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Home My WebLink About00-02750 " ,',' , '.',", , .' 4 y~.> . ,. ~ '. '~ C ~~ '!J ... ," IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY . PENNA. STATE OF . Kathleen M. Groome No. 00-2750 VER$US Thomas'R. Groome DECREE IN DIVORCE AND NOW, ~~~ , 2002 ,IT IS ORDERED AND DECREED THAT Kathleen M. Groome , PLAINTIFF, AND Thomas R. Groome , DEFENDANT, ARE DIVORCED FROM THE BONDS OF MATRIMONY. THE COURT RETAINS JURISDICTION OF THE FOLLOWING CLAIMS WHICH HAVE BEEN RAISED OF RECOIR~ IN ~HISACTION FOR WHICH A FINAL ORDER HAS NOT YET BEEN ENTERl':D; ~ The Agreement of the parties, dated October 25, 2002, attached hereto, shall be incorporated, but shall not merege, into the final Decree in Divorce. . BY TH ATTEST: . J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -. . , f"'""'~ " , If. / co? -.0..2 /1- /.2 . tJ.;2 "";,-,",.,-,,.,,,.,.--~ " , " ',~ "t" ,," ""~ -'.,>',' '" ~'~"~'''>~' " , 1111, .t' -. ,. !, ""l M-(?~ M4~ ~ a7I ~ 'J1~ ~J1/ ;? df" ~ "","--'f'~ ,,_~i!'f1liI!I~~~!!1~~,",_ .1'~lIIII!lI!l!"~~lm - . - ~ ,- ~ ~ ~ , KATHLEEN M. GROOME, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Vs. NO. 00 - 2750 CIVIL THOMAS R. GROOME, Defendant IN DIVORCE THE MASTER: Today is Friday, October 25, 2002. This is the date set for a pre-hearing conference; however, counsel have appeared with the parties and have engaged in a conference to settle this case. Present in the hearing room, are the Plaintiff, Kathleen M. Groome, and her counsel James W. Abraham, and the Defendant, Thomas R. Groome, and his counsel Melissa Peel Greevy. The parties were married on September 7, 1974, and separated in May 1997. They are the parents of three children, all of whom are emancipated. The complaint in divorce was filed on May 3, 2000, raising grounds for divorce of irretrievable breakdown of the marriage and indignities. The Master has been provided affidavits of consent and waivers of notice of intentions to request entry of divorce decree signed by both parties and dated today so therefore the divorce will be able to proceed under Section 3301(c). The Master's office will file the affidavits and waivers with the Prothonotary. The complaint also raised economic issues of - f61 .' , equitable distribution, alimony, alimony pendente lite and counsel fees and expenses. As previously noted, the parties engaged in negotiations today to attempt to settle this case and have resolved the outstanding economic issues. We are here in the hearing room for the purpose of having counsel put an agreement on the record in the presence of the parties resolving all of the economic claims. The agreement as stated on the record will be considered the substantive agreement of the parties not subject to any changes or modifications except for correction of typographical errors which may be made during the transcription. Consequently, when the parties and counsel leave the hearing room today after the statement of the agreement on the record, the parties will be bound by the terms of the agreement even though there is no subsequent signing of the agreement affirming the terms of settlement. However, the parties and counsel are going to return later today to review the agreement for typographical errors and , then affix their signatures affirming the terms of settlement as stated in the agreement on the record. Following the receipt by the Master of the completed agreement, the Master will prepare an order vacating his appointment. Counsel will then be able to file a praecipe transmitting the record to the Court requesting that the Court ",' , I ",'. '" ~ ;. , enter a final decree in divorce. Mr. Abraham. MR. ABRAHAM: Thank you, Mr. Elicker. 1. The parties are waiving any claim for counsel fees. The only claim was with Plaintiff, Kathleen M. Groome, and the parties shall be responsible for their own attorney fees. 2. Except as otherwise stated in this agreement, wife and Defendant husband, Thomas R. Groome, have divided their tangible and intangible personal property to their mutual satisfaction and neither party will make any claims against the others' tangible or intangible personal property in their current possession. 3. As to the former marital residence, wife shall receive all sales proceeds from the sale of the marital residence in a lump sum. Wife shall be fully responsible and liable for any and all tax consequences as to said proceeds. Wife shall receive the proceeds within ten days of this agreement. 4. As to husband's defined benefit plan pension, that pension plan shall become the sole and separate property of husband. 5. Wife shall receive the amount of $38,130.00 from husband's retirement income plan with the Teamsters through his employer which shall be contained in a QDRO as prepared by wife's attorney and approved by husband's attorney. Wife shall be entitled to growth and/or interest on the $38,130.00 from the retirement income plan as of the date of the divorce decree to the date of distribution at a rate of interest provided by the plan. 6. As to alimony, wife shall receive alimony in the amount of $500.00 per month from husband until husband reaches the age of 59 1/2. The term and amount of alimony is modifiable only if husband is partially or totally disabled as verified by a physician at which time alimony is modifiable. Alimony shall otherwise terminate upon the death of either party, remarriage or cohabitation of wife. 7 . shall As of the entry of the decree in divorce, each party be responsible for their own medical insurance coverage. 8. Except as herein otherwise provided, each party may dispose of his or her property in any way and each party hereby waives and relinquishes any and all rights he or she may now have or hereafter acquire under the present or future - '~ " . , laws of any jurisdiction to share in the property or the estate of the other as a result of the marital relationship including without limitation, statutory allowance, widow's allowance, right of intestacy, right to take against the will of the other, and right to act as administrator or executor in the other's estate. Each will at the request of the other execute, acknowledge, and deliver any and all instruments which may be necessary or advisable to carry into effect this mutual waiver and relinquishment of all such interest, rights, and claims. MR. ABRAHAM: I am sitting here with Kathleen M. Groome, the Plaintiff. Kathleen, you heard me dictate the agreement of the parties, do you have any questions? MS. GROOME: No. MR. ABRAHAM: Do you fully understand and accept the terms of the agreement as dictated? MS. GROOME: Yes, I do. MS. GREEVY: I am with Thomas R. Groome, the Defendant in this action, and he has been present for the negotiations and for the dictation of this agreement. Do you understand the terms of the agreement? MR. GROOME: Yes. MS. GREEVY: And do you have any questions that you would like to ask about the agreement at this time? MR. GROOME: No. MS. GREEVY: And are you willing to accept the terms of this agreement? MR. GROOME: Yes, I am. ,,,', I ~ . . " I acknowledge that I have read the above stipulation and agreement, that I understand the terms of settlement as set forth herein, and that by signing below I ratify and affirm the agreement previously made and intend to bind myself to the settlement as a contract obligating myself to the terms of settlement and subjecting myself to the methods and procedures of enforcement which may be imposed by law and in particular Section 3105 of the Domestic Relations Code. WITNESS: DATE: fd -;) J"() J.-, lftiJnu1h~ athleen M. Groome James W. Abraham Attorney for Plaintiff /~'-" Melissa Peel Greevy Attorney for Defendant .1lIiIo(' , :Il.i:D.-.: """'''-,~ '~iIIIi6II_'"'"'. - ilt. "fMI'llJ1l'~~lf.~~l__';"\" '~' :u, ,-" "i.,,,",,i,.';' ~ L1L " ~.;,;' , ~ ., (") -V~ n- L. 21~.~".; / , t?~: ~::~ 5:;~;~ 2. ~ " , ~ , , '-' i~ ;;~ =J () --7'1 [fJ C) :T'~,. f}i, s: S:J -< co ~ <;:) co . - .. " " . <,f . " . .. . KATHLEEN M. GROOME Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. v. NO. 00-2750 THOMAS R. GROOME Defendant CIVIL ACTION - LAW DIVORCE PRAECIPE TO TRANSMIT RECORD TO THE PROTHONOTARY: Please transmit the Record, together with the following information, to the Court for entry of a divorce decree: I. Grounds for divorce: irretrievable breakdown under Section (xl 3301(cl (l 3301(dl of the Divorce Code. 2. Date and manner of service of the Complaint: By certified mail on May 6, 2000; see attached Affidavit of Service; original filed on 7/8/02. 3. Complete Paragraph (a) or (b): (a) Date of execution of the Affidavit of Consent required by Section 3301(c) of the Divorce Code: by Plaintiff on 10/2S/02, recorded on 10/25/02; by Defendant on 10/25/02, recorded on 10/25/02. (b) (I) Date of execution of Plaintiff's Affidavit required by Section 3301(d) of the Divorce Code: ; (2) date of service of Plaintiff's Affidavit upon the Defendant: See attached Affidavit of Service. 4. Related claims pending: None pursuant to Agreement of the parties dated October 25, 2002 and filed herein. 5. Date and manner of service of the Notice of Intention to File Praecipe To Transmit Record, a copy of which is attached f the decree is to be entered under section 3301(d) (i) of the Divorce Code: 6. Date and manner of service of Notice of Intention to file Praecipe To Transmit Record, a copy of which is attached, if the decree is to be entered under section 3301(c) of the Divorce~ ; OR, date of execution of Waiver of Not ice 0 f Intention 10/25/02; date of filing Waiver 10/25/02. ~ James W. Abraham, Esq. 513 North Second St. Harrisburg, PA 17101 (717) 232-7825 DATE: 11/1/02 Attorney for Plaintiff ~IUlillillllll!!!lllf!iljgi~~~lillli'ill~'M~Ji;~iMllMiiktt,ciij:&'1I1~~l>\1(.<;J:~:~\Ytll,.f>W':i",~iIll!lI!m ~ .,~ " ..' <~ "~.L. ltt~"~~' "~l.lllill' 2 :?' -05:; mrn -;7"-,' "- ~-:- :?:- [~~ (j')~-, ~~~~) .2::; C) ~() J>c:: ~ - o N Z ":J ~.r.::: -Iii.. o -n ".., ...o:~. , ~ c -j"P .--~}-y ~~(f~ 91(1'1 ~ '-< 9? :....'"J ,10 . , '"', -~'"-, , '. ~ ~ KATHLEEN M. GROOME Plaintiff v. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. NO. 00-2750 THOMAS R. GROOME Defendant CIVIL ACTION - LAW DIVORCE AFFIDAVIT OF SERVICE I, James W. Abraham, Esquire, the undersigned, attorney for Plaintiff, Kathleen M. Groome, in the above-captioned action, hereby swear and affirm that the Complaint in divorce in the above- captioned action was served upon the Defendant, Thomas R. Groome, certified mail, return receipt requested, on May 8, 2000, as verified by the green return card from the U.S. Post Office, which is attached hereto: . Complele Ilems 1. 2. and 3. Also corhplele item 4 if Restricted Delivery 15 desIred. . Print your name and address on the reverse so that we can return the card to you. . Attach this card Ic the back of the mallplece, or on the front if space permits. 17$v;:A~ to r< . r; (LDQut $ OJ.-(lJ S,EJA,..4rE ,4"'2 'ti,(, o /'tLMI' H I'i....l..\ PI! 1'7/)/1 :q 3,~lceType ~,~ ~ertlfied Mall' 0 Express Mail :. ::' 0 Registered 0 Return Receipt for Merchandise o Insured Msll 0 C.O.D, 4. Restricted Delivery? (Extra Fee) 0 Yes 2. Article Number (Copy from seNlee ~be!L. f? 0 /(0 (;l Cf '-i '1;2..U PS Form 3811, July 1999 Domestic Return Receipt ~ C61Ml<..?4\~1 102595.99.M.1789 DATE: 7/8/02 James W. Abraham, Esquire ..~~ , "~~ .......... . ,-- -l!.1 ,.""'''''~"' ,~,- . , .:. ~ Kathleen M. Groome, Plaintiff v. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 00-2750 Thomas R. Groome, Defendant CIVIL ACTION - LAW IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under Section 3301(c) of the Divorce Code was filed on May 3, 2000. 2. The marriage of plaintiff and defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final Decree in Divorce after service of notice of intention to request entry of the Decree. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. ~~7fJ~ K hleen M. Groome, Plaintiff Date: /1~f,6 7- WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER SECTION 3301(cl OF THE DIVORCE CODE 1. I consent to the entry of a final Decree of Divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a Divorce Decree is entered by the Court and that a copy of the Decree will be sent to me immediately after it is filed with the Prothonotary. