7 ~ v IN THE CIRCUIT COURT, FOURTH JUDICIAL CIRCUIT, IN AND FOR DUVAL COUNTY, FLORIDA Crusoe Ce OTS 128 oKKKHA IN THE MATTER OF: | Z>) turn supPLeMENTAL DIVIsY ON CV-D ¢_ ) TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS FILED OF SHANARA L. MOBLEY uf commer 8 (CATION FOR AUTHORIZATI SUPPLEMENTAL TRANSFER OF STRUCTURED SETTLE! (YMENT. DEBORAH H. MILLER (hereafter sometimes referred to as “Transferee” or as “Miller’), by and through its undersigned counsel, hereby submits this Application pursuant to Section 626.9296, Fla. Stat., et seq., to this Honorable Court for an Order approving a transfer of structured settlement rights. In support thereof, Transferee states as follows: Jurisdictional Statement 1. Deborah H. Miller is an adult individual with her principal place of residence in Jacksonville, Duval County, Florida. Miller's tax identification number or social security number is as follows: XXX-XX-2068 and will be provided as required by law. 2, SHANARA L. MOBLEY, is an adult person currently residing at 9064 Monroe Avenue, Jacksonville, FL 32208 (hereafter sometimes referred to as “Payee’)~ ~ 3, This Court has jurisdiction to award the relief requested pursuant to Section 626.99296, Fla. Stat., et seq. and Florida’s general venue statute, Section 47.011, Fla. Stat,, et seq. Statement of Facts 4. On or about July 10, 1998, SHANARA L. MOBLEY ("Payee") suffered personal injuries resulting from an incident wherein Shands Jacksonville Medical Center, Inc., formerly known as University Medical Center, Inc. and Methodist Medical Center, Inc., failed to provide security for and protection of an infant, Kamiyah Teresiah Tasha Mobley, resulting in personal injury to Payee and in personal injury to or death of said infant. As a result, the Payee entered into a Settlement Agreement and Release with Shands Jacksonville Medical Center, Inc., formerly known as University Medical Center, Inc. and Methodist Medical Center, Inc. (‘the Settlement’) dated on or about June 8, 2000, entitling Payee to receive periodic payments from New York Life Insurance And Annuity Corporation pursuant to a Structured Settlement. 5. Pursuant to the Settlement, New York Life Insurance And Annuity Corporation promised to pay to the Payee periodic payments as follows: (A) Payee: Shanara L. Mobley, $3,644.00 payable on the 1" of each month beginning August 1, 2000. These payments are guaranteed for 20 years or forthe life of SHANARA L, MOBLEY, whichever is longer. The final guaranteed payment will be July 1, 2020. [Note: By previous Orders of the Circuit Court in Case Number 02-04861-CA, in Case Number 16-2003-CA.002031 and in Case Number 16-2003- CA.008709 in Duval County, Florida, three-quarters of ‘the ‘guaranteed monthly payments under said annuity were approved to be sold to Deborah H, Miller, along with ninety ife-contingent payments in the amount of One thousand Bight Hundred Twenty- Two and No/i00" Dollars (Si,822.00) per month from September 2020 through February 2028; and were subsequently so sold. Tt is row proposed that additional lfe-contingent payments be sold to Deborah H, Miller as hereafter described.] (B) Payee: Shenara L. Mobley, but SHANARA L. MOBLEY directs that if KAMIYAH TERESIAH TASHA MOBLEY is 2we w alive on July 10, 2016, and properly identified through DNA, then SHANARA L, MOBLEY shall direct in writing the assignee and ‘annuity issuer to make said payment to KAMIYAH TERESIAH TASHA MOBLEY; otherwise such payment will be made to SHANARA L. MOBLEY. {$307,644.00 guaranteed lump sum payable on July 10, 2016. (The payments described in subparagraph (A) above are hereafter collectively referred to as “Periodic Payments.) 6. New York Life Insurance And Annuity Corporation assigned its obligation to make the above-described Periodic Payments to New York Life Insurance Company (hereinafter referred to as “Obligor’), The Obligor purchased and owns an annuity policy, bearing annuity policy number FP207894 (hereinafter referred to as “the Annuity’), issued by New York Life Insurance Company (hereinafter referred to as the “Annuity Issuer’) to cover the Periodic Payments due to the Payee. Through this Annuity, the Annuity Issuer makes the Periodic Payments required of the Obligor. 