of
maximum charges legally permitted by Section 627.736(5)(a)(1), Florida Statutes (2012)(or
Section 627.736(5)(a)(2), Florida Statutes (2008)), Plaintiff’s claim or claims do not exceed
those legally permitted limits.
16. Plaintiff would derive a direct benefit from the Court ordering the Defendant to pay
benefits, interest, postage, penalty and attorney fees, even ifDefendant pays all or some of the
disputed benefits before judgment is entered.
17. Plaintiff is entitled to an award of reasonable attorneys' fees pursuant to Sections
57.041, 57.104, 627.428 and 627.736(8), Florida Statutes.
18. Plaintiff is entitled to simple interest on the amount of said medical bills or charges
pursuant to Section 627.736(4)(c), Florida Statutes.
WHEREFORE, Plaintiff, WATT FAMILY CHIROPRACTIC, LLC, as assignee of Nickolas
Hawley, demands judgment against Defendant, SAFECO INSURANCE COMPANY OF ILLINOIS, for
damages in the amount range of $500.01 to $2,500.00 dollars exclusive of interest, costs, and
attorney’s fees.
PLAINTIFF HEREBY DEMANDS A JURY TRIAL ON ALL ISSUES SO TRIABLE.
Respectfully submitted this 2nd day of April, 2021.
/s/ ROBERT HOAG
ROBERT HOAG, ESQUIRE
Florida Bar No. 27925
MORGAN & MORGAN, P.A.
20 N. Orange Avenue, 4th Floor
Orlando, FL 32801
(321) 327-6974 – Phone
(321) 327-6958 – Fax
Primary Email: rhoag@forthepeople.com
Secondary Email:
jleverone@forthepeople.com
Attorneys for Plaintiff
###EFMESES###
Exhibit A
July 13, 2020
SENT VIA CERTIFIED MAIL
*9935734*
Safeco Insurance Company of Illinois
Dan Kosten
Corporation Service Company 1201 Hays St
Tallahassee, FL 32301-2699
Written Notice of Intent to Initiate Litigation
This is a demand letter under §627.736(10) as required by Florida Statute (effective date - January
1, 2008) and/or §627.736(11)(prior statute), or under any policy of insurance
RE: [9935734] Watt Family Chiro a/a/o Hawley, Nikolas vs Safeco
Insured: Hawley, Yvonne
Patient: Nickolas Hawley
Claim/Policy#: 0408012560003
Date of Loss: August 29, 2019
Our File#: 9935734
Dear Sir/Madam:
This is a demand letter under section 627.736 (10), Florida Statutes, and under any policy of insurance.
The personal injury protection (PIP) benefits (and medpay benefits if applicable), claimed are for payment
of reasonable charges for related and necessary treatment, services, accommodations or supplies to the
above-referenced patient. The below-identified provider has not been properly paid.
Name of medical provider rendering treatment, services, accommodations or supplies that form the basis
of this claim: Watt Family Chiropractic, LLC.
Specifically, this demand is for payment of the below listed amounts for the listed dates of service at the
reasonable amount billed minus any payments received by Watt Family Chiropractic, LLC from said
PIP insurer. (Please note that if this policy contains medpay coverage, the amount demanded is at 100%
of the reasonable billed amount minus any payments received from said PIP insurer). If the insurer has
information supporting that a lesser amount is owed and/or this demand is not payable due to deductible,
co-payment, exhaustion, Florida Statute §627.736(1)(a), §627.736(2), §627.736(4), §627.736(5),
§627.736(6), §627.736(7), or for any other reason, please provide the appropriate explanation pursuant to
§627.736(4)(b).
20 North Orange Ave, Suite 1600, Orlando, FL 32801 | (407) 420-1414 | ForThePeople.com
Ifthe insurer has made an unambiguous election in its insurance policy pursuant to Fla. Stat. Section
627.736(5)(a)(1)(2012), permitting the insurer to limit payment to 80% of 200% of the allowable amount
under the Medicare Part B Physicians Fee Schedule and/or the 80% of the maximum reimbursable
allowance under workers’ compensation, then the amounts demanded herein are subject to those legally
permitted amounts. The policy of insurance is in the insurer’s possession, and the insured and/or its
assignee is unable to determine the specific amount owed without this documentation.