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unswom falsification to authorities. I -- . .~" ~" ". ~ '.. ... Kathleen M. Groome, Plaintiff v. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 00-2750 Thomas R. Groome, Defendant CIVIL ACTION - LAW IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under Section 3301(c) of the Divorce Code was filed on May 3. 2000. 2. The marriage of plaintiff and defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final Decree in Divorce after service of notice of Intention to request entry of the Decree. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein e made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to a horltle . Date: WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DlVORCEDECREE UNDER SECTION 3301(0) OF THE DIVORCE CODE 1. I consent to the entry of a final Decree of Divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses If I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a Divorce Decree is entered by the Court and that a copy of the Decree will be sent to me Immediately after It Is filed with the Prothonotary. I verify that the statements made In this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unswom faISificatl:;l::Ies. Thomas R. Groo v"'. Defendant 1"/ ~-jQ4 Date: .~~" , " KATHLEEN M. GROOME Plaintiff v. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. NO. DC -~ 7.s'O C.;~ i 't-~ CIVIL ACTION - LAW DIVORCE THOMAS R. GROOME Defendant NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take prompt action. You are warned that if you fail to do so the case may proceed without you and a decree in divorce or annulment may be entered against you by the Court. A judgment may also be entered against you for any other claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rights important to you, includig custody or visitation of your children. When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. A list of marriage counselors is available in the office of the Court Administrator, 4th Floor, Cumberland County Courthouse, Carlisle, Pennsylvania, 17013. IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER'S FEES OR EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM ANY OF THEM. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEpHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP: Court Administrator 4th Floor Cumberland County Courthouse Carlisle, PA 17013 717.240.6200 , KATHLEEN M. GROOME Plaintiff v. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. NO. 01) 0 ;J 150 c;JJ-r..t-o- THOMAS R. GROOME Defendant CIVIL ACTION - LAW DIVORCE COMPLAINT AND NOW, comes Plaintiff, Kathleen M. Groome, by and through her attorney, James W. Abraham, Esquire, Abraham Law Offices, Harrisburg, Pennsylvania, and files the following: COUNT I DIVORCE PURSUANT TO SECTION 3301(c} OF THE DIVORCE CODE 1. Plaintiff, Kathleen M. Groome, is an adult individual who currently resides at 1174 Kingsley Road, Camp Hill, Cumberland County, Pennsylvania, 17011. 2. Defendant, Thomas R. Groome, is an adult individual who currently resides at 210 Senate Avenue, No. l21, Camp Hill, Cumberland County, pennsylvania, 17011. 3. Plaintiff and Defendant have been bona fide residents of the Commonwealth of Pennsylvania for at least six (6) months immediately prior to the filing of this Complaint. 4. Plaintiff and Defendant were married on September 7, 1974 in New Cumberland, Pennsylvania. 5. There have been no prior actions of divorce or for annulment between the parties. 6. The marriage is irretrievably broken. " b' 7. Plaintiff has been advised that counseling is available and that Defendant may have the right to request that the Court require the parties to participate in counseling. 8. Plaintiff and Defendant are not members of the Armed Forces of the United States. WHEREFORE, Plaintiff requests Your Honorable Court to enter a decree in divorce dissolving the marriage. COUNT II - INDIGNITIES 9. Defendant has caused such indignities against Plaintiff which has made life burdensome and intolerable for plaintiff, the innocent and injured spouse. WHEREFORE, Plaintiff requests Your Honorable Court to enter a decree in divorce dissolving the marriage. COUNT III - ALIMONY, ALIMONY PENDENTE LITE & COUNSEL FEES IO. Plaintiff has insufficient funds to support herself in accordance with the standard of living the parties established during the marriage through appropriate employment. II. Defendant has had steady employment and substantial income, and/or earning capacity for substantial income, well in excess of Plaintiff, from which he is able to contribute to the support and maintenance of Plaintiff and to pay alimbny in accordance with the Divorce Code of Pennsylvania. 12. Plaintiff is without sufficient funds to support herself and is unable to appropriately maintain herself during the course of this litigation and the pendency of this action, and Defendant's substantial income enables Defendant to pay alimony pendente lite to Plaintiff in accordance with the Divorce Code of Pennsylvania. 13. Plaintiff is without sufficient funds to retain and/or continue to retain counsel to represent her in this matter; and without competent counsel, Plaintiff cannot adequately prosecute her claims against Defendant and adequately litigate her rights in this matter. 14. Defendant enjoys a substantial income and is well able to pay Plaintiff's attorney fees and the costs and expenses of the litigation hereto. WHEREFORE, Plaintiff requests Your Honorable Court to award Defendant alimony and alimony pendente lite, in an amount which is reasonable and adequate to support and maintain Plaintiff in the station of life to which she has become accustomed during the marriage; and award Plaintiff attorney fees and expenses hereto. COUNT IV - EQUITABLE DISTRIBUTION IS. Plaintiff and Defendant have accumulated real and personal property and other assets during the course of their marriage, which are marital property and marital assets; as well as debts during their marriage which are marital debts. ''''- .'" --" '<L"" ..'." ,'.,,'" E, ,,-,,_, >-,< 16. Plaintiff is entitled to the fair and equitable distribution of Plaintiff's equitable share of said property and assets in accordance with the Divorce Code of Pennsylvania. WHEREFORE, Plaintiff requests Your Honorable Court to equitably distribute the marital property and debts hereto. Respectfully submitted: James W. Abraham, Esq. Abraham Law Offices 513 North Second St. Harrisburg, PA 17101 (717) 232-7825 Attorney for Plaintiff DATE: 5/3/00 - 1""',,,",",lWa, VERIFICATION I, ~Mf-~ itf~, the undersigned, hereby verify and confirm that I have reviewed the foregoing document and the statements therein are true and correct to the best of my knowledge, information and belief. I further understand that any false statements made herein are subject to the penalties of IS Pa.C.S.A. Section 4904, relating to unsworn falsification to authorities. DATE: <f-~7-ritJ ;frjhPA<)7!1~ ~.~.... : . CERTIFICATE OF SERVICE I, James W. Abraham, Esquire, the undersigned, do hereby certify that I have served a true and correct copy of the foregoing document, by certified mail, on the date indicated below, to the following person(s) : Thomas R. Groome 210 Senate Ave., No. Carlisle, PA 17013 121 DATE: 5/3/00 James W. Abraham, Esquire ~,., '.." - ~~., -.~"~,-- -= ~,_ '~<'._N~'"'-_""~~""'jjiil~ .~ <, .GIiMil.ii1JY ~ "",' 7J~ It:. l Y..: cR~ -..! L-\ ~\ - . ~ Yv V\ . I d ~ 6 I f ~ r" )~ - ~~ . , L~ '~~....._~ ~_."'!lii ~ ~ U\~ . I 8c I ~ umf:l" o c:: -~ -0 tti rr'~.<-: ~~ -<.c, c::O ---;:;: ...... "z::' C'" -- (-... >c z:: :< ,~ o a ::x o 71~1 :;\,-n~ G ;;~Q ~ -0 ::1::rl :JC ~2 0 /..-rn ~ ~ ~ I W ca "'" (u . ~.~ -""lJd: KATHLEEN M. GROOME Plaintiff v. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. NO. 00-2750 THOMAS R. GROOME Defendant CIVIL ACTION - LAW DIVORCE AFFIDAVIT OF SERVICE I, James W. Abraham, Esquire, the undersigned, attorney for Plaintiff, Kathleen M. Groome, in the above-captioned action, hereby swear and affirm that the Complaint in divorce in the above- captioned action was served upon the Defendant, Thomas R. Groome, certified mail, return receipt requested, on May 8, 2000, as verified by the green return card from the U.S. Post Office, which is attached hereto: . Complete items 1. 2, and 3. Also complete item 4 if Restricted Delivery is desired. . Print your name and address on the reverse so that we can return the card to you. . Attach this card to the back of the mailpiece, or 011 the front if space permits. 1T;;;~to: 1<.. G(2.00t41$ OLf'l) SI5/A..A-,e .,4trt' o ~1M.f' H ,1...1... PII 1'1/)11 ,\ 'it 3.~iceType , i;,~ ~ertifled Mail" " f 0 Registered o Insured Mail o Express Mail o Return Receipt for Merchandise o C.O.D. 4. Restricted Delivery? (Extra Fee). 0 Yes , .ur" _pt 102S95-99.M-1789 . DATE: 7/8/02 James W. Abraham, Esquire ,~~":lll:~Bj.iimllil~l1tiIIIIlliait1l.l~im"lil!j;ji.i;.Hjlilll~""""11-i'''''""'''''llIIf' -,,~ .~,"~. - ~ . ~--==I- .liiIiI"'"" " "fl'= <,< d,' ~~ IUlIIlJ?iJ '1'11111[. . ~jjj .. c ',j ;g: ,- -l:JnJ c:: n:r::', ~,;.'- , 2~ r-- en ,,-- \.0 -</- r:: C) ~ ~(! ..... """c") Pc :=-1 Z ::;! N - c..: ..u -, , ] . "'.1 " I . Kathleen M. Groome, Plaintiff v. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 00-2750 Thomas R. Groome, Defendant CIVIL ACTION - LAW IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under Section 3301 (c) of the Divorce Code was filed on May 3, 2000. 2. The marriage of plaintiff and defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final Decree in Divorce after service of notice of intention to request entry of the Decree. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. ~/A()7IJ~ K hieen M. Groome, Plaintiff Date: /1~1jJ5 2.. - ,,~,... WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER SECTION 3301 (c) OF THE DIVORCE CODE 1. I consent to the entry of a final Decree of Divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a Divorce Decree is entered by the Court and that a copy of the Decree will be sent to me immediately after it is filed with the Prothonotary. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. 1i/!h~~/4~ ~ thleen M. Groome, Plaintiff Date:/t}b~ ;2- I_i'~'~~''"'-._ - """""""-" .~-,~ - "~-"'- - "",'-' ~. ",- .. o c: ? ""t1fij fl<rc; z-" 0~~' ~'Cj p :z:0 <:;:-c) -c: -,. ~ I, '" ~ C> I\J ::::> ;:-, -I No CO o -1'1 ::;! ~.,-i 21 ,- -;=:;-m ';0 fJ~ c.SfT"J );: :0 -< ~'?:) -,." --"'" :.n , ~ _ '_' ". ~o' .,", ""'-~;c' Kathleen M. Groome, Plaintiff v. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 00-2750 Thomas R. Groome, Defendant CIVIL ACTION - LAW IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under Section 3301 (c) of the Divorce Code was filed on May 3, 2000. 2. The marriage of plaintiff and defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final Decree in Divorce after service of notice of intention to request entry of the Decree. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein e made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to a horitle Date: 1. o co O' C tv WAIVER OF NOTICE OF INTENTION TO REQUEST ;;"f' .:: ENTRY OF A DIVORCE DECREE UNDER ;:Rk'" g .',-,-, SECTION 3301 (c) OF THE DIVORCE CODE ~~ ~,,:'n 0~ ?::,:: {X> '. :~~ 0 --0:",__ C'l L I consent to the entry of a final Decree of Divorce without notice;:: C CJ :~'Sc: >' C--' __,'0 ,-, __ f Z' ~~ ....,. I understand that I may lose rights concerning alimony, divisio~rop~y, l<ii~r's fees or expenses if I do not claim them before a divorce is granted!Ej :.n ~ -< -< I understand that I will not be divorced until a Divorce Decree is entered by the Court and that a copy of the Decree will be sent to me immediately after it Is filed with the Prothonotary. 2. 3. