03/30/2081 10:37 785-233-7061 DAVID MILLER OR LR Pace 02 ? Mariage of Richardsor/Dembrowsk!, 8-D-217, Respondents DRA FILED BY FAX LEONARD M. ROBINSON, #8313 Attorney at Law 201 NW Hwy. 24, Ste. 140 P.O. Box #138 Topeka, Kansas 66608-0138 4785) 233-7001 IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION TWO In the Matter of the Marriage of — ) HAL RICHARDSON, } Petitioner, ) and } Case No. 96-D-217 CLAUDINE DOMBROWSKT, ) _ Respondent. ) RESPONDENT'S POMBSTIC RELATIONS AFFIDAVIT Petitioner's Date oF Bizth Social Security No BadEeSS 2. Respondent's __04/10/65 11-74-9645 Date of Birth Social Security No. PO Box 984, Manhattan, KS 66505 Address 3. Date of Marriage: 11/22/95 4. Number of Marriages: 2 2 Petitioner Respondent 5. Wumber of Children of Marriage: 1 6. Names, social security numbers and ages of minor children of the marriage: NAME, Sh: DATE OF BIRTH AGE Rikki Dombrowski $13-11-4344 42/12/94 6 yrs 7. Names, social security numbers and ages of minor children of previous marriage and facts as to custody and support payments paid or received, if any: NAME SS “N/A DATE OF BIRTH AGE03/30/2081 18:37 785-233-7061 DAVID MILLER OR LMR PAGE 03 Mariage of Richardeor/Oombrowaki, 96:0-217, Respondents DRA FILED BY FAX Q. If this is a post. divorce matter, please list any names, social security numbers, and ages of minor children from your present marriage or relationship: Name. of Name of Residential Date of Support Child(ren) Custodian SS. Nunbe: Birth Paid/Rovd None _ 9. Petitioner is employed by: (Nahe and Address of Enployer) Respondent is employed by: Temporarily unable to work due to relight foot “disability, “waiting to "retrain" See attached Exhibit A (Name and Address of Employer) with monthiy income as follows: A, Wage Earner Petitioner Respondent Gross Income Other Income Subtotal Gross Income Federal withholding: (Claiming exemptions) Federal Income Tax. IST. (Social Security/Medicaid). ansas Withholding Subtotal Deductions Net Income (Line A.3. minus Line A.8.) B. Self-Employed Gross Income from self-employment Other Income Subtotal Gross Incotte Reascnable Business Expenses (Itemize on attached exhibit "A") . Self-Employment Tax Estimated Tax Paymeats (Claim Exemptions) Federal Tncome Tax: Kansas Withholding Subtotal Deductions. Net Income - (Line 8.3. minus Line B..)03/30/2001 10:37 785-233-7261 DAVID MILLER OR LR Pace 04 Marriage of Richardsor/Dombroweki, 96-0-217, Respondents DRA FILED BY FAX Pay period: Petitioner” Respondent 20. Work Related child ‘Care Expenses: Weekly Expense Name and Address of Provider $ i1. Health Insurance Expenses: Family Coverage Yes ie Name of Health Insurance Plan, Name and Address Administrator: _ Respondent has no health insurance Which party pays for family health insurance coverage? Petitioner Respondent Monthly co8t of, health ingurance $ ; monthly cost of dental insurance 5. 7 Persons insured on family plan: What is the increased cost for.providing family plan over the party's cost of single plan coverage? § Any additional cost’ for number of dependents, IF so, fou much? ——— Ss Amount. of annual deductible. § Coinsurance. 12. The assets of the parties are: Asset and Joint er Date, Fair Date of Market Value Valuation Ho Checking Account! Bank of America Ind 9/06 § 50.00 3/15/01 B. Savings Accounts & Certificates of Deposit: None $ C, Cash on Hand: Petitioner $ Respondent S__none. ‘PARAGRAPHS 12D. THROUGH 1215 19,4: 1SARO 58 NEED NOT BE ANSWERED IN POST JUDGMENT PROCEEDINGS D. Employer Retirement/Savings/ Pension Plans (401K, Pensions, Profit Sharing, etc.): E> Real Estate: Cea opr Vue F, Stocks, Bonds, Mutual Funds, & Other Marketable’ Securities:03/30/2081 18:37 785-233-7061 DAVID MILLER OR LHR PAGE a5 G. Money