If the insurer contends that it has made an election to limit payment subject to the schedule of maximum
charges noted above, please recite to us or provide us with the portion of the insurance policy that
provides for limiting payment to the schedule of maximum charges.
Please provide a copy of the PIP payout log and/or copies of all explanation of benefits/reimbursements
that have been made on behalf of the above-referenced patient/claimant.
We dispute the payments made by the insurer and request the insurer to notify us that the policy limits
under this section have been reached within 15 days after the limits have been reached as required by
§627.736(6)(f).
The following is demanded:
1. Amount of $2,091.86 or @ 80% $1,012.86, subject to applicable policy limits, and any
proper election under §627.736(5)(a)(5) to limitpayment to the schedule of maximum
charges legally permitted under §627.736(5)(a)(1)-(4), pending verification of medical
benefits for date(s) of service 09/17/2019 - 03/09/2020 made payable to Watt Family
Chiropractic, LLC and mailed to our office.
2. Interest on the amount due, at the statutory rate, commencing 30 days after the date the
billfor services (CMS 1500) was received by the carrier and up to the date payment
made make payable to Morgan & Morgan P.A.
3. Penalty of 10% of amount due (Maximum penalty $250.00) and certified or registered
mail, return receipt requested, cost made payable to Morgan & Morgan P.A. our tax
identification number is 59-2920684.
4. The demand response must reference file number 9935734
Also, enclosed please find the following:
1. Assignment of Benefits
2. Itemized Statement
Further, in the event the carrier decides to not honor this claim and/or demand, we hereby request or
demand the carrier reserve or escrow sufficient benefits to satisfy this outstanding claim prior to any
exhaustion of benefits, pending resolution of any action reasonably filed after this letter. We seek to
preserve and pursue all rights as provided by law and to minimize or avoid litigation ifpossible.
Additionally, we request any reply further denying or not satisfying this claim/demand to outline the exact
reasons why the carrier denies this claim/demand for denied or overdue benefits and other damages.
Failure to fully and completely comply with this demand letter within 30 days will result in suit being filed
for all amounts legally due, including applicable costs and attorney’s fees.
Govern yourselves accordingly.
Sincerely,
Robert Hoag, Esquire
RDH/db
Enclosure(s)
9935734 - HAWLEY, Nikolas
DATE CPT TTL BILLED
AMNT
9/17/19 99204 $190.00
9/17/19 72050 $100.00
9/17/19 72020 $35.00
9/17/19 72100 $70.00
9/17/19 99070 $15.00
9/17/19 99070 $5.00
9/19/19 97535 $30.00
9/19/19 98941 $80.00
9/19/19 97012 $30.00
9/19/19 98943 $30.00
9/24/19 98941 $80.00
9/24/19 97012 $30.00
9/24/19 98943 $30.00
9/25/19 98941 $80.00
9/25/19 97012 $30.00
9/25/19 98943 $30.00
9/27/19 98941 $80.00
9/27/19 97012 $30.00
9/27/19 98943 $30.00
9/27/19 97140 $180.00
9/30/19 98941 $80.00
9/30/19 97012 $30.00
9/30/19 98943 $30.00
10/02/19 98941 $80.00
10/02/19 97012 $30.00
10/02/19 98943 $30.00
10/04/19 98941 $80.00
10/04/19 97012 $30.00
10/04/19 98943 $30.00
10/04/19 97140 $180.00
10/08/19 98941 $80.00
10/08/19 97012 $30.00
10/08/19 98943 $30.00
10/11/19 98941 $80.00
10/11/19 97012 $30.00
10/11/19 98943 $30.00
10/11/19 97140 $180.00
10/16/19 98941 $80.00
10/16/19 97012 $30.00
10/16/19 98943 $30.00
10/18/19 98941 $80.00
10/18/19 97012 $30.00
10/18/19 98943 $30.00
10/18/19 97140 $180.00
10/23/19 98941 $80.00
10/23/19 97012 $30.00
10/23/19 98943 $30.00