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn faISificati:;;e::ies. Thomas R. Groo Defendant Date: 10 I '-;I):?' ~'__'~,,-'- l' ;;", ~ ~"i KATHLEEN M. GROOME, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - LAW NO. 00 - 2750 CIVIL THOMAS R. GROOME, Defendant IN DIVORCE NOTICE OF PRE-HEARING CONFERENCE TO: James W. Abraham , Attorney for Plaintiff Melissa Peel Greevy Attorney for Defendant A pre-hearing conference has been scheduled at the Office of the Divorce Master, 9 North Hanover Street, Carlisle, Pennsylvania, on the 25th day of October 2002, at 9:30 a.m., at which time we will review the pre-trial statements previously filed by counsel, define issues, identify witnesses, explore the possibility of settlement and, if necessary, schedule a hearing. Very truly yours, Date of Notice: 9/5/02 E. Robert Elicker, II Divorce Master .. ". OFFICE OF DIVORCE MASTER CUMBERLAND COUNTY COURT OF COMMON PLEAS 9 North Hanover Street Carlisle. PA 17013 (717) 240-6535 E. Robert Elicker, II Divorce Master Traci .10 Colyer Office Manager/Reporter West Shore 697-0371 Ex!. 6535 August 5, 2002 James W. Abraham, Esquire 513 North Second Street Harrisburg, PA 17101 Melissa Peel Greevy Attorney at Law JOHNSON,DUF~E,STEWART & WEIDNER 301 Market Street, P.O. Box 109 Lernoyne, PA 17043 RE: Kathleen M. Groorne vs. Thornas R. Groorne No. 00 - 2750 Civil In Divorce Dear Mr. Abraham and Ms. Greevy: Both counsel have certified that discovery is cornplete. Therefore, we will proceed with a directive for the filing of pretrial statements. A divorce cornplaint was fIled on May 3,2000, raising grounds for divorce of irretrievable breakdown of the rnarriage and indignities and econornic clairns of alimony, alirnony pendente lite, counsel fees and equitable distribution. In accordance with p.R.e.p. 1920.33(b) I am directing each counsel to file a pretrial staternent on or before Monday, August 26,2002. Upon receipt of the pretrial staternents, I will irnrnediately schedule a pre- hearing conference with counsel to discuss the issues and, if necessary, schedule a hearing. It is my assumption that there is no issue with regard to grounds for divorce or any date of separation issues. I assurne, also, that all discovery is complete and the case will be ready for trial at the tirne we ~, . ~ 1'"' ri. -,"'~<.'_ ~_ ~' -,-/"" '--.-,--. ,""'~', Mr. Abraham and Ms. Greevy, Attorneys at Law 5 August 2002 Page 2 conclude the pre-hearing conference. NOTE: Very truly yours, E. Robert Elicker, II Divorce Master Sanctions for failure to file the pretrial staternents are set forth in subdivision (c) and (d) of Rule 1920.33. THE ORIGINAL PRETRIAL STATEMENT SHOULD BE FILED IN THE MASTER'S OFFICE AND A COPY SENT DIRECTLY TO OPPOSING COUNSEL. FAILURE TO FILE PRETRIAL STATEMENTS AS DIRECTED BY THE MASTER MAY RESULT IN THE MASTER'S APPOINTMENT BEING VACATED. ~~ . '" ,. KATHLEEN M. GROOME IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION LAW vs. NO. 00 - 2750 CIVIL 19 THOMAS R. GROOME IN DIVORCE Defendant STATUS SHEET DATE: ACTIVITIE~ : -- 1 ',1(0 4. . III ~, f.: o.4-t ~ ~ ~. rt...... "./lqf tho . " "k:>~ a.t......~ ~.4t7./'..kl\.......1 tAe~('_~~ 1:~..~~~~ ~ ~ " . -- " ... .... JI' KATHLEEN M. GROOME, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 00 - 2750 CIVIL THOMAS R. GROOME, Defendant IN DIVORCE TO: James W. Abraham , Attorney for plaintiff Melissa Peel Greevy , Attorney for Defendant DATE: Wednesday, July 17, 2002 CERTIFICATION I certify that discovery is complete as to the claims for which the Master has been appointed. OR IF DISCOVERY IS NOT COMPLETE: (a) Outline what information is required that is not complete in order to prepare the case for trial and indicate whether there are any outstanding interrogatories or discovery motions. -"~" ... ; (b) Provide approximate date when discovery will be complete and indicate what action is being taken to complete discovery. DATE COUNSEL FOR PLAINTIFF COUNSEL FOR DEFENDANT NOTE: PRETRIAL DIRECTIVES WILL NOT BE ISSUED FOR THE FILING OF PRETRIAL STATEMENTS UNTIL COUNSEL HAVE CERTIFIED THAT DISCOVERY IS COMPLETE, OR OTHERWISE AT THE MASTER'S DISCRETION. AFTER RECEIVING THIS DOCUMENT FROM BOTH COUNSEL OR A PARTY TO THE ACTION, IF NOT REPRESENTED BY COUNSEL, INDICATING THAT DISCOVERY IS NOT COMPLETE, THE DIRECTIVE FOR FILING OF PRETRIAL STATEMENTS WILL BE ISSUED AT THE MASTER'S DISCRETION. HOWEVER, IF BOTH COUNSEL, OR A PARTY NOT REPRESENTED, CERTIFY THAT DISCOVERY IS COMPLETE, A DIRECTIVE TO FILE PRETRIAL STATEMENTS WILL BE ISSUED IMMEDIATELY. THE CERTIFICATION DOCUMENT SHOULD BE RETURNED TO THE MASTER'S OFFICE WITHIN TWO (2) WEEKS OF THE DATE SHOWN ON THE DOCUMENT. "". COURT OF COMMON PLEAS OF CUMBERLAND COUNTY. PENNSYLVANIA NAME, Kathleen M. Groome Plaintiff v. NO. 00-2750-Civil Term NAME, Thomas R. Groome Defendant (Plaintiff) ( X ( ( x ( x CIVIL ACTION - DIVORCE MOTION FOR APPOINTMENT OF MASTER ~ moves the court to appoint a master with respect to the following claims: Divorce Annulment Alimony Alimony Pendente Lite Distribution of Property Support Counsel Fees Costs and Expenses x x X and in support of the motion states: AND NOW. ~9 is appointed master with respect to the following claims: Date: 7/5/02 (I) Discovery is complete as to the claim(s) for which the appointment of a master is requested, (2) The defendant (has) (~ appeared in the action (~ (by his attorney) Esquire, Melissa P. Greevy, Esq. The statutory ground(s) for divorce (is) ~ irretrievable breakdown (3) (4) Delete the inapplicable paragraph(s): (a) . . (b) (c) The action is contested with respect to the following claims: All claims stated above. The action (~) ("o~nOlinvolve) complex issues of law or fact. (5) (6) The hearing is expected to take on~ (days), (7) Additional information, if any, relevant to the otion: James W. raham, Esq .Attorney for Plaintiff 513 N.2nd St., Harrisburg, PA 17101 (717) 232-7825 ORDER APPOINTING MASTER .~: EjJ~.r~J rr (' , Esquire All listed above. BY THE COURT: "."" >- 0:; ~ Cl OF CI;P"\,'~l'-::"':frT !",,"",";'''.jrtIVl: i~:\OTmY 02 J{!j -Cl " , Pti I: 71; ",..w C""". , 'iJiVi;"::,tr-r'j f~',"., n C(':J )1'.J1"'( ""t,;;\',-;;':'\,;":r/~'":"" r-c.lJN,)/L,r\:'JA (") ", r z :::J<,"" ~~ ,-~:'65 ___.JL~ t{~1~ '5 () ..J_ ""'.::::: en , ("-,\ (.:::J ..~ ,.", ~....~,.,....~ ,~' ... 1-F~~~~\fI~~;I,~~!lt~~<=,_~"""p ~~~..~'''IIU!~lll . '" "I. :'L.'. , " -"",,'j .. o ({/oY(v KATHLEEN M. GROOME, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 00 - 2750 CIVIL THOMAS R. GROOME, Defendant IN DIVORCE TO: James W. Abraham , Attorney for Plaintiff Melissa Peel Greevy Attorney for Defendant DATE: Wednesday, July 17, 2002 CERTIFICATION I certify that discovery is complete as to the claims for which the Master has been appointed. OR IF DISCOVERY IS NOT COMPLETE: (a) Outline what information is required that is not complete in order to prepare the case for trial and indicate whether there are any outstanding interrogatories or discovery motions. .. . " , L ,'- -r' '.j', ,," C"_ -,-,.'o''''C;''; ~ , (b) Provide approximate date when discovery will be complete and indicate what action is being taken to complete discovery. ~ COUNSEL FOR PLAINTIFF ( ) COUNSEL FOR DEFENDANT ~) NOTE: PRETRIAL DIRECTIVES WILL NOT BE ISSUED FOR THE FILING OF PRETRIAL STATEMENTS UNTIL COUNSEL HAVE CERTIFIED THAT DISCOVERY IS COMPLETE, OR OTHERWISE AT THE MASTER'S DISCRETION. AFTER RECEIVING THIS DOCUMENT FROM BOTH COUNSEL OR A PARTY TO THE ACTION, IF NOT REPRESENTED BY COUNSEL, INDICATING THAT DISCOVERY IS NOT COMPLETE, THE DIRECTIVE FOR FILING OF PRETRIAL STATEMENTS WILL BE ISSUED AT THE MASTER'S DISCRETION. HOWEVER, IF BOTH COUNSEL, OR A PARTY NOT REPRESENTED, CERTIFY THAT DISCOVERY IS COMPLETE, A DIRECTIVE TO FILE PRETRIAL STATEMENTS WILL BE ISSUED IMMEDIATELY. THE CERTIFICATION DOCUMENT SHOULD BE RETURNED TO THE MASTER'S OFFICE WITHIN TWO (2) WEEKS OF THE DATE SHOWN ON THE DOCUMENT. , . ~ ~C' ABRAHAM LAW OFFICES JAMES W. ABRAHAM AITORNEY AT LAW 513 NORTH SECOND STREET HARRISBURG, PA 17101 (717) 232-7825 FAX: (717) 232-7827 9 SOUTH WATER STREET HUMMELSTOWN. PA 17036 (717) 566.9380 * Reply to Harrisburg July 31, 2002 E. Robert Elicker, II, Esq. Divorce Master 9 North Hanover St. Carlisle, PA 17013 RE; Groome v. Groome - Divorce No. 00-2750 Dear Mr. Elicker: This office represents Plaintiff, Kathleen M. Groome in the above referenced action. Enclosed is the Certification on behalf of Plaintiff that discovery is complete in this action. c-:: ~' James W. Abraham JWA: da Enclosure c: Melissa P. Greevy, Esq. j, ~ - .., ~, "", <^ lil'T ~ "~' ~10/0~ KATHLEEN M. GROOME, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 00 - 2750 CIVIL THOMAS R. GROOME, Defendant IN DIVORCE TO: James W. Abraham , Attorney for Plaintiff Melissa Peel Greevy , Attorney for Defendant DATE: Wednesday, July 17, 2002 CERTIFICATION I certify that discovery is c~mplete ~as toth claims for which the Master has been appolnted. _ ~ - x( OR IF DISCOVERY IS NOT COMPLETE: Outline what information is required that is not complete in order to prepare the case for trial and indicate whether there are any outstanding interrogatories or discovery motions. ,,'.',~ ~~~ A. ,t_ n",,"j . \ KproVide approximate date when discovery will be complete and indicate what action is being taken to complete discovery. 7~J {--OIl- DATE ~- COUNSEL FOR PLAINTIFF (--r- COUNSEL FOR DEFENDANT ( ) NOTE: PRETRIAL DIRECTIVES WILL NOT BE ISSUED FOR THE FILING OF PRETRIAL STATEMENTS UNTIL COUNSEL HAVE CERTIFIED THAT DISCOVERY IS COMPLETE, OR OTHERWISE AT THE MASTER'S DISCRETION. AFTER RECEIVING THIS DOCUMENT FROM BOTH COUNSEL OR A PARTY TO THE ACTION, IF NOT REPRESENTED BY COUNSEL, INDICATING THAT DISCOVERY IS NOT COMPLETE, THE DIRECTIVE FOR FILING OF PRETRIAL STATEMENTS WILL BE ISSUED AT THE MASTER'S DISCRETION. HOWEVER, IF BOTH COUNSEL, OR A PARTY NOT REPRESENTED, CERTIFY THAT DISCOVERY IS COMPLETE, A DIRECTIVE TO FILE PRETRIAL STATEMENTS WILL BE ISSUED IMMEDIATELY. THE CERTIFICATION DOCUMENT SHOULD BE RETURNED TO THE MASTER'S OFFICE WITHIN TWO (2) WEEKS OF THE DATE SHOWN ON THE DOCUMENT. ~- ,'- ABRAHAM LAW OFFICES JAMES W. ABRAHAM AITORNEY AT LAW 513 NORTH SECOND STREET HARRISBURG, PA 17101 (717) 232-7825 FAX: (717) 232-7827 August 23, 2002 E. Robert Elicker, II, Esq. Divorce Master 9 North Hanover St. Carlisle, PA 17013 RE: Kathleen M. Groome v. Thomas R. Groome NO. 00 - 2750 Civil In divorce Dear Mr. Elicker: -L' .. ~~",g 9 SOUTH WATER STREET HUMMELSTOWN. PA 17036 (717) 566.9380 . Reply 10 Harrisburg Enclosed please find Plaintiff's Pre-Trial Statement in the above referenced action per your Order. --=w James W. Abraham JWA: da Enclosure c: Kathleen Groome Melissa P. Greevy, Esq. I I IllLIl.J. . " , <<'~: JERRY R. DUFFIE RICHARD w. STEWtJm', 'I ':: C. ROY WEIDNER. !JR. ' , EDMUND G. MYERS' , DAVID W. DELUCE: , I', RALPH H. WRIGHJ1. JRi DAVID J. LANZA MARK C. DUFFIE , MELISSA PEEL GREE;vY MICHAEL J. CASSIDY , ROBERT M. WALKER LAW OFFICES JOHNSON, DUFFIE, STEWART & WEIDNER A Professional Corporation 301 MARKET STREET P. O. BOX 109 LEMOYNE, PENNSYLVANIA 17043-0109 WEBSITE: www.jdsw.com (f; @ ~)'~f / ! if ! HORACE A. JOHNSON COUNSEL TO THE FIRM TELEPHONE 717.761.4540 FACSIMILE 717.761.3015 E..MAIL mail@jdsw.com KEIRSTEN WALSH DAVIDSON OF COUNSEL WRITER'S EXT. NO. 18 E-MAIL 1l1pg@jdsw.com August 29, 2002 , ~" ' James W,.i,Abraham, Esquire i ,j' : :' 513 N, SEfi~ond S(reet Harrisburg" PA 17101 ,! Re: K;;!tl1leen M. Groome v. Tl10mas R. Groome Nd. 00-2750 In Divorce Dear Mr. Abraham: I am writing to confirm our conversation of August 23, 2002, wherein you agreed to delay in the fili(1g of the Pre-Trial Statement and Inventory and Expense Report in the above- captioned matter. Those filings are due on August 26, 2002. I anticipate that the filings will be filed no later than August 30, 2002. Of course, you will be provided with a copy of the document~ filed. I thank you for the courtesy of this brief extension of time. I have also informed Tracy of Mr. Elicke'r's office that you have agreed to allow for a delay in filing. Very truly yours, JOHNSON, DUFFIE, STEWART & WEIDNER Melissa Peel Greevy MPG:jlb:162136 cc: Thomas R. Groome E. Robert Elicker, II, Esquire ~..~. .'. ,,-, Commerce "Banlc Commerce Bank/Harrisburg N.A 100 Senate Avenue Camp Hill Pa 17011 888-S37 -0004 Page 1 of 1 CG(Q)~v STATEMENT DATE THOMAS R GROOME MELISSA PEEL GREEVY POBOX 109 LEMOYNE PA 17043 05 ACCOUNT NO. '"** CHECKING ... NOW ACCOUNT NUMBER 0513181842 PREVIOUS STATEMENT BALANCE AS OF 09/16/02 ...... .................. FLUS 1 DEPOSITS AND OTHER CREDITS ... ........ ........ LESS 0 CHECKS AND OTHER DEBITS. ............. ... ..... C~NT STATEMENT BALANCE AS OF 10/15/02 ....... .... ...... ........ NUMBER OF DAYS IN THIS STATEMENT PERIOD 29 CYCLE-014 44,405.02 26.47 .00 44,431.49 ----------------------------------------------------------------------------------- ... CHECKING ACCOUNT TRANSACTIONS ... DATE DESCRIPTION 10/15 INTEREST PAYMENT DEBITS CREDITS 26.47 ... BALANCE BY DATE ... 09/16 44,405.02 10/15 44,431.49 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE 23-2324730 174.78 ... INTEREST EARNED THIS STATEMENT PERIOD DAYS IN PERIOD ......................... INTEREST EARNED ........................ ANNUAL PERCENTAGE YIELD EARNED (APY).... ..* 29 26.47 0.75% /f.oPY TO: j:VbUENT 0 WOIENCl ~ I/o-- o WI~~CL J{ Kf N. " 4- Sent /W~J-B'i: f~~JJ JOHNSON, DUFFIE, STEWART & WEIDNER ~''''~f,''\~i.j'~''~'fl n!!:,,\;!b[,1I111:,;; OCT ! B 2002 JOHNSOI, U"! ',''''''': , "" ,r>,.; STEWART AND WEiDNER NOTE, SEE REVERSE SIDE FOR IMPORTANT INFORMATION Member FDIC ~ .,. ~'~ '.- , ;~.I i'{,1. Johnson, Duffie, Stewart & Weidner By: Melissa Peel Greevy LD. No. 77950 301 Market Street P. O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 8{3010Z. ~F'H Attorneys for Defendant KATHLEEN M. GROOME, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff NO. 00-2750 v. CIVIL ACTION - LAW THOMAS R GROOME, Defendant DEFENDANT'S INVENTORY AND APPRAISEMENT Defendant, Thomas R Groome, files the following inventory of all property owned or possessed by the parties at the time this action was commenced and all property transferred within the preceding three (3) years as verified by Defendant pursuant to the signed Verification. Submitted by, JOHNSON, DUfAE~l)WART & WEIDNER BY: c~kzt&t~ Melissa Peel Greevy Attorney I.D. #77950 301 Market Street P.O. Box 109 Lemoyne, PA 17043-0109 (717) 761-4540 Attorneys for Defendant :162072 ._,," ~, ASSETS OF PARTIES Defendant marks on the list below those items applicable to the case at bar and itemizes the assets on the following pages. (X) 1. (X) 2. ( ) 3. ( ) 4. (X) 5. (X) 6. ( ) 7. ( ) 8. ( ) 9. ( ) 10. ( ) 11. ( ) 12. ( ) 13. ( ) 14. ( ) 15. ( ) 16. ( ) 17. (X) 18. ( ) 19. ( ) 20. ( ) 21. ( ) 22. ( ) 23. ( ) 24. (X) 25. (X) 26. Real property Motor vehicles Stocks, bonds, securities and options Certificates of deposit Checking accounts, cash Savings accounts, money market and savings certificates Contents of safe deposit boxes Trusts Life insurance policies (indicate face value, cash surrender value and current beneficiaries) Annuities Gifts Inheritances Patents, copyrights, inventions, royalties Personal property outside the home Businesses (list all owners, including percentage of ownership, and office/director positions held by a party with a company) Employment termination benefits-severance pay, worker's compensation claim/award Profit sharing plans Pension plans, thrift savings plans (indicate employee contribution and date plan vests) Retirement plans, Individual Retirement Accounts Disability payments Litigation claims (matured and unmatured) MilitaryN.A. benefits Education benefits Debts due, including loans, mortgages held Household furnishings and personalty (include as a total category and attach itemized list if distribution of such assets is in dispute) Insurance benefits ,'- '" "". -~ "'~--~ ' .~. ~, MARITAL PROPERTY Defendant lists all marital property in which either or both spouses have a legal or equitable interest individually or with any other person as of the date this action was commenced: Item Number Description of Property 1174 Kingsley Road, Camp Hill, PA Former Marital Residence Sold, $44,375.83 as of 8/15/02 Names of All Owners 1. Plaintiff and Defendant 5. a) 1990 Ford Mustang GTO b) 1988 Chevrolet Nova Checking Account - Fulton Bank Plaintiff and Defendant Plaintiff and Defendant 2. Plaintiff and Defendant 6. Savings Account - Fulton Bank Plaintiff and Defendant 18. Husband's Teamsters Retirement Income Plan Account balance as of 12/31/01 - $170,727.00 Account balance as of 12/31/96 - $92,760.00 Account balance as of 12/31/97 - $120,690.00 Annualized rate of return for 1997 was 21.1 % Defendant 25. Husbands Teamsters Defined Benefit Plans Separation value - $20,832.00 Household Personal Property - $10,000.00 Plaintiff and Defendant Plaintiff and Defendant 26. Insurance Benefits Proceeds from homeowners insurance three (3) checks totaling $1,195.00 --.~ , -"- _ '~~ ',,0, J,ilil'li""" MARITAL DEBTS Defendant claims $2,285.00 for materials and the services of a painter associated with preparing the formal marital residence for sale. Defendant also claims $511.00 for unpaid utility bills which appeared on the credit report sought by Defendant for UGI & Bell Atlantic. These bills were incurred during the time that the Plaintiff resided in the home. NON-MARITAL ASSETS - -,..~-, .,-." < '~~" Defendant reserves his rights as to all claims or defenses with any regard to non-marital property. -"'c_" .^'~ _. '~_L ''"'".- ~"~. NON-MARITAL DEBTS Defendant is not aware of any debts which may be in dispute as to whether they are marital or non- marital except as to the claims listed under marital debts mentioned above. Defendant reserves his rights as to any issue or defense in regard to non-marital debts. ,~ '.' PROPERTY TRANSFERRED ~- '., ~.~- '~" '..' ~'" ,- "~,C' As referenced in the itemization of marital assets, the marital home was sold jointly by the parties and the proceeds have been kept in escrow. It is alleged that the Plaintiff has converted to her use the proceeds of three (3) home insurance checks in the amount of $399.24, $263.69, and $532.49. These amounts total $1,195.42. It is believed and therefore averred by Defendant that these home insurance proceeds were for claims that were made by the Plaintiff without the knowledge or consent of the Defendant. Additionally, the checks were cashed by Plaintiff without the knowledge or consent of Defendant. Defendant reserves his right to claim reimbursement for his equitable share of these proceeds transferred or converted by the Plaintiff. _.,~ Johnson, Duffie, Stewart & Weidner By: Melissa Peel Greevy LD. No. 77950 301 Market Street P. O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 Attorneys for Defendant KATHLEEN M. GROOME, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff NO. 00-2750 v. CIVIL ACTION - LAW THOMAS R. GROOME, Defendant VERIFICA TlON I, Thomas R. Groome, hereby verify that the statements made in this Inventory and Appraisement are true and correct. I understand that false statements made herein are subject to the penalties of 18 Pa.C.S. ~4904 relating to unsworn falsification to authorities. :162075 "',. .. -,- ~~i:' CERTlFICA TE OF SERVICE AND NOW, this 29 th day of August, 2002, the undersigned does hereby certify that she did this date serve a true and correct copy of the foregoing I nventory and Appraisement upon the other parties of record by causing same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, on the date indicated below, to the following persons: James W. Abraham, Esquire 513 N. Second Street Harrisburg, PA 17101 JOHNSON, DUFFIE, STEWART & WEIDNER ~i/(H~tn~v-l Melissa Peel Greevy I ........~ -. ....d&;!, , , , , v. ~t~'Dtf- THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNA. : NO. 00-2750-CIVIL TERM KATHLEEN M. GROOME Plaintiff THOMAS R. GROOME Defendant : CIVIL ACTION - LAW IN DIVORCE PLAINTIFV'S PRE-TRIAL STATEMENT (Pursuant to Pa. R.C.P. 1920.33) AND NOW, comes Plaintiff, Kathleen M. Groome, by and through his attorney, James W. Abraham, Esquire, Abraham Law Offices, Harrisburg, Pennsylvania, and files the following: 1. Plaintiff, Kathleen M. Groome (hereinafter "Wife") currently resides in Shallote, North Carolina. Wife is presently forty-eight (48) years of age, born on July II, 1953. 2. Defendant, Thomas R. Groome, (hereinafter "Husband") has a last known address of 210 Senate Ave., No. 121, camp Hill, Pennsylvania. Husband is presently forty-nine (49) years of age, born on December I, 1952. 3. The parties have been married for twenty-three (23) years from the date of their marriage on September 7, 1974 in New Cumberland, Pennsylvania, through their date of final separation, on or about May, 1997, when Husband left the former marital residence, located at 1174 Kingsley Road, Camp Hill, Pennsylvania (hereinafter "marital residence"). 4. At the time of separation in May, 1997, the parties had two (2) minor children, Jamie Kathleen Groome, born May 3D, 1982, who was fifteen (15) and Jordan Donald Groome, born August 4, 1979 who as seventeen (17) as of the date of separation, both of whom continued to reside with Wife at the marital residence ~~"- , ,~, ~~ ..~ ~ ;1 for another three (3) years until Wife moved to North Carolina in the fall of 2000. The parties other child is Marshall Thomas Groome, born May 2, 1977. 5. Husband has been employed by United Parcel service ("UPS") for twenty-five (25) years, which employment commenced in September, 1977, three (3) years after the parties were married. Husband's current annual income is excess of $55,000.00. Husband's 1999 tax return states a gross income from UPS of $53,278.93. Husband's paystub from July, 2000 indicates a gross, weekly pay of $980.20, for 45 hours at $21.76 per hour. A true and correct copy of Husband's 1999 tax return and July, 2000 paystub is attached hereto as Exhibit "A". 6. Wife has been employed in minimum wage jobs for the last three (3) years and currently earns $7.00 per hour. While the parties' three (3) children were growing up, Wife was the primary caretaker and Husband worked. Wife's highest income during the the last five (5) years was as a secretary at Theo's Foods, Inc. in 1999, in which she earned $16,000 for said year. A true and correct copy of Wife's income tax returns from 1996 through 2000 are attached as Exhibit "A" to Wife' Income & Expense Statement. 7. Since the date of final separation, on or about May, 1997, Husband paid spousal and/or child support by making the mortgage payment and/or hOme equity loan payments for the marital residence totalling approximately $1,200.00 per month. 8. After Wife moved to North Carolina in the fall of 2000, Husband moved back into the marital residence. _....~, ~"""~'1j'IDli 9. Thereafter, Wife filed for spousal support and on February 12, 2001, a support order was issued through Cumberland county Domestic Relations which provides that Husband pays the amount of $550.00 per month in spousal support to wife and maintaining wife on Husband's medical insurance through his employer, UPS. A true and correct copy of said support Order is attached hereto as E~hibit "B". 10. As to marital assets, the two (2) most valuable assets are first: A. the former marital residence located at 1174 Kingsley Drive, camp Hill, Pennsylvania marital residence, which was sold on March 30, 2001 as agreed by the parties; and which has a definite value in the amount of the net sales proceeds, currently held in escrow, in the amount of $44,300; and second, B. Husband's two (2) pension plans: I) the Teamsters Retirement Income Plan, with a current value in excess of $156,218 (as of 12/31/99); and separation value of $120,690 (as of 12/31/97); and 2) the Teamsters Defined Benefit Plan, with a current value in e~cess of $21,000 and a separation value of $20,832. A true and correct copy of the Commerce Bank statement of th,e escrowed sales proceeds is attached as Exhibit "e"; and a true and correct copy of Husband's May, 2000 and March, 1998 Retirement Income Plan statements, stating the $156,218 and $120,690 amounts respectively; and the Pension Appraisers, Inc. valuation report for the Defined Benefit Plan with the separation value of $20,832, are attached hereto as Exhibit "0". 11. Husband submits that regardless of whether the date of separation value or date Of the hearing value is used as to Husband's retirement benefits, Husband's marital share of the net sales proceeds from the marital residence sale should be offset , . . ~ against Husband's Teamsters Retirement Income Plan, which has a minimum value as of the separation date, of $120,690. 