Owed To You: $ H. bige Insurance: Tan va $ = I. Automobiles and Motorcycles: Make/Model/VINF FrirMata oe Caden Va) $ T Wiscellanéous Personal Property: ~ Boats, trailers or camper: Hand or power tools: Jewelry? Suns: Camera Equipment? Bnviques: Household goods and furnishings: “Barscnal Injury or Workers Comp. Cli Ky List any other Assets not included above! $ TS. ist all liabifities oe the parties: Include mortgages and indebtedness to banks, ‘individuals,, loan companies or on credit accounts. Indicate ‘actual balance due as of the date this document is prepared. If secured, state the property which secures the loan. Amount of Creditor ig Balance Monthly Fymt. Security $ Totals: 14, Recapitulation: Assets Checking Accounts Savings Accounts + Cash Retirement. Plans Real Estate Marketable Securities Accounts Réceivable Life Insurance Automobiles + Misc. Personal Property ; Other Assets Total Value of Assets ROH ROM MOO DD03/30/2081 10:37 785-233-7061 DAVID MILLER OR LR PAGE 06 Marriage of Richardsonvombrowski, 96-D-217, Respondents DRA FILED BY FAX Liabilities R Real Estate Mortgage(s) § B. Auto Loans § ¢. Total Other Debts g Total Liabilities g Parties’ Net Worth 5 (assets Minus Liabilities) Identify the property if any owned by each of the parties prior to marriage or acquired during marriage by family gift, will or inheritance. List any payments or contributions received or paid, by che parties: (Specify source or payee and the amount denoting (*) Af income and (-) if payment.) Source Petitioner Respondent 3 nthly expenses of each party are: Living Expens Petitioner Respondent A. House payment, rent or mortgage §_15 B. Food 3 S250 C. Utilities: = Trash sevice $ $__39. - Newspaper § 5 - Telephone § s_ 200 > Gas & Lights 3 $200 - Water § $30. - Cable . S25 D. Insurance: - Life 3 3 = Health § 3 = Car § $35 - House 5 § ~ other § § E. Uninsured health $ $200 F. Child care (Babysitting) § § G. Clothing $ seme H. School expenses s s ‘Hair cuts & beauty § S30 uJ. Car repair § 3100 K. Gas & oil § $100 1. Personal property tax s si M. Miscellaneous (specify) Rikki medical bills.est. totel $ $_300 TRape/assault fedical est total S $1500 TORBL EXPENSES & se (Please inaicate with an asterisk ail figures Which are eetiristes:rather than actual figures taken from records.) NOTE: Above items paid when I can with others’ finances. Most go unpaid.03/30/2001 10:37 785-233-7061 DAVID MILLER OR Le PAGE 87 Marriage of Richardson/Dombrowski, 90-217, Respondents DRA FILED BY FAX Z have read the above affidavit and to the best of my knowledge believe that the information is accurate CRAUDINE DOMBROWSKT Respondent SUBSCRIBED AND SWORN TO befor, Y) day of March, 2001, by Claudine Dombrowski. CERNIVICATE Oo” SERVICE I, Leonard M. Robinson, hereby certify that I served the above and foregoing document on this 30th day of March, 2001, to the following and in the following manner: By faxin ORIGINAL TO: Office of Mrs. Joyce D. Reeves, Clerk Shawnee County District Court FAX NO. 291-4911 SRAMBER COPY: Office of Ms. Lori f, Yockers Administrative Hearing Officer FAX NO. 291-4917 cory To: Mr. Donald Hoffman, Attorney for Petitioner FAX NO. 233-2173 Mr. Harry Moore Court Services FAX NO. 291-4959 Via hand delivery Ms. Claudine Dombrosk NARD W. ROBINSON DIVORCE WOMBROWSKidavdineDRA03/30/2001 10:37 78 DAVID MILLER OR LHe PAGE 08, TALLORASSONTIIOPEDIG CLIN & SPORTR NBEACDOR #81 NORNE TORHKA steam cSBII-IET ‘Chart #152204 DOB : 04/10/65 For: DOMBROWSKI, CLAUDINE AGE: 38 Acct : 677880 2901 Problem: ICD: 719.47 Doctor: CRAIG L VOSBURGH MD (CHIEF COMPLAINT: Right foot pain, HISTORY: The patient is « 35 -year-olf white fem involved in & motor vehicle accident two {strand one month ago, At tha tis ah