10/25/19 98941 $80.00
10/25/19 97012 $30.00
10/25/19 98943 $30.00
Page 1 of 2
9935734 - HAWLEY, Nikolas
10/25/19 97140 $180.00
10/30/19 99214 $190.00
10/30/19 98941 $80.00
10/30/19 97012 $30.00
10/30/19 98943 $30.00
11/01/19 97140 $180.00
11/15/19 97535 $30.00
11/15/19 98941 $80.00
11/15/19 97012 $30.00
11/15/19 98943 $30.00
11/20/19 98941 $80.00
11/20/19 97012 $30.00
11/20/19 98943 $30.00
11/22/19 98941 $80.00
11/22/19 97012 $30.00
11/22/19 98943 $30.00
11/26/19 98941 $80.00
11/26/19 97012 $30.00
11/26/19 98943 $30.00
12/06/19 98941 $80.00
12/06/19 97012 $30.00
12/06/19 98943 $30.00
12/10/19 98941 $80.00
12/10/19 97012 $30.00
12/10/19 98943 $30.00
12/12/19 98941 $80.00
12/12/19 97012 $30.00
12/12/19 98943 $30.00
12/12/19 97140 $180.00
12/18/19 98941 $80.00
12/18/19 97012 $30.00
12/18/19 98943 $30.00
1/2/2020 98941 $80.00
1/2/2020 97012 $30.00
1/2/2020 98943 $30.00
1/6/2020 98941 $80.00
1/6/2020 97012 $30.00
1/6/2020 98943 $30.00
3/9/2020 98941 $80.00
3/9/2020 97012 $30.00
TOTAL $5,395.00
Page 2 of 2
Preview
Filing # 124231479 E-Filed 04/02/2021 10:19:39 AM 9935734 IN THE SMALL CLAIMS COURT OF THE NINTH JUDICIAL CIRCUIT IN AND FOR ORANGE COUNTY, FLORIDA WATT FAMILY CHIROPRACTIC, LLC a/a/o CASE NO.: NIKOLAS HAWLEY, DIV. NO.: Plaintiff, vs. SAFECO INSURANCE COMPANY OF ILLINOIS, Defendant. ___________________________________/ COMPLAINT WATT FAMILY CHIROPRACTIC, LLC, (hereinafter "Plaintiff"), as assignee of Nickolas Hawley, (hereinafter "Insured"), sues the Defendant, SAFECO INSURANCE COMPANY OF ILLINOIS, (hereinafter "Defendant"), pursuant to the Ninth Judicial Circuit Court Administrative Order 2009-12-02 applies and alleges: 1. This is an action for damages in the amount range of $500.01 to $2,500.00 dollars exclusive of interest, costs, and attorney’s fees. 2. At all times material hereto, Defendant was a corporation duly licensed to transact insurance in the State of Florida and maintained agents for transaction of its customary business in Orange County, Florida. 3. On or about August 29, 2019, the Insured was involved in a motor vehicle accident. The Insured sustained personal injuries in, or as a result of, said accident. 4. As a direct and proximate result of the personal injuries the Insured sustained in the accident, the Insured incurred reasonable expenses for related and necessary medical and rehabilitative treatment and therapy, supplies, diagnostic testing, nursing and remedial care performed or provided by the Plaintiff in the State of Florida. 5. Defendant issued an insurance policy that provided personal injury protection (PIP) benefits required by law to comply with Section 627.730 - 627.7405, Florida Statutes, and/or medical payment coverage. A copy of the policy is not available, but it is in the possession of the Defendant. Plaintiff is not in possession of the policy and Defendant is not prejudiced by the policy not being attached to this complaint. 6. The above described policy was in full force and effect on the date of the accident and provided PIP and/or medical payment coverage for the Insured for bodily injuries sustained in said accident. 