12. As to marital debts, after over five (5) years of separation, the only significant marital debt was the mortgage against the former marital residence which was resolved by the sale of the marital residence. wife submits that due to Husband's superior income and/or earning capacity, Husband should incur any payment for any existing marital debts, which to wife's knowledge, are nominal. 13. Plaintiff submits that she is entitled to alimony, alimony pendente litg and continuing medical insurance coverage by Husband after the divorce, as well as attorney fees, for several reasons, including but not limited to, the following facts in further accordance with the Divorce Code: A. the length of the marriage was twenty-five (25) years. B. Husband's annual income has always been significantly greater than wife's income and is three (3) times higher than Wife with Husband at $55,000 to $60,000 and Wife, even including earning capacity, at $16,000 to $20,000. C. Husband's financial Wife. futUre is much more secure than D. Wife is almost fifty the ability to earn economic situation. (50) years old and does not have more money than her current E. Wife had custody of the minor children as of the date of separation and Wife was the primary caretaker of the children during the marriage while they were growing up as HUsband worked. ~~I"'"."~ , ~ - ~ ~"'" F. Wife's entitlement to alimony and need for alimony is evident as Wife has received spousal support in the amount of $550 per month pursuant to the February 12, 2001 support order and prior thereto in the amount of payment by Husband of the mortgage on the former marital residence. 14. Wife submits that she should be awarded alimony and/or alimony Dendente ~ to be paid by Husband in the indefinite amount of $500 per month, for an indefinite period of time: and that Husband is to pay for and/or provide Wife's medical insurance coverage after the divorce until Wife is eligible for coverage through Medicare: ,and which alimony, alimony Dendete lite and medical coverage shall only terminate by Wife's death, remarriage or cohabitation. 15. Wife's proposal for equitable distribution is that Wife is entitled to the majority of the marital estate, for several reasons, including but not limited to, the length of the marriage of twenty-five (25) years: the superior income and earning capacity of Husband: the superior financial future of Husband as compared to Wife: Wife will soon be fifty (50) years of age: and Wife was the homemaker for the parties' three (3) children and custodian of their minor children upon separation, and therefore the marital estate should be distributed as follows: A. Wife to receive the $43,300 in sales proceeds from the sale of the former marital residence in a lump sum: B. Wife to receive sixty-five (65%) percent of Husband's retirement benefits, less thirty (35%) percent of the sales proceeds from the marital residence, which amount~ to $15,155. Said sixty-five (65%) percent, less $l5,155 shall be payable through a Qualified Domestic Relations Order ("QDRO"). ,"""" ,,< _Ill!'[~:i\k C. Wife and Husband to keep any and all personal property in their current possession, including but not limited to, the 1990 Ford Mustang GTO currently in Husband's possession. D. Husband would be responsible to pay any marital debt as determined by the Master. 16. Wife submits that due to the aforesaid facts of the case and Divorce Code factors stated in Paragraph 15 hereto, Husband's retirement benefits should be valued as of the date of the Master's hearing as opposed to the date of separation value, which will better serve economic justice in the division of the marital estate. 17. Length of Hearing: Wife submits that the Master's hearing will take one (I) day. 18. witnesses and Exhipits: Wife's witnesses will be herself and Husband on cross-examination. Wife reserves the right to call additional witnesses. Wife's exhibits will include: I. SpOUSal Support Order. 2. Tax Returns of Husband and Wife. 3. Wage information of Husband and wife. 4. Teamsters Income Plan Statements. 5. Pension Appraisers Report re: Teamsters Defined Benefit Plan. 6. HUD-l Settlement Statement dated 3/30/01 re: sale of marital residence. 7. Commerce Bank statement for sales proceeds escrow amount. 8. Itemization of Attorney Fees of Wife. 9. Invoices re: repairs and/or materials relating to the marital residence. wife reserves the right to supplement the above list of Exhibits. ~""~.~.~ '~- ~~, .. ,<~ "f__ , 19. Special Evidentiary Issues: wife is not aware of any special evidentiary issues, however, there are the standard legal issues as to the valuatiop date, i.e., date of separation or date of hearing, particularly as to the value of Husband's retirement benefits subject to equitable distribution. WHEREFORE, Wife respectfully requests Your Honorable Court to grant the following relief: A. Entry of the final Decree in Divorce; B. Distribution of the marital assets and aforesaid debts as stated above. C. Award Wife alimony, alimony gendente ~ and medical insurance coverage after the divorce and attorney fees and costs. Respectfully submitted: ~~ James W. Abraham, Esquire Abraham Law Offices 513 North Second st. HarriSburg, PA 17101 (717) 232-7825 Attorney for Plaintiff Kathleen M. Groome DATE: ~~ ", .~-"'"' VERIFICATION I, j{.k7lfli='L:J{ u{ ~M&: . , the undersigned, hereby verify and confirm that I have reviewed the foregoing document and the statements therein are true and correct to the best of my knowledge, information and belief. I further understand that any false statements made herein are subject to the penalties of 18 Pa.C.S.A. Section 4904, relating to unsworn falsification to authorities. DATE: 4~~~.2- ~/&hIJ7/1~ "H '",' ..,,"-,""'",- I;' "~ ,J, ~ "'" ~ ~.-- ',,~~ ?~ "...,.-.", ~, 1 040 Department of the Treasury-Intemal Revenue Service ~@99 1(1) U.S. Individual Income Tax Return , IRS Use Only-Do not write or slaDle In thi~ space. For the year Jan. 1-Dec. 31, 1999, or other tax year beglnnlng ,1999, ending \ OMS No. 1545-0074 Label Your first name and initial f2.. Last name .. Your social secuflty number (See L i---('/-i:JfYI(JS ~W1'i- :d()? . '1-"' '(/71' instructions A B If a joint return, spouse's first name and initial Last name : Spouse's social security number on page 18,) E Use the IRS L label. H Home address (number and street). If you have a P,O. box, see page 18. I AP(~I j. IMPORTANT! j. Otherwise, E ()JO )rN'~Tl-- VI v'i... please print R You must enter or type. E ~own or par' office, state, and ZIP (Jde. If you have a foreign address, see page 18. your SSN(s) above, Presidential VV1f> {ru.. ,'I 170\1 Ves No ~ote~ C~eck(r,g Filing Status Check only one box. Exemptions If more than six dependents, see page 19. Do you want $3 to go to this fund? . If a joint return, does your spouse want $3 to go to this fund? . Single Married filing joint return (even if only one had income) Married filing separate return. Enter spouse's social security no. above and full name here..... /9'/ Y0 J Lfyo Head of household (with qualifying person). (See page 18.) If the qualifying person is a child but not your dependent, enter this child's name here. .... Oualifying wldow(er) with dependent child (year spouse died ~ 19 ). (See page 18.) Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax} No. of boxes return, do not check box 6a. . . . . . , . . . . . . . " checked on 6a and 6b b 0 Spouse No. 01 your chlldreoonSc who: . lived with you . did not live with you dlle to divorce orseparalion (see page 19\ Dependents 00 6c notenleredabove_ Add numbe~ IJJ entered on Itnesabovell- d 7 Income Sa Attach b Copy B 01 your 9 Forms W-2 and 10 W.2G here. Also attach 11 Form(s) 1OS9.R 12 if tax was 13 withheld. 14 If you did not 15a get a W.2, 16a see page,20. 17 Enclose, but do 18 not staple, any 19 payment. Also, 20a please use Form 1040-Y. 21 22 23 IRA deduction (see page 26) . 24 Student loan Interest deduction (see page 26) . 25 Medical savings account deduction, Attach Form 8853 26 Moving expenses, Attach FOml 3903 27 One.hall 01 self-employment tax. Attach Schedule SE 28 Se\1-employed heatth insurance deduction (see page 28) 29 Keogh and self-employed SEP and SIMPLE plans 30 Penalty on early withdrawal 01 savings 31a Alimony paid b Recipient's SSN Ir 32 Add lines 23 through 31 a . 33 Subtract line 32 from line 22. For Disclosure, Privacy Act, and Paperwork Reducti Adjusted Gross Income ~~ 5 6a c . " Dependents: (2) Dependent's (3) Dependent's 141~',iI quaH~in9 social security number relationship to child lor child lax (1) First name last name YOU credit lsee 0'"19) 0 0 0 0 0 0 Total number of exemptions claimed Wages, salaries, tips, etc. Attach Form(s) W-2 . Taxable interest. Attach Schedule B if required Tax-ex'empt interest. DO NOT Include on line 8a . Ordinary dividends. Attach Schedule B if required Taxable refunds, credits, or offsets 01 state and local income taxes (see page 21) Alimony received Business income or (loss). Attach Schedule C or C-EZ . Capital gain or (loss). Attach Schedule 0 if required. If not required, check here ~ 0 Other gains or (losses). Attach Form 4797 . ............ Total IRA distributions . ~ U b Taxable amount (see page 22) Total pensions and annuities L!~..J I--.J b Taxable amount (see page 22) Rental real estate, royalties, partnerships, S corporations, trusts, etc, Attach Schedule E Farm Income or (loss). Attach Schedule F Unemployment compensation . Social security benelits . I 20a , " b ~ax~bl~ a~ou~t (s~e ;ag~ 24i Other Income. List type and amount (see page 24) ,,,,,'...........,..,,.,,'......,,,, Add the amounts in the far right column for lines 7 through 21. This is your total income .... 23 24 25 26 27 28 29 ~O 3\a 8b EXHIBIT I~ ,me ~ Cat. No. 113208 ~ Yes Will not change your tax or reduce your refund. I 3. 9 10 11 12 13 14 15b 16b 17 18 19 20b 21 22 /" .0:..::. "33 y c, '1'1 '>5)';0 "'c Fo'm 1040 (1999) ~~ Form 1040 (1999) Tax and Credits Standard Deduction for Most People Single: $4,300 Head of household: $6,350 Married filing jointly or Qualifying widow(er): $7,200 Married filing separately: $3.600 Other Taxes Payments Refund Have it directly deposited! ~ b See page 48 and fill in 66b. ~ d 66c. and 66d. 67 Amount You Owe Sign Here Joint return? See page 18, Keep a copy for your records. Paid Pre parer's Use Only 36 Amount frorr line 33 (adjusted gros~ income) . , . . . . . . , Check if: 0 You were 65 or older, 0 Blind; 0 Spouse was 65 or older. 0 Blind, Add the number of boxes checked above and enter the total here, , .. 35a b If you ,are nlarried filing separately and your spouse itemizes deductions or you were a 'idual~status allen, see page 30 and check here , . , , , ," 35b 0 Enter your itemized deductions from Schedule A. line 28, OR standard deduction shown on t~e left. But see page 30 to find your standard deduction jf you checked any box on line ':358 or 35b or if someone can claim you as a dependent. . , . , , Subtract lint 36 from line 34 . If line 34 is $94,975 or less, multiply $2,750 by the total number of exemptions claimed on line 6d, If lirie 34 is over $94,975, see the worksheet on page 31 for the amount to enter. Taxable income. Subtract line 38 from line 37, If line 38 is more than line 37, enter ~O- Tax (see page 31). Check if any tax is from a 0 Form(s) 8814 b 0 Form 4972 Credit for child and dependent care expenses. Attach Form 2441 41 Credit for the eiderly or the disabled. Attach Schedule R . 42 Child tax credit (see page 33) 43 Education credits. Attach Form 8863 . 44 Adoption credit. Attach Form 8839 . 