Preview
FILED: YATES COUNTY CLERK 09/14/2023 10:47 AM INDEX NO. 2023-5239
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/14/2023
STATE OF NEW YORK
SUPREME COURT: COUNTY OF YATES
In the Matter of the Application of
DELMAR BURKHOLDER, PETITION OF DELMAR
BURKHOLDER
Petitioner Index No.
for leave to Settle the Claim of D.B., an infant,
Delmar Burkholder, being duly sworn, deposes and says:
1. I am the Father and Natural Guardian of the in the above-
Infant, D.B.,
entitled proceeding.
2. The Infant is now ten (10) years of age, having been born on July 27, 2012.
He currently resides with myself and his mother, Lydia Burkholder, at 1274 Himrod Road,
Penn Yan, New York.
3. On October 28, 2022, my son, D.B. was a bicyclist who was struck by a
vehicle being operated by Shawn M. Lanphear on Himrod Road in the Town of Milo.
4. From the scene of the accident, he was taken to Soldiers & Sailors Memorial
hospital in Penn Yan, and was thereafter transferred to the University of Rochester
Medical Center where he was discharged on October 31, 2022.
5. As a result of the accident, my son, D.B., was diagnosed with fractures of
5th
his right parietal calvarium, his right clavicle, and his left distal metatarsal.
6. AII medical expenses for the treatment of my son, D.B., have been paid by
the no-fault portion of the insurance policy issued by State Farm Mutual insurance
Company to Shawn Lanphear.
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FILED: YATES COUNTY CLERK 09/14/2023 10:47 AM INDEX NO. 2023-5239
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/14/2023
7. On November 21, 2022, my son, D.B., was seen by Dr. Kevin Walter, MD,
at the University of Rochester Medical Center. At that visit, he was deemed to be in a
status"
"stable neurologic and was released to participate in regular activities, as
tolerated.
8. My son, D.B., is well and able to perform all activities of a person his age
and has recovered well from the accident.
9. Subsequent to the accident, I spoke with representatives of State Farm and
was advised that Shawn Lanphear was insured under a liability insurance policy
containing limits of $100,000. In these discussions, I came to an agreement with State
Farm to resolve the claim against Mr. Lanphear for the sum of $80,000.
10. I am aware of my right to retain counsel to represent the interests of myself
and my son, D.B. in this matter. I have voluntarily chosen not to retain counsel in this
matter and have made the foregoing agreement to settle the claim on my own volition.
11. To my knowledge, there are no outstanding medical bills for my son, D.B.,
nor am I aware of any liens regarding my son's accident of October 28, 2022.
12. I have considered the offer from State Farm and consent to it. I further
agree that it is fair and reasonable.
13. Therefore, I respectfully request that the proposed settlement and
compromise of the claim of the infant, D.B. in the total sum of Eighty Thousand Dollars
($80,000) be approved.
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FILED: YATES COUNTY CLERK 09/14/2023 10:47 AM INDEX NO. 2023-5239
NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/14/2023
Dated: May / , 2023
DELMAR. BURKHOLDER
On this day of May 2023, before me personally appeared DELMAR
BURKHOLDER, to me known, or who provided sufficient proof of his identity, and he did
affirm before me the truth of the contents hereof.
DONALD A. SCHNEIDER
62-8829130
Notary Public No.
Notary Public Yates County, State of New York
Commission Expires March 30, 202
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Preview
FILED: YATES COUNTY CLERK 09/14/2023 10:47 AM INDEX NO. 2023-5239 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/14/2023 STATE OF NEW YORK SUPREME COURT: COUNTY OF YATES In the Matter of the Application of DELMAR BURKHOLDER, PETITION OF DELMAR BURKHOLDER Petitioner Index No. for leave to Settle the Claim of D.B., an infant, Delmar Burkholder, being duly sworn, deposes and says: 1. I am the Father and Natural Guardian of the in the above- Infant, D.B., entitled proceeding. 2. The Infant is now ten (10) years of age, having been born on July 27, 2012. He currently resides with myself and his mother, Lydia Burkholder, at 1274 Himrod Road, Penn Yan, New York. 3. On October 28, 2022, my son, D.B. was a bicyclist who was struck by a vehicle being operated by Shawn M. Lanphear on Himrod Road in the Town of Milo. 4. From the scene of the accident, he was taken to Soldiers & Sailors Memorial hospital in Penn Yan, and was thereafter transferred to the University of Rochester Medical Center where he was discharged on October 31, 2022. 5. As a result of the accident, my son, D.B., was diagnosed with fractures of 5th his right parietal calvarium, his right clavicle, and his left distal metatarsal. 6. AII medical expenses for the treatment of my son, D.B., have been paid by the no-fault portion of the insurance policy issued by State Farm Mutual insurance Company to Shawn Lanphear. 1 1 of 3 FILED: YATES COUNTY CLERK 09/14/2023 10:47 AM INDEX NO. 2023-5239 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/14/2023 7. On November 21, 2022, my son, D.B., was seen by Dr. Kevin Walter, MD, at the University of Rochester Medical Center. At that visit, he was deemed to be in a status" "stable neurologic and was released to participate in regular activities, as tolerated. 8. My son, D.B., is well and able to perform all activities of a person his age and has recovered well from the accident. 9. Subsequent to the accident, I spoke with representatives of State Farm and was advised that Shawn Lanphear was insured under a liability insurance policy containing limits of $100,000. In these discussions, I came to an agreement with State Farm to resolve the claim against Mr. Lanphear for the sum of $80,000. 10. I am aware of my right to retain counsel to represent the interests of myself and my son, D.B. in this matter. I have voluntarily chosen not to retain counsel in this matter and have made the foregoing agreement to settle the claim on my own volition. 11. To my knowledge, there are no outstanding medical bills for my son, D.B., nor am I aware of any liens regarding my son's accident of October 28, 2022. 12. I have considered the offer from State Farm and consent to it. I further agree that it is fair and reasonable. 13. Therefore, I respectfully request that the proposed settlement and compromise of the claim of the infant, D.B. in the total sum of Eighty Thousand Dollars ($80,000) be approved. 2 2 of 3 FILED: YATES COUNTY CLERK 09/14/2023 10:47 AM INDEX NO. 2023-5239 NYSCEF DOC. NO. 1 RECEIVED NYSCEF: 09/14/2023 Dated: May / , 2023 DELMAR. BURKHOLDER On this day of May 2023, before me personally appeared DELMAR BURKHOLDER, to me known, or who provided sufficient proof of his identity, and he did affirm before me the truth of the contents hereof. DONALD A. SCHNEIDER 62-8829130 Notary Public No. Notary Public Yates County, State of New York Commission Expires March 30, 202 3 3 of 3