7. Pursuant to all or a combination of the following, Plaintiff has standing to pursue this action directly against the Defendant, and to collect all reasonable attorney's fees pursuant to Sections 627.733 et seq., 627.736(4)(c), 627.736(8), and 627.428, Florida Statutes: A. a written assignment of benefits wherein the Insured assigned to Plaintiff the rights to any potential benefits under the PIP policy of insurance issued by the Defendant (A copy of said assignment of benefits is contained in Exhibit "A"); B. an equitable or implied assignment (hereinafter "equitable assignment"), that exists between the patient and Plaintiff wherein the patient assigned the rights to any potential benefits under the PIP policy of insurance issued by the Defendant; and/or C. as the real party in interest as Plaintiff has a sufficient stake in the controversy addressed in this count, will be effected by the outcome of this matter and is the actual party that stands to lose or gain. 8. Defendant received notice of the covered losses. 9. Defendant failed to make proper payment of said PIP benefits within thirty (30) days as required by Section 627.736(4)(b), Florida Statutes. 10. A demand for PIP and/or medical payment benefits was made for all reasonable charges that were for necessary medical and rehabilitative treatment and therapy, supplies, diagnostic testing, nursing, and remedial care related to the subject accident. (The medical bills, charges, and items that are the subject of this claim are attached hereto as Exhibit “A”). 11. The Plaintiff has performed all conditions precedent to entitle Plaintiff to recover PIP and medical payment benefits for reasonable, related and necessary medical and rehabilitative treatment and therapy, supplies, diagnostic testing, nursing and remedial treatment regarding the above-described policy, or those conditions have been waived. 12. Despite the fact that Defendant had no reasonable proof to establish that it was not responsible for the payment, Defendant has failed to pay Plaintiff for covered losses. 13. Due to Defendant’s failure to pay PIP benefits in accordance with Florida law, Plaintiff has been required to retain the undersigned law firm for the prosecution of this lawsuit. The Plaintiff has agreed to pay, and the attorneys have agreed to accept, any Court-awarded attorneys’ fee. 14. Defendant has failed to pay the applicable statutory interest, postage, penalties, and the statutory attorney fees required by law. 15. The determination of the reasonableness of charges is subject to Section, 627.736(5), Florida Statutes and Defendant’s policy language. To the extent Defendant has made a legally sufficient election allowing it limit payment pursuant to the schedule of maximum charges legally permitted by Section 627.736(5)(a)(1), Florida Statutes (2012)(or Section 627.736(5)(a)(2), Florida Statutes (2008)), Plaintiff’s claim or claims do not exceed those legally permitted limits. 16. Plaintiff would derive a direct benefit from the Court ordering the Defendant to pay benefits, interest, postage, penalty and attorney fees, even ifDefendant pays all or some of the disputed benefits before judgment is entered. 17. Plaintiff is entitled to an award of reasonable attorneys' fees pursuant to Sections 57.041, 57.104, 627.428 and 627.736(8), Florida Statutes. 18. Plaintiff is entitled to simple interest on the amount of said medical bills or charges pursuant to Section 627.736(4)(c), Florida Statutes. WHEREFORE, Plaintiff, WATT FAMILY CHIROPRACTIC, LLC, as assignee of Nickolas Hawley, demands judgment against Defendant, SAFECO INSURANCE COMPANY OF ILLINOIS, for damages in the amount range of $500.01 to $2,500.00 dollars exclusive of interest, costs, and attorney’s fees. PLAINTIFF HEREBY DEMANDS A JURY TRIAL ON ALL ISSUES SO TRIABLE. Respectfully submitted this 2nd day of April, 2021. /s/ ROBERT HOAG ROBERT HOAG, ESQUIRE Florida Bar No. 27925 MORGAN & MORGAN, P.A. 20 N. Orange Avenue, 4th Floor Orlando, FL 32801 (321) 327-6974 – Phone (321) 327-6958 – Fax Primary Email: rhoag@forthepeople.com Secondary Email: jleverone@forthepeople.com Attorneys for Plaintiff ###EFMESES### Exhibit A July 13, 2020 SENT VIA CERTIFIED MAIL *9935734* Safeco Insurance Company of Illinois Dan Kosten Corporation Service Company 1201 Hays St Tallahassee, FL 32301-2699 Written Notice of Intent to Initiate Litigation This is a demand letter under §627.736(10) as required by Florida Statute (effective date - January 1, 2008) and/or §627.736(11)(prior statute), or under any policy of insurance RE: [9935734] Watt Family Chiro a/a/o Hawley, Nikolas vs Safeco Insured: Hawley, Yvonne Patient: Nickolas Hawley Claim/Policy#: 0408012560003 Date of Loss: August 29, 2019 Our File#: 9935734 Dear Sir/Madam: This is a demand letter under section 627.736 (10), Florida Statutes, and under any policy of insurance. The personal injury protection (PIP) benefits (and medpay benefits if applicable), claimed are for payment of reasonable charges for related and necessary treatment, services, accommodations or supplies to the above-referenced patient. The below-identified provider has not been properly paid. Name of medical provider rendering treatment, services, accommodations or supplies that form the basis of this claim: Watt Family Chiropractic, LLC. Specifically, this demand is for payment of the below listed amounts for the listed dates of service at the reasonable amount billed minus any payments received by Watt Family Chiropractic, LLC from said PIP insurer. (Please note that if this policy contains medpay coverage, the amount demanded is at 100% of the reasonable billed amount minus any payments received from said PIP insurer). If the insurer has information supporting that a lesser amount is owed and/or this demand is not payable due to deductible, co-payment, exhaustion, Florida Statute §627.736(1)(a), §627.736(2), §627.736(4), §627.736(5), §627.736(6), §627.736(7), or for any other reason, please provide the appropriate explanation pursuant to §627.736(4)(b). 20 North Orange Ave, Suite 1600, Orlando, FL 32801 | (407) 420-1414 | ForThePeople.com Ifthe insurer has made an unambiguous election in its insurance policy pursuant to Fla. Stat. Section 627.736(5)(a)(1)(2012), permitting the insurer to limit payment to 80% of 200% of the allowable amount under the Medicare Part B Physicians Fee Schedule and/or the 80% of the maximum reimbursable allowance under workers’ compensation, then the amounts demanded herein are subject to those legally permitted amounts. The policy of insurance is in the insurer’s possession, and the insured and/or its assignee is unable to determine the specific amount owed without this documentation. If the insurer contends that it has made an election to limit payment subject to the schedule of maximum charges noted above, please recite to us or provide us with the portion of the insurance policy that provides for limiting payment to the schedule of maximum charges. Please provide a copy of the PIP payout log and/or copies of all explanation of benefits/reimbursements that have been made on behalf of the above-referenced patient/claimant. We dispute the payments made by the insurer and request the insurer to notify us that the policy limits under this section have been reached within 15 days after the limits have been reached as required by §627.736(6)(f). The following is demanded: 1. Amount of $2,091.86 or @ 80% $1,012.86, subject to applicable policy limits, and any proper election under §627.736(5)(a)(5) to limitpayment to the schedule of maximum charges legally permitted under §627.736(5)(a)(1)-(4), pending verification of medical benefits for date(s) of service 09/17/2019 - 03/09/2020 made payable to Watt Family Chiropractic, LLC and mailed to our office. 