45 Foreign tax credit. Attach Form 1116 if required 46 Other. Check if from a 0 Form 3800 b 0 Form 8396 cD Form 8801 d 0 Form (spacity) Add lines 41, through 47. These are your total credits Subtract line 48 from line 40, If line 48 is more than line 40, enter ~o- . Seif.empioyment tax. Attach Schedule SE . Alternative minimum tax, Attach Form 6251 Social security and Medicare tax on tip income not reported to employer. Attach form 4137 Tax on IRAs~, other retirement plans, and MSAs. Attach Form 5329 if required Advance earned income credit payments from' Form(s) W~2 , Household employment taxes. Attach Schedule H. Add lines 4~ through 55, This is your total tax. Federal Income tax withheld from Forms W-2 and 1099 1999 estimated tax payments and amount applied fr<!lm 1998 return . Eamed income credit. Attach Sch. EIC IT you have a qualifying child Nontaxable eamed income: amount . . ~ I I I and type ~ '............."m.....'......................... 5ga Additional child tax credit. Attach Form 8812 . 60 Amount paid with request for extension to file {see page 48) 61 Excess social security andRRTA tax withheld (see page 48) 62 Other payments. Check if from a 0 Form 2439 b 0 Form 4136 63 Add lines 57. 58. 59a, and 60 through 63. These are your total payments . ~ If line 64 is more than line 56, subtract line 56 from line 64. This is the amount you OVERPAID Amount of line 65 you want REFUNDED TO YOU. . .. """""~jfr" , Page 2 <J ~ >'10 cl ",2. .. ~ 48 49 50 51 52 53 54 55 56 () \ 1 C' 34 35a 37 38 39 40 41 42 43 44 45 46 47 47 48 49 50 51 52 53 54 55 56 ~ <:) Routing number Account number Amount of line 65 68 if line 56 is more than line 64. subtract line 64 from line 56. This Is the AMOUNT YOU OWE. For details on how to pay, see page 49 . . ~ 69 Estimated tax penalty. Also include on line 68 . 69 Under penalties of periury, I declare that t have examined this retum and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. 57 58 59a b 60 61 62 63 64 65 66a Your signature ~ Spouse's s;gnature. If a joint retum. BOTH mus' sign. Preparer's ~ signature r Firm's name (or yours ~ if self-employed) and address Your occupation Date Date Spouse's occupation Date Check if self-employed 0 Preparer's SSN or PTIN EIN ZIP code Form 1040 (1999) - ~. ~ '0 ~ <- ~~ """""~~,!(f",' W'v ,"" - I !a....., "'- 0 a ~~ '" '" W I V1~ ~ W - ... W, ... I~B z N co . . en 1'-6 0 "'" 0 IWCl>_.-- o~ I ' Ii: 0 I '" . . , I 'f~ I g ;. _3 ...0 I~ , 10, 0 - 0 1 '" 0 I , n' 0 , ~ Q.m'ma "'3iiH;: ~ I j '" !rm:;3.g 2.'8~" ~ ~ 0 H.~~~~ 0 0 -01 Ct> l;I ::f"~'< ~ , ~o---o " O:g ~ c.f3 Z 00 )>1 '< ... CD ,5'.,,<,0 ~~~!H ~ . , '" :-ltlJ.,m:'- en ~ . >'l:.!,,";;- ~ 01 ... '" 0';, ",Q.- ~2: : tl>i S "" g ~, .(f): :'~,,_ "~BH '^ ~ . -0 "" ~ I::~}Y' ~ b ~I~ ... ~ ~...' ~ 0 0 ~=~ cr 0 I g~:,,8,L il~g ~ , . ~.a' " " I '" ~i~H " ~ :: 00 , " w - I 0 > '" ~ '" ~ I 0 0 z < g 0 g " g 0 " ~ , 0 ~ n ~ ~, ~ . ~ = 0 . 1 s . , ~ ~ ~ m ~ . - ~I ~ . " ~, en' V1;:;' <J>" ~ " '< wg w~ ws ~I~' 0 , "'. N. NO 0; 3 ~ ",,0 ....0 ...., , ~I~ . ",= ~~ "', 0 . ~ . , "'''* . I.D€' '" r.c.i WI'" W. w w~ , I . ~ g ~ ;; 0 . . . n . < '" T 0 I " 0 0 0 . 0 g- o 0 g ~ 0 ~ ~ I , 0 0 i ~ ~ ~ 0 n = . . ~. ~ ~ , 0 Q I , 0 . w2 --...J" -I~ "- ~' wa, "'J' m 0 . ....' " 0 ..... o~ <0' 3 , 0"'- ~ , ~~ W. N, " 0,1 :.} 0 . , s ~ 0 U1!i "" - ~ " 0 0 01 .... = ...~ (.Os-: 0 0 " ~ " .- S ~ 1 - " 0 0 0 I a. . '" '" o o " o , 3 . "- ~ ~ . , , o . - ., ,- . 3 ~ ~ . < . ..., ,'- ~', "...'~""'--''''''''''~ CURRENT PAY RATE NJA VACATION 21.76 45.00 CuRRENT TOTALS Y-T-D TOTALS 870.59 979.20 979.20 19,927.70 TAXES fICA 60.71 fICA MEOICARE 14.20 fEDERAL TAX 134.57 ST TAX- PA 27.42 C DAUPHIN 9,79 TOTALS 246.69 DEDUCTIONS UNITED~AY '00 5,0() CREDIT UNION 80,0() TOT ALS 85,00 T I >f< I, ~, WORK LOCATION 94 PO?I 4 TA .. EDER L TATUS 5T TEWO K 208-42-4774 MOO M 00 PERIOD END TOTAL EARNINGS TOTAL TAXES TOTAL 07 15 000 9 4 1,235,52 288.95 2,998,84 557,97 199,27 100.00 1/600.00 .~--". ~ -" -'"" '," In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION KATHLEEN M. GROOME: ) Order Number 00017 S 2001 Plaintiff ) vs. ) P ACSES Case Number 817102950 THOMAS R. GROOME ) Docket Number 00017 S 2001 Defendant ) Other State ID Number ORDER OF COURT <il Final 0 Interim 0 Modified AND NOW, 12TH DAY OF FEBRUARY, 2001 ,based upon the Court's determination that the Payee's monthly net income is $ N/A and the Payor's monthly net income is $ N/A , it is hereby ordered that the Payor pay to the Pennsylvania State Collection and Disbursement Unit FIVE HUNDRED AND FIFTY Dollars ($ 550.00 ) a month payable MONTHLY as follows: first payment due SEE OTHER CONDITIONS. ARREARS INCLUDE FEES OF $30.00 DUE DRO. The effective date of the order is 01/05/01 . Arrears set at $ -110.00 as of FEBRUARY 12, 2001 are due in full 1M MEDIA TEL Y. All terms of this Order are subject to collection and/or enforcement by contempt proceedings, credit bureau reporting and tax refund offset certification and will not be initiated as long as obligor does not owe overdue support. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all the means listed above. F or the Support of: Name KATHLEEN M. GROOME Birth Date EXHIBIT a. Form OE.518 Worker ID 21105 Service Type M I --. GROOME ,~ ""'~'" V. GROOME PACSES Case Number: 817102950 The defendant owes a total of $ sso. 00 MONTHLY $ 500.00 per month payable for current support and $ 50.00 for arrears. The defendant must also pay fees/costs as indicated below. This order is allocated and monies are to be applied as follows: Frequency Codes: Payment Amount! Freqllenc.y $500.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0 .00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 1 = One Time B = BiWeekly 2 = Bi-Monthly 5 =Semi-Annually S =Semi-Monthly A =Annuaily M =Monlhly W =Weekly Q = Quarterly Deht Typp. ne~r.ription Rp..ne:fidary 1M SPOUSAL SUPPORT KATHLEEN M. GROOME I I I I I I I I I I I I I I I I I I I Said money to be turned over by the Pa SCDU to: KATHLEEN M. GROOME . Payments must be made by check or money order. All checks and money orders must be made payable to Pa SCDU and mailed to: Pa SCDU P.O. Box 69110 Harrisburg, Pa 17106-9110 Payments must include the defendant's PACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. Service Type M Page 2 of 4 Form OE-518 Worker ID 2110S - , I . J _~, GROOME V. GROOME PACSES Case Number: 817102950 Unreimbursed medical expenses that exceed $250.00 annually per child and/or spouse are to be paid as follows: 60 % by defendant and 40 % by plaintiff. The plaintiff is responsible to pay the first $250.00 annually (per child and/or spouse) in unreimbursed medical expenses. Gi) Defendant 0 Plaintiff 0 Neither party to provide medical insurance coverage. Within thirty (30) days after the entry of this order, the OPlaintiff Gi) Defendant shall submit to the person having custody of the child(ren) written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at a minimum, of: 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage contract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms. Other Conditions: PAYMENT IS DUE ON OR BEFORE THE 15TH OF EACH MONTH. Defendant shall pay the following fees: Fee Total $ 5.00 $ 25.00 $ 0.00 $ 0.00 $ 0.00 Fee Description furJUDICIAL COMPUTER FEE for COURT COSTS for for per per for Payment Frequencv Payable at $ 5.00 Payable at $ 25.00 Payable at $ 0.00 Payable at $ 0.00 Payable at $ 0.00 per ONE TIME per ONE TIME per Page 3 of4 Form OE-518 Worker ID 21105 Service Type M . GROOME v. GROOME PACSES Case Number: 817102950 IMPORTANT LEGAL NOTICE PARTIES MUST WITHIN SEVEN DAYS INFORM THE DOMESTIC RELATIONS SECTION AND THE OTHER PARTIES, IN WRITING, OF ANY MATERIAL CHANGE IN CIRCUMSTANCES RELEVANT TO THE LEVEL OF SUPPORT OR THE ADMINISTRATION OF THE SUPPORT ORDER, INCLUDING, BUT NOT LIMITED TO, LOSS OR CHANGE OF INCOME OR EMPLOYMENT AND CHAt'JGE OF PERSONAL ADDRESS OR CHANGE OF ADDRESS OF ANY CHILD RECEIVING SUPPORT. A PARTY WHO WILLFUUY FAILS TO REPORT A MATERIAL CHANGE IN ClRCUMSTANCES MAY BE ADJUDGED IN CONTEMPT OF COURT, AND MAY BE FINED OR IMPRISONED. PENNSYLVANIA LAW PROVIDES THAT ALL SUPPORT ORDERS SHALL BE REVIEWED AT LEAST ONCE EVERY THREE (3) YEARS IF SUCH REVIEW IS REQUESTED BY ONE OF THE PARTIES. IF YOU WISH TO REQUEST A REVIEW AND ADJUSTMENT OF YOUR ORDER, YOU MUST DO THE FOLLOWING: CALL YOUR ATTORNEY. AN UNREPRESENTED PERSON WHO WANTS TO MODIFY (ADJUST) A SUPPORT ORDER SHOULD CONTACT THE DOMESTIC RELATIONS SECTION. A MANDATORY INCOME ATTACHMENT WILL ISSUE UNLESS THE DEFENDANT IS NOT IN ARREARS IN PAYMENT IN AN AMOUNT EQUAL TO OR GREATER THAN ONE MONTH'S SUPPORT OBLIGATION AND (1) THE COURT FINDS THAT THERE IS GOOD CAUSE NOT TO REQUIRE IMMEDIATE INCOME WITHHOLDING; OR (2) A WRITTEN AGREEMENT IS REACHED BETWEEN THE PARTIES WHICH PROVIDES FOR AN ALTERNATE ARRANGEMENT. UNPAID ARREARAGE BALANCES MAY BE REPORTED TO CREDIT AGENCIES. ON AND AFTER THE DATE IT IS DUE, EACH UNPAID SUPPORT PAYMENT SHALL CONSTITUTE. BY OPERATION OF LAW, A JUDGMENT AGAINST YOU, AS WELL AS A LIEN AGAINST REAL PROPERTY . IT IS FURTHER ORDERED that, upon payor's failure to comply with this order, payor may be arrested and brought before the Court for a Contempt hearing; payor's wages, salary. commissions, and/or income may be attached in accordance with law; this Order will be increased without further hearing by 0 % a month until all arrearages are paid in full. Payor is responsible for court costs and fees. Copies delivered to parties ;) )1 t;; I 0 \ Date ~~Y' ;'''I.I'.''.=--: .' ','.' ,/ 'h i +'~. .~ r ", /../ ~.;. , Plaintiff ,/ .j '/ J /,;r>;l';' ! 'j,.. Defendant ' / ( _.<.'.::'~~~'I,_/*-:-...-o' ..;'7'",-::-,./ ~/~:~::::~ Consented: _~~;---"..<.... I, PlaintiffJs"Atrorney I'~ " '.,:' , / /' j, .. -"" /- ,,' '''';' .." ~ .",.,-. .,.~ "',' ___~",ro," , '..______~. > _/" .' or' ,.' ,~ ' Defe1:idant's Attorney nRO: M. H. Calvanelli 00: Kathleen M. Groome, plaintiff Thomas R. Groome, defendant Melissa P. Greevy, Esquire James W. Abraham, Esquire Service Type M BY THE COURT: ! . /! ' .~~ ! IJL..L .{ ../ .~/ :.. / I " ~-,- .~7 -- ;..-' : J.{ IWesley Oler,'. J1='~, . I. _ - Judge , Page 4 of4 V Form OE-5 18 Worker ID 2~~05 ,.....---'~ ~ "_ c_ J Commerce "Ban/c Commerce Bank/Harrisburg N.A. 100 Senate Avenue Cemp Hili. PA 17011 888-937-0004 THOMAS R GROOME MELISSA PEEL GREEVY 214 SENATE AVE STE 105 CAMP HILL PA 17011 *** CHECKING *** NOW ACCOUNT NUMBER 0513181842 PREVIOUS STATEMENT BALANCE AS OF 02/15/02 ........................ PLUS 1 DEPOSITS AND OTHER CREDITS.............. ..... LESS 0 CHECKS AND OTHER DEBITS. ... ......... ......... CURRENT STATEMENT BALANCE AS OF 03/15/02 . ........................ NUMBER OF DAYS IN THIS STATEMENT PERIOD 28 BEGINNING RATE ... CHECKING ACCOUNT TRANSACTIONS ... DATE DESCRIPTION 03/15 INTEREST PAYMENT DEBITS CREDITS 10.19 .*. BALANCE BY DATE ..* 02/15 44,279.27 03/15 44,289.46 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE 23-2324730 32.75 *.* INTEREST EARNED THIS STATEMENT PERIOD DAYS IN PERIOD ......................... INTEREST EARNED ........ ....... ......... ANNUAL PERCENTAGE YIELD EARNED (APY).... *** 28 10.19 0.30% EXHIBIT Ie ,. ,"w" \ll:_ . STATEMENT DATE 03/15/02 0513181842 ACCOUNT NO. CYCLE-014 0.30000 44,279.27 10.19 .00 44,289.46 ,--_.~ ~- liJ:.~-P' . THE CENTRAL PENNSYLVANIA ~EAMST~RS RETIREMENT 1055 SPRING STREET WYOMISSING, PA 19610 MAILING ADDRESS: P.O. BOX 15223 READING, PA 19612-5223 1999 ANNUAL EMPLOYEE BENEFIT STATEMENT INCOME PLAN 1987 . 5/2000 GROOME THOMAS R 210 SENATE AVE APT 121 CAMP HILL PA 17011 SOCIAL SECURITY - 208-42-4774 1. BIRTH DATE - 12/01/1952 2. SPOUSE NAME - KATHLEEN GROOME 3. SPOUSE BIRTH DATE - 07/11/1953 4. SPOUSE SOCIAL SECURITY NO. - 191-46-1440 5. REPORTED DATE OF HIRE - 09/01/1977 6. VESTED STATUS - 100% VESTED 7. ESTIMATED NORMAL RETIREMENT DATE ~ 01/01/2010 8. DETAILS OF ADDITIONAL MONIES POSTED TO YOUR ACCOUNT FOR THE YEAR 1999 THAT WERE RECEIVED BY 3/31/2000. EMPLOYER MONTH HOURS TOTAL DOLLARS ------------------------------------------------------------------------------------- UNITED PARCEL SERVICE INC JAN. ,1999 UNITED PARCEL SERVICE INC FEB. ,1999 UNITED PARCEL SERVICE INC MAR.,1999 UNITED PARCEL SERVICE INC APR.,1999 UNITED PARCEL SERVICE INC MAY., 1999 UNITED PARCEL SERVICE INC JUN. ,1999 UNITED PARCEL SERVICE INC JUL. ,1999 UNITED PARCEL SERVICE INC AUG.,1999 UNITED, PARCEL SERVICE INC , SEP.,1999 UNITED PARCEL SERVICE ~N.C ., OCT" 1999 UNITED PARCEL SERVICE INC NOV. ,1999 UNITED PARCEL SERVICE INC DEC.,1999 798.19 798.19 798.19 798.19 798.19 798.19 798.19 841.53 841.53 841.53 841. 