was soe iitally by Dr. Flaka in Groat Bend. She ‘sustained fractures of te foot. She was told frilly abe wold have arthritis in that foot. The {inital treaunent included muliple pitting, at leat wight Kites according to medical records, Several of these exited rough the metitartal heads and undemeath the great, vecond and third tocs. ‘These were subsequently removed. In Aiigest of 2000, seven months after the iayury, she tanderwent fusion ofthe 1*, 2nd and 3*tarsorsetatareeljoft. This was performed with iliac erest bone ‘graft and eventually healed. Subsequent, ono or twa screws Were removed operatively. For eight, ‘acaths, the patient worked at the Larned State Hoppial and this was accommodating n that ube had a sedentary position. However, becaite of m child suet ruling, ahe was forced 10 give up this potition, and find employment in Topeka She has (ollowed up with Dr. Jones who referred her here ‘today. (Currently, the patiot complains of prin in the region ofthe second and third metatarsal aecks, Well over the dorsal medial spect of tie foot. She nota that if be stands for an extended period of ime, it ie quite painful. She pparently warked for proximately six weeks at KN, but was unable to tolerate the pain nod ewalling. She also repors at times it is Sustrating. ‘Yesverday while in chaceh, the foot wis palnfd no matter wit postion. EXAMINATION: On examidation of the right foot, the pation has « somewhat irregular but vwell-healed ongiudinal incision along tho Goraal medial aspect ofthe fist ray. Her medial arch is quite pronounced. iis inact both seat@/and stnding. Witk smbultion the patient unloads the medial ‘spect of her foot bearing minimal weight along the fret ray Her motion at the ankle and subse joint 4s tuple and nontander. Valgus Joadiig Of the mid toot cast no discomfor, varus loading is somewhat ‘uncomfonable. She is very tendet along the:vecond nd thitd thettarsa nock region. She is very tender both so deep palpation and light touch slong the surgical site. Thee is no grows deformity, no ‘alls sted on the plantor aspect ofthe Toot, EXHIBIT LA03/30/2081 10:37 785-233-7061 A DAVID MILLER OR LMR ) PAGE a8 -qauuonnsonrisoFEDIe LARI HPOTO MEDICONE 3 WORME TOPEKA te 782-77} 2 (Chart. 1522204 DOB: 04/10/65 For: DOMBROWSKI, CLAUDINE Age: 35 Acct: 67798.0 ANGI (Coat @omeenennons X-RAYS: Three views ofthe right fotare muggestive of «fist metatarsal cmeiforn fusion. HRAYS Titer previon rene 00d and aiimetaars exh, Wel a# Ae ‘pave ofthe second mmetsareal, Overall signin i satisfactory IMPRESSIONS: Pervistent pain, tight foo", natus post Trsclite and eudseqoent ariwodesis. this time for additions) surgery. prevent Soay awearing hecled clogs with a fairy a a eaesonper We eased thx puny feild woh seopon on te Ch nay be beneficial for ater types oF wea, but io nh subay indicated. Her symptoms me 80 diffuse ‘at this time # Jocal injection would sot ‘of significant beabhit. With her current symptoms now a eo ajay he ot sco wall 4 Wi make ay iia Emprone permitting any type of occupation regi Torn ending ot beavy Nitin. I vaspect se will require Prove sedentary work.. Bt appears tha Gat 20 two hous of 31 standing or walking during the day ‘Would be amaxiaaura. 1 Hiewine pongact that any inde ng oF var climbing wil be guile {ate nyse per ta i. Dombownk wl oe deny os oo ‘This wil be quite difficult w performs ta an LPN, She inform me thas the fnsurance Compeny mty ‘provide vecsional retraining if iadicied. Ar thin tne, feel that woutd be most appropri RECOMMENDATIONS: twas {yale cles to Mi: Darbrow a that there is no indiation : Sede “The pit appears to undaatand a ebcommendatons a fis me and se wil eal fr follow-up as needed. (Copy to Dr Jones) C 4. Vosburgh, MDIrga