2. Interest on the amount due, at the statutory rate, commencing 30 days after the date the billfor services (CMS 1500) was received by the carrier and up to the date payment made make payable to Morgan & Morgan P.A. 3. Penalty of 10% of amount due (Maximum penalty $250.00) and certified or registered mail, return receipt requested, cost made payable to Morgan & Morgan P.A. our tax identification number is 59-2920684. 4. The demand response must reference file number 9935734 Also, enclosed please find the following: 1. Assignment of Benefits 2. Itemized Statement Further, in the event the carrier decides to not honor this claim and/or demand, we hereby request or demand the carrier reserve or escrow sufficient benefits to satisfy this outstanding claim prior to any exhaustion of benefits, pending resolution of any action reasonably filed after this letter. We seek to preserve and pursue all rights as provided by law and to minimize or avoid litigation ifpossible. Additionally, we request any reply further denying or not satisfying this claim/demand to outline the exact reasons why the carrier denies this claim/demand for denied or overdue benefits and other damages. Failure to fully and completely comply with this demand letter within 30 days will result in suit being filed for all amounts legally due, including applicable costs and attorney’s fees. Govern yourselves accordingly. Sincerely, Robert Hoag, Esquire RDH/db Enclosure(s) 9935734 - HAWLEY, Nikolas DATE CPT TTL BILLED AMNT 9/17/19 99204 $190.00 9/17/19 72050 $100.00 9/17/19 72020 $35.00 9/17/19 72100 $70.00 9/17/19 99070 $15.00 9/17/19 99070 $5.00 9/19/19 97535 $30.00 9/19/19 98941 $80.00 9/19/19 97012 $30.00 9/19/19 98943 $30.00 9/24/19 98941 $80.00 9/24/19 97012 $30.00 9/24/19 98943 $30.00 9/25/19 98941 $80.00 9/25/19 97012 $30.00 9/25/19 98943 $30.00 9/27/19 98941 $80.00 9/27/19 97012 $30.00 9/27/19 98943 $30.00 9/27/19 97140 $180.00 9/30/19 98941 $80.00 9/30/19 97012 $30.00 9/30/19 98943 $30.00 10/02/19 98941 $80.00 10/02/19 97012 $30.00 10/02/19 98943 $30.00 10/04/19 98941 $80.00 10/04/19 97012 $30.00 10/04/19 98943 $30.00 10/04/19 97140 $180.00 10/08/19 98941 $80.00 10/08/19 97012 $30.00 10/08/19 98943 $30.00 10/11/19 98941 $80.00 10/11/19 97012 $30.00 10/11/19 98943 $30.00 10/11/19 97140 $180.00 10/16/19 98941 $80.00 10/16/19 97012 $30.00 10/16/19 98943 $30.00 10/18/19 98941 $80.00 10/18/19 97012 $30.00 10/18/19 98943 $30.00 10/18/19 97140 $180.00 10/23/19 98941 $80.00 10/23/19 97012 $30.00 10/23/19 98943 $30.00 10/25/19 98941 $80.00 10/25/19 97012 $30.00 10/25/19 98943 $30.00 Page 1 of 2 9935734 - HAWLEY, Nikolas 10/25/19 97140 $180.00 10/30/19 99214 $190.00 10/30/19 98941 $80.00 10/30/19 97012 $30.00 10/30/19 98943 $30.00 11/01/19 97140 $180.00 11/15/19 97535 $30.00 11/15/19 98941 $80.00 11/15/19 97012 $30.00 11/15/19 98943 $30.00 11/20/19 98941 $80.00 11/20/19 97012 $30.00 11/20/19 98943 $30.00 11/22/19 98941 $80.00 11/22/19 97012 $30.00 11/22/19 98943 $30.00 11/26/19 98941 $80.00 11/26/19 97012 $30.00 11/26/19 98943 $30.00 12/06/19 98941 $80.00 12/06/19 97012 $30.00 12/06/19 98943 $30.00 12/10/19 98941 $80.00 12/10/19 97012 $30.00 12/10/19 98943 $30.00 12/12/19 98941 $80.00 12/12/19 97012 $30.00 12/12/19 98943 $30.00 12/12/19 97140 $180.00 12/18/19 98941 $80.00 12/18/19 97012 $30.00 12/18/19 98943 $30.00 1/2/2020 98941 $80.00 1/2/2020 97012 $30.00 1/2/2020 98943 $30.00 1/6/2020 98941 $80.00 1/6/2020 97012 $30.00 1/6/2020 98943 $30.00 3/9/2020 98941 $80.00 3/9/2020 97012 $30.00 TOTAL $5,395.00 Page 2 of 2