53 841.53 TOTAL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9,794.98 9. LATE CONTRIBUTIONS/ADJUSTMENTS TO PREVIOUS YEARS - .00 10. DEVELOPMENT OF ACCUMULATED ACCOUNT BALANCE FROM 12/1998 TO 12/1999 A. ACCOUNT BALANCE AS OF 12/31/1998 - B. ADDITIONAL MONIES RECEIVED DURING 1999 - C. NET EARNINGS ADDED DURING 1999 - D. ACCOUNT BALANCE AS OF 12/31/1999 - 141,700.91 9,794.98 4,722.57 156,218.46 * INCLUDES #9 11. ANNUALIZED RATE OF RETURN EARNED ON THE TOTAL FUND FOR 1999 - 3.6 % NOTE: NET EARNINGS ARE ACTUALLY CREDITED TO YOUR ACCOUNT BASED ON QUARTERLY RATES OF RETURN, THEREFORE THIS RATE CAl'ffiOT BE USED TO VERIFY THE "NET EARNINGS ADDED" AMOUNT ABOVE. YOUR ACCOUNT BALANCE SHOWN ABOVE IS SUBJECT TO ADDITIONS,DELETIONS AND CORRECTIONS. EXHIBIT j 1> ,- ~ ~'""", . T~IC CENT~~L PENNSYLVANIA TEAMSTERS RETIREMENT l055'SPRI~G STREET WYOMI5SING. PA 19610 [NCC~I', PLAN . MAILING AOD~ES5 : P.O. DOX 152?3 READINGt PA 11612""5223 1~97 ANNUAL EMPLOYEE BENEF!T STATEMENT J/J1/9A GROOME THO,'IAS R 210 SENATE AVE APT 121 CAMP HI~L PA 17011 SOCIAL SECUI'ITY -. 7:::'B~'-ic.' 1+ 174 1. BlRTH DAT~ - 12/01/~2 2. SPOUSE NAME - KATHL~EN GROOME J. SPOUSE BIRTH DATE - 7/11/~J 4. SPOUSE SOCIAL SECURITY NO. 191"40-1440 5. REPORTED DATE OF H[PE - 9/01/77 6. VESTED STATUS .- 100% V~5TEO 7. ESTIMATED NOWMAL RETTREMENT DATE. OI/OI/ZOIC B. DETAILS OF EMPLOYER CONTRIBUT[oNS POSTED TO YOUR ACCOUNT Fon THE YEAR 1997 THAT WERE RECEIVED BY 2/10/98. EMPLOYER MONTH PD FOR HOUR~i F..IA I D TO f AL DOLLAPS ____'-._ _..._ ___ ~"... _..... ___ .'. _.~ -...,. ~~." ..._.M.... ~. .. _...,_ ,.. _. ."_ ...... .~....'...u. '.... ..._. .. "<0 ,. ."~""'''.' ".... .....H .... _ '" -. ".' UNITED PARCEL SERVICE UNITED PARCEL SERVICe UNITED PARCEL SERVICE UN[TEO PARCEL SERVICE UNITED PARCEL SERVICE UNITED PARCEL SERVICE UNITED PARCEL SERVIce UNITED PA~CEL SERVICe UN[TED PARCEL SERVICE UNITED PARCEL SERVICE UNITED PARCEL SERVICE UNITED PARCEL SERVICr: [NC INC [NC [NC INC INC INC INC INC INC INC INC JAN. ,97 FEfI,.97 NAR".,97 APR.,97 '.lAY.,97 JUN..97 ..JUL.,97 AUG.,97 SEt-"). t 97 OCf..97 NOV~,97 DEC..,97 621. J') 621.3Y 621..]9 621.J9 621,39 621.. 39 621.J9 621.J-) b21 " -J") t!21 , .3.;0 621, )lJ 621. OJ) TOT A L '. I . , . , . . " " , -t . . . 11 . .. " . . .. .. . . 1Io " . . ~ . " . . . . it <t . . .. II ... .. . . .. . . . 4 ". -, ., 4 5 t. ,I 6 ~ 9. LATE CONTPIRUT[ONS/ADJUSTMENTS TO PREVIOUS YEA~S .. 1~ 10. D[VELOP~fNT OF ACCUMULATED ACCOUNT 8ALANCF FROM 12/9b TO 12/~7 : A. ACCOUNT BALANCE AS OF 1?/31/IY96 - 8. CONTRIBUTIONS RECEIVED DUR[NG lq~7 - C. NET EARNINGS ADDED DUPING 1997 - D. ACCOUNT BALANCE AS OF 12/31/1997 - Q2, '75q~ ~H) 7,456.6B ?':j, 473. H5 120.,690..39 k tNCLUOf: oj #4 11. ANNUALIZED ?ATE OF RETURN EARNED ON fHE TOTAL FUND FOR 1)91 ~ 1 01 1 . ,. NOTE: NET EARNINGS ARE ACTUALLY CREDITED TO YOUR ACCOUNT HAScD ON QUARTERLY RATES OF RETURN. fHEREFORE TH[S RATE CANNOT BE USED TO VERIFY THE "NLT EARNINGS ADDeD" AMOUNT ABove. YOUR ACCOUNT t>ALANCt: 5HUWN ~t:(.VC. I', SUBJ~CT fa ADOITIoNS.DELETIONS AND CORRCCTIONS. ,.,........"~.o~oo . ~:--:: '"l\ ~~I1~, . @ PENSION APPRAISERS INC. . P.O. Box 4396 · Allentown, PA 18105-4396 1-800-447-0084 · Fax 610-770-9342 E-MAIL: penapp@pensionappraisers.com WWW: http://www.pensionappraisers.com August 10, 2001 Melissa Peel Greevy, Esq. 214 Senate Avenue, Suite 105 Camp Hill, Pennsylvania 17011-2336 RE: Present Value of Thomas R. Groome's Defined Pension Benefit File No. OB-06-01-054-2394G Dear Attorney Greevy: We have determined the present value of Thomas R. Groome's defined pension benefit by the GATT Method as of August 6,2001 to be $20,832.89. This valuation was developed and prepared in conformity with the requirements of the Actuarial Standards of Practice No. 34. These Standards were developed by the Pension Committee of the Actuarial Standards Board of the American Academy of Actuaries. The purpose is to set standards for Members and Other Persons Interested in Actuarial Practice Concerning Retirement Plan Benefits in Domestic Relations Actions. Pension Appraisers, Inc. relies on the requestor to provide the information necessary to value pensions. In some cases, information not provided by the requestor may be obtained from plan summaries on file in Pension Appraisers, Inc.'s offices. All information received from the requestor is reviewed for practicability and reasonableness. Any information in question is verified with the requestor, when possible. Any deficiencies in data may materially affect the results of the appraisal. Pension Appraisers, Inc. utilizes the fractional rule allocation method in valuing all pensions for equitable distribution purposes unless otherwise stated. BIRTH DATE: December 1,1952 SEX: Male MARRIAGE DATE: September 7,1974 VALUATION DATE: August 6,2001 PENSION PLAN: Central Pennsylvania Teamsters Defined Benefit Plan DATE EMPLOYMENT STARTED: September 1, 1977 (Assumed date pension holder began participation in the plan) DATE BENEFITS STOPPED ACCRUING: December 31, 1986 (Assumed date pension holder ended participation in the plan) ASSUMED DATE MARRIAGE ENDED: May 15,1997 (Assumed) AGE WHEN BENEFITS COMMENCE: 57 Years "Valuators of Defined Pension Benefits for Equitable Distribution" " ~. "'", . . . . . GATT Actuarial and Mortality Tables Method August 1 0, 2001 Thomas R. Groome - # 08-0S-01-054-2394G Page 2 MORTALITY TABLES: 1983 Group Annuity Mortality Tables INTEREST RATE ASSUMPTIONS: 5.52% 3D-Year U.S. Treasury Bond Constant Maturity Rate for the Month of the Date of Valuation. ASSUMED MONTHLY BENEFIT: $227.08 Monthly pension benefit the pension holder would receive at ' retirement age with a fully vested pension based upon compensation and plan provisions as of December 31, 1986. REDUCTION FOR NON-VESTING: 1.0000 Represents a reduction for the probability of service to 100 percent vesting as equal to the portion already completed. REDUCTION FOR MARITAL COVERTURE FRACTION: 1.0000 Represents that portion of the value of the benefits attributable to the marriage. The numerator of the fraction represents the total period of time the pension holder participated in the plan during the marriage and the denominator is the total period the pension holder participated in the benefits program. PRESENT VALUE BEFORE REDUCTIONS: $ 20,832.89 Reduction for Non-vesting: Reduction for Marital Coverture: x 1.0000 1.0000 x VALUATION FOR EQUITABLE DISTRIBUTION: $ 20,832.89 - .._~ -~ili'1';", ~ . . . . CERTIFICATE OF SERVICE I, James W. Abraham, Esquire, the undersigned, do hereby certify that I have served a true and correct copy of the foregoing document, by first class mail, on the date indicated below, to the following person(s) : Melissa P. Greevy, Johnson Duffie 301 Market St. PO Box 109 Lemoyne, PA 17043 Esq. DATE: 7/5/02 ~~ James W. Abraham, Esq. _. ..~. KATHLEEN M. GROOME Plaintiff IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNA. v. : NO. 00-2750-CIVIL TERM THOMAS R. GROOME Defendant CIVIL ACTION - DIVORCE PLAINTIFF'S INVENTORY AND APPRAISEMENT Plaintiff, Kathleen M. Groome, files the following Inventory and Appraisement of all property owned or possessed by either party at the time this action was commenced and all property transferred within the preceding three years as verified by Plaintiff pursuant to the signed Verification attached hereto and made part hereof. ABRAHAM LAW OFFICES - J#' James W. Abraham, Esq. Abraham Law Offices 513 North Second st. Harrisburg, PA 17l0l (717) 232-7825 Attorney for Plaintiff, Kathleen M. Groome DATE: 1/- S- l) '- "~ ~ L._ "" ~:,! ASSETS OF PARTIiS Plaintiff marks on the list below those items applicable to the case at bar and itemizes the assets on the following pages. (x) (x) ( ) ( ) (x) (x) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) (x) ( ) ( ) ( ) ( ) ( ) ( ) (x) I. Real Property 2. Motor vehicles 3. stocks, bonds, securities and options 4. Certificates of Deposit 5. Checking accounts, cash 6. Savings accounts, money market and savings certificates 7. Contents of safe deposit boxes 8. Trusts 9. Life insurance policies (face,cash surrender value/benef.) 10. Annuities 11. Gifts 12. Inheritances 13. Patents, copyrights inventions, royalties 14. Personal property outside the home 15. Business (owners & percentage, positions held by party) 16. Employment termination benefits/severeance pay/work.comp. 17. Profit sharing plans 18. Pension plans (employee contributions/date plan vests) 19. Retirement plans, IRA's 20. Disability payments 21. Litigation claims (matured/unmatured) 22. MilitaryjV.A. benefits 23. Education benefits 24. Debts due, including loans, mortgages held 25. Household furnishings and personalty (include as a total category/attach itemized list if distribution of said asssets is disputed) ( ) 26. other: 2 ITEM NO. 1 2 5&6 18 18 25 ,-- ~ ~'. 'N"~" MARITAL ASSETS PROPERTY DESCRIPTION NAMES OF ALL OWNERS Real Property - former marital residence 1174 Kingsley Road, Camp Hill, PA (Value: Sold, $44,300 net sales proceeds in escrow) Joint VehiCles: 1990 Ford Mustang GTO ($9,000) 1988 Chevrolet Nova ($400 ) Joint Checking & Savings Accounts Fulton Bank Joint Husband's Teamsters Retirement Income Plan (Value 12/90: $156,218; separation Value 12/97:$120,690; *Projected Current Value: $175,000) Husband's Teamsters Defined Benefit Plan (Separation Value: $20,832; *projected Current Value:$30,OOO) Joint Joint Household personal property ($IO,OOO) Joint *Projected values pending written confirmation) MARITAL DEeTS Defendant is claiming approximately $1,839 in repairs to the former marital residence paid for by Defendant; and Plaintiff is cliaming approximately $1,314 in repairs as well. Defendant makes an insurance proceeds claim of $597 and utility payments of $511. 3 " .. '..,~" NON-MARITAL ASSETS Plaintiff is not aware of any property in dispute which are non-marital property. Plaintiff reserves her rights as to any claim or defense in regard to non-marital property. NON-MAR!TAL DEBTS Plaintiff is not aware of any debts which are non-marital debts and/or are in dispute as to non-marital debts, except the respective claims of Plaintiff and Defendant as the afore stated items under "MARITAL DEBTS". Plaintiff reserves her rights as to any issue or defense in regard to non-marital debts. PROPERTY 'l'RANSF:ERR.ED No property of the marital estate has been transferred or converted by Plaintiff, except of the sale of the marital residence on March 30, 2001 by both Plaintiff and Defendant. It is unknown as to any property of transferred and/or converted by Defendant, however, Defendant may have done so. Plaintiff reserves her rights as to any claim or defense as to property transferred or converted by Defendant. 4 ll<i<'!., VERIFICATION i' I, tA7lfU::'2:'I1. iiI- ~ , the undersigned, hereby ;,' if verify and confirm that I have reviewed the foregoing document and the statements therein are true and correct to the best of my knowledge, information and belief. I further understand that any false statements made herein are subject to the penalties of IS " I:; DATE: 5i?rJ/6;b / -f-P//AJ.,m ~ ( I" I I'; I Pa.C.S.A. Section 4904, relating to unsworn falsification to authorities. .....,c. ~- - ~~'",. CERTIFICATE OF SERVICE I, James W. Abraham, Esquire, the undersigned, do hereby certify that I have served a true and correct copy of the foregoing document, by first class mail, on the date indicated below, to the following person(s) : Melissa P. Greevy, Esq. Johnson Duffie 301 Market St. PO Box 109 Lemoyne, PA 17043 DATE: 7/5/02 James W. Abraham, Esq. 118biirtiliii"fJbb" JUJlJIIIL . MI. ~a :.IlllflilIllIMili!ll~ru~,t!".~'!1"'~~~_W~ ,~,_ ,,~, ~~, "',,'-'" =J~ -"<-,, -'~ ,"~ " ",'~"- "" '""'-~~'~~ .. .~Jaill:il ' - ...... & .1 '"..^- o c.::. ""(]t{ ?2':~'~; ?~;1;:_ =--< ~.-:: "~ _.~ ?;t~ '7 ~ .'~ ',~ I'.) ," . ,,',~, ;',~ ~ -,--'-"\ , _...iT\ _.';':';:-7 :-------. : ~~ ;~,:.rn ':::--1 ~ :'b -< c -.0 ~A) :J1 ....J > - , . o '--_ .0'': . .. . " . .. KATHLEEN M. GROOME Plaintiff : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNA. . . v. : NO. 00-2750-CIVIL TERM . . THOMAS R. GROOME Defendant : CIVIL ACTION - DIVORCE PLAINTIFF'S INCOME & EXPENSE STATEMENT Plaintiff, Kathleen M. Groome, files the following Income & Expense Statement in the above-captioned action pursuant to Pa.R.C.P. 1920.31 as acknowledged and affirmed by Defendant pursuant to the signed Verification attached hereto and made part hereof. ABRAHAM LAW OFFICES ~ ~ :') James W. Abraham, Esq. 513 North Second st. Harrisburg, PA 17lo1 (717) 232-7825 Attorney for plaintiff, Kathleen M. Groome DATE: ?