7. The Payee desires to receive a lump sum payment in lieu of specific future life-contingent Periodic Payments the Payee would receive pursuant to the Settlement provided she is alive on such dates. To accomplish this goal, Payee has agreed to transfer to Miller, her successors, and/or assigns, the legal rights to the following: ‘As used herein, the term (the “Term”) means the period ‘commencing September 1, 2020 and ending August 1, 2030 and covers the following payments: $1,822.00 commencing September 1, 2020 and continuing on the First (Ist) of each month thereafter through and including August 1, 2030, all of said payments being contingent on the life of the Seller. [Previously, with court approval, the Seller has sold to Purchaser one-half of the life-contingent monthly payments from 9/1/2020 through 2/1/2028. The present agreement to sell involves sale of the other portions of the payments during the said Term not heretofore transferred, (The payments identified in this paragraph are collectively referred herein to as the “Assigned Payments). 38. Payee has executed a “Purchase And Sale Agreement (“Agreement”), under which the Payee agreed to transfer to Miller (Transferee), its successors andior assigns the Assigned Payments (said Agreement being attached hereto as Exhibit ‘A’), This document constitutes the “Transfer Agreement’ as referenced by Section 626.99296 (2) (s) and (3) (a) (8), Fla. Stat. 9. The Agreement provides that any dispute under the Agreement shall be governed in accordance with the laws of this State, where the Payee resides, ‘and that the domicile state of the payee is the proper venue to bring any cause of action arising out of any breach of the agreement, thus complying with Florida Statute 626.99296 (3) (a) (6). 10. Miller has timely provided the Payee with the Disclosure Statement required by Florida Statute 626.9296 (3) (a) (2), at least ten (10) days prior to the date on which the Payee first incurred an obligation with respect to the transfer (said Disclosure Statement being attached hereto as Exhibit “B") 14. This transfer complies with Florida Statute 626.99296, Transfers of Structured Settlement Payment Rights, and does not contravene any other applicable law. 12. The transfer is fair and reasonable and in the best interests of the Payee and her dependent(s). Payee has the following minor dependents, to wit: Lashawne Ariyan Miranda Rivera, who was born on February 3, 2003; Christopher Barnes, who was born on February 14, 2006; and Chrisanna Bares, who was born on March 20, 2007. Payee is currently with child, 13, Payee works at Publix and has sources of income other than the periodic payments, to wit: her income from Publix and from child support.ww ~ 14. Payee resides at 9061 Monroe Avenue, Jacksonville, Florida 32208 and is single. 15, In consideration of these facts, and such other facts that the Court may find, the Payee indicates this structured settlement transfer is fair and reasonable and in the best interests of the Payee. 16. Payee has been advised in writing to seek independent financial, tax, accounting and legal advice in connection with this transfer and has knowingly and voluntarily waived that right, as permitted by Florida Statute 626.99296 (3) (a) (4). Payee's Waiver of Independent Legal Advice (contained in Payee's “Affidavit’) is attached hereto as Exhibit °C.” 17. The Annuity Issuer, Obligor, and all interested parties will receive written notice of the Transfer and the Transferee's name, address, and taxpayer identification number, pursuant to Florida Statute 626.99296 (3) (a) (5). 18. Pursuant to Florida Statute 626.99296 (4) (a)-(e), at least twenty (20) days prior to the scheduled hearing on this application, the Annuity Issuer, the Obligor, and all interested parties will be provided with A. A copy of the Transferee’s Application to the Court; B. A copy of the Transfer Agreement; C. A copy of the Disclosure Statement required under Florida Statute 626.99296 (3); D. Notification that an interested party may support, oppose, or otherwise respond to the Transferee's Application, in person or by counsel, by submitting written comments to the court or by participating in the hearing; and~ w E. Notification of the time and place of the hearing and notification of the manner in which and the time by which any written response to the application must be filed in order to be considered by the court, Demand For Relief WHEREFORE, having satisfied all statutory requirements for the transfer of the structured settlement payment rights identified in this Application, and having established that such transfer is fair, just, reasonable, and in the best interests of the Payee, Applicant respectfully requests this Court to grant this Application. +l— Respectfully submitted this ZY day of September, 2009, rah H. Miller(Transferee) BOYER, TANZLER & SUSSMAN, P.A. » LAE HerberT, Sussman, Esquire Florida Bar No. 306320 210 East Forsyth Street Jacksonville, FL. 32202 (908) 3583030 facsimile: (904) 634-0036 Attomeys For Transferee Ex A~—transfer agreement (Purchase And Sale Agreement) Ex B ~ Disclosure Statement Ex C~Payee's Affidavit Waiver of Independent Advice