-S-O'J.- . 'i _J__ "^ ~ ~ . . . INCOME ANt> EXPENSE STATEMENT PLAINTIFF, KATHLEEN M. GROOME Silver Coast Winery 6680 Barbecue Road. Ocean Isle Beach. NC 28469 Office AS!ilistant ' Per Period: $7,00/hr. for 30-35 hours.: $388.50 bi- weekly Deductions: (See attached paystub) Federal Withholding: Social Security: Medicare: Local Wage Tax: State Income Tax: Unemployment: Retirement: savings Bonds: credit Union: Health Insurance: Life Insurance: Union Dues: Other (Specify): Employer: Address: Position: GrosS Pay Net Pay per period: Net Monthly Wage Income: other Income (Net Amounts): Interest: Dividends: Annuity: Social Security: Rents: Royalties: Expense Account: Gifts: Unemployment Compensation: Worker's Compensation: Other (Specify): Spousal Support Total: Total Net Monthly Income: INCOMl!: $ 327.78 $ 7l0.19 Month ~ 500.00 $ 500.00 $ 1.210.19 $ 6.000.00 ~ .........." "~ ~ Residence: Mortgage/Rent Utilities: Electric Gas Telephone Water/Sewer Personal: Food & Clothing Other Automobiles: Payments: Insurance: Repairs/Maintenance: Medical: Doctor: Dentist/Orthodontist: Hospital: Medicine: Special Needs: (eye care, etc.) Education: Private/Parochial School: College: Credit payments: Credit cards: Charge Accounts: Memberships: Outstanding Loans: Creditor: Creditor: Miscellaneous: Household Help: Child Care: pay/cable TV: papers/BooksfMagazines: Legal Fees: Charitable Contributions: Vacation: Entertainment: Gifts: Other (Specify): Support/Alimony: Total Expenses: , " " -", ... .. EXPENSES Month ~ 500.00 6.000.00 175.00 2.100.00 50.00 600.00 400.00 4.800.00 350.00 4.200.00 50.00 600.00 25.00 300.00 25.00 300.00 30.00 360.00 100.00 1.200.00 37!;1.QO 4.500.00 $ 2.080.00 $ 24.960.00 -~" ~. ...""" = '';'~I~~fu&"i ::,;::;',}:Y< .,<';'.... .::nf: <:,; '. .. ''I. ''---..-'<'.'..-...-.'. 'J" "".'.l" """':r.' -',;'.:, .cU. 54-2940 KATHLEENll(i GROOM SS# 191-46-14 0 EMP# Earrli(1g~ Current 388.50 726.25 0294000009 Taxes 60.72 109.45 Dep Per Beg Per End Check Date Check No. De 3 726.25 MEDICARE SOC sec FEDERAL NORTH CAROLIN Deductions and Taxes Deductions Amount YTO Amount 5.63 lQ,53 24.09 45,03 14.04 23.01 16.96 30.88 Earnings Type REGULAR Rate 7.0000 Quantity 55.50 Amount 388.50 Year to Date SILVER COAST WINERY 6680 BARBEQUE ROAD OCEAN ISLE, NC 28469 Accruals Balance Taken VACATION SICK HOLIDAY PERSONAL Direct Deposits and Net Pay Prepared By ~llllY'~l3~~.m " Net pay heck Amt 327.'78 327.7 'I DETACH ALONG THIS PERFORAT -~ .'^ - . "'~ , .. . VER;J:FICATION I, Kathleen M. Groome, the undersigned, hereby verify and confirm that I have reviewed the above Income & Expense statement and the information therein is true and correct to the best of my knowledge, information and belief. I further understand that any false false statements made herein are subject to the penalties of Title 18 Pa.C.S.A. section 4904, relating to unsworn falsification to authorities. DATE: 54&-~~ / / /frd~~/!2~ 22 Add the amounts in the far ri ht column for lines 7 through 21. This is your total income Ill- 23a Your IRA deduction (see Instructions) 23a b Spouse's IRA deduction (see ins1ructions) 23b 24 Moving expenses. Attach Form 3903 or 3903.F 24 25 Ona.half of self-employment tax. Attach Schedule SE 25 If line 31 is under 26 Self.employed health insurance deduction (see inst.). 26 $28.495 (under 27 Keogh & self-employed SEP plans. If SEP, check ~ 0 27 $9.500 if a child 2B Penalty on early withdrawal of savings 2B did not live with you), see 1he 29 Alimony paid. Recipienl's SSN ~ 29 instructions for 30 Add lines 23a through 29 . line 54. 31 Subtract line 30 from line 22. This Is our adju ed gross,income V:or Priva€fy Act and PaperWork Reduction Act Notice, see page 7. /'.' f1040 Label IS.. pag,-11.) L . e E L Use the IRS label. Otherwise, please print or type. P,esldenttal Eleelion Campaign It. See age 11. r 1 Filing Status 2 3 4 H E R E Check only one box. 5 6a Exemptions b c If more than six dependents, see the instructions for line 6c. d Income 7 Ba Attach b Copy B of your 9 Forms W~2, 10 W-2G, and 1099-R here. 11 If you did not 12 gel a W-2. 13 see the 14 instructions 15a for line 7. 16a Enclose, but do 17 not attach, any 16 payment. Also, please enclose 19 Form 1040.V 20a (see the instructions 21 for line 62). Ad justed Gross Income ",,-,~\ - - Department of the Treasury-Internal Revenue Service U.S. Individual Income Tax Return ~@96 (1) IRS Use Only-Do not write or staple in thiS space. , 1996, ending , 19 OMf! No. 1545-0074 Your soclal security number Spouse's social security number Apt. no. For help finding line instructions, see pages 2 and 3 In the booklet. City. town or post office, stale. and ZIP code. If you have a foreign address. see page 11. Yes No Nete: Checking "Yes" will nol change your tax or reduce your refund. Do you want $3 to go to this fund? . If a joint return, does your spouse want $3 to go to this fund? . o o Single Married filing joint return (even if only one had income) Married filing separate relurn. Enter spouse's social security no. above and full name here. ~ Head of household (with qualifying person). (See instructions.) If the Qualifying person Is a child but not your dependent, enter this child's name here. .... Quallfyin widow(er) with dependent child ( ear souse died ~ 19 ). (See instructions.) Yourself. If your parent (or someone else) can claim you as a dependent on hIS or her tax} No. 01 bOles return, do not check box 6a. . . . . . . . . . . . . . . . checked on lines 5a and 6b Spouse. . . . . . . . . . . .. ......... No. 01 your children on line 6cwho: .lIvedwllhyoll . dId nolllve with YOll dllelo divorce orseparsllon (seelnstructlonsl_ Dependents on 6c nolenleredabove_ Add numbers entered on IInesabllve ~ Dependents: (2) Dependent's social (3) Dependenl"s (4) No, of monlhs security number,ll born relaliorlshiplO li~djnyour (1) Firsl name Lasl name in Dec. 1996. see inst. 'ou home in 1996 [2J Total number of exam \lons claimed Wages. salaries, tips. etc. Attach Form(s) W-2 Taxable Interest. Attach Schedule B if over $400 . Tax-exempt Interest. DO NOT Include on line 8a 8b Dividend Income. Attach Schedule B if over $400 Taxable refunds, credits, or offsets of state and local income taxes (see instructions) Alimony received BusIness Income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). If required, attach Schedule 0 Other gains or (losses). Attach 'Form 4797. .. .,........ Total IRA dIstributions. . ~ LJ b Taxable amount (see jnst.) Total pensions and annuities ~ J OJ-I? '1 ~ b Taxable amount (see ins!.) Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Farm income or (loss). Attach Schedule F Unemployment compensation . . Social security benefits . 120a I '1 b Taxable amount (see inst.) Other income. List type and.~mount-see instructions _.._.._______....._._______..... ,::; L J 2 ~? 2;- 9 10 11 12 13 14 15b 16b 17 18 19 l. (, t),2t 20b ~ ~ ,/, "''' ~'<\ Form 1040 (1996) Cat. No. 11320B "' ""' "t '~ = '" - r 'm 1040 (1996) Tax Compu- tatiol. If you want the IRS to figure your tax, see the instructions for line 37, Credits Other Taxes Payments Attach Forms W-2, W-2G, and 1099-R on the front. Refund Have it sent directly to your bank account! See inst. and fill in 6Db. c. and d, Amount You Owe Sign Here Keep a copy of this return for your records. .d1. ~ ~--.,\ Amount from Une 31 (adjusted gross Income) . . . . . , . . . , . . Check If; 0 You were 65 or older. 0 Blind: 0 Spouse was 65 or older, 0 Blind, Add the number of b9xes checked above and enter the total here. IJl- 33a G,';) ~c,;1 Page 2 )} 32 33a 3<l b If you are married filing separately and your spouse itemizes deductions or you were a dual-status allen, see instructions and check here . ... 33b 0 j Itemized deductions from Schedule A, line 28, OR Enter Standard deduction shown below for your filing status. But see the t,he Instructions If you checked any box on line 33a or b or someone arger can claim you as a dependent. of your: 0 Slng10-$4.000 0 Married filing Jointly or Qualifying wldow(er)-$6,700 . Head of household-$5,900 . Married filing separately-$3,350 Subtract line 34 from line 32 . If line 32 is $88,475 or less, multiply $2,550 by the total number of exemptions claimed on line 6d. If line 32 is over $88,475, see the worksheet in the inst. for the amount to enter Taxable Income. Subtract line 36 from !tne 35. If line 36 Is more than line 35, enter -0- Tax. See instructions. Check if total Includes any tax from a 0 Form(s) 8814 b 0 Form 4972. . . . . . . . . . . . . O~ /0'ib:f ') ) \' :1<;(0 00 r 35 36 37 36 ~ 39 Credit for child and dependent care expenses. Attach Form 2441 39 40 Credit for the elderly or the disabled. Attach Schedule R . 40 41 Foreign tax credit. Attach Form 1116 41 42 Other. Check if Irom a 0 Form 3800 b 0 Form 8396 c 0 Form 8801 d 0 Form (specify) 42 43 Add lines 39 through 42 44 Subtract line 43 from line 38. If line 43 Is more than line 38, enter -0- . ... 45 Self-employment tax, Attach Schedule SE . 46 Alternative minimum tax. Attach Form 6251 47 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 . 48 Tax on qualified retirement plans, including IRAs. If required, attach Form 5329, pJ 0 . 49 Advance earned income credit payments from Form(s) W-2 50 Household employment taxes. Attach Schedule H . 51 Add lines 44 throu h 50. This is our total tax. 52 Federal income tax withheld from Forms W.2 and 1099 53 1996 estimated tax payments and amount applied from 1995 relurn , 54 Earned Income credit. Attach Schedule EIC If you have a qualifying child. Nontaxable earned Income: amount.... I I I and type ~ ..............h.h.hhhh...................... 55 Amount paid with Form 4868 (request for extensIon) . 56 Excess social security and RRTA tax withheld (see Inst.). , 57 Other payments. Check if from B 0 Form 2439 b 0 Form 4136 58 Add lines 52 through 57. These are our total payments . ~ 59 If line 58 is more than line 51, subtract line 51 from line 58..This Is the amount you OVERPAID 60a Amount of line 59 you want REFUNDED TO YOU. ~ ~ b Routing number rrr::::o=IJI[] c Type: 0 Checking 0 Savings 43 44 45 46 47 48 49 50 51 , .... d Account number 81 Amount of line 59 ou wanl APPLIED TO YOUR 1997 ESTIMATED TAX ~ 82 If line 51 Is more than line 58. subtract line 581rom line 51. This is the AMOUNT YOU OWE, For details on how to pay and use Form 1040-V, see Instructions. . ... 63 Estimated tax penait . Also Include on line 62 . 63 Under penalties of perjury, 1 declare that I have examined this return and accompanyIng schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on an Information of which pteparer has any knowledge. ~ Your signature ~ Date '(our occupation Spouse's signature. It a Joint return. BOTH must sign. Date Spouse's occupation Paid Pre parer's Use Only . . Date I Preparer's social security no Check if self-employed D : I EIN I ZIP code Preparer's ~ signature , Firm's name (or yours ~ if self.employed) and address . . Conlro! number I I Copy C For EMPLOYEE'S RECORDS (s.. Notice back.) 1,\_1:,\ on OMS No. 1545-0008 b Employer's Identification number 1 Wages. Ilps, olher compensalion 2 Federal income lax withheld :>r'.; 1 f.[~[,;C' I '1 ,'I',. " I I " , c Employer's name, address, and ZIP code 3 Social securily wages 4 Social securily tax withheld ! III'.!.I F. ~11.:PCIII)l'lr!:' .-~; ;~:~ 1 '-i . ;'-"'\ \ '~':\ (,j ;.1\ l:nlfP('iI fII. V.U 5 Medicare wages and lips . Medicare tax withheld , . (H'I[" I-I1U., r'n I lfllj 1. ." 't(l. ".) il(" (, ~~ 7 Social security tips . Allocated lips d Employee's social security number . Advance E1C payment 10 Dependent care benefits \ {):I ".It-Cl 1/1./"(,71 Employee's name, address, and ZIP code 11 NonquaHfled plans I-:,-----~-~-- e 12 Benelils included in box I l'nnIU::FN 1'1. l~nl)[!I'IF 13 See Instrs. for box 13 14 Other l. 7/~ .~Jl\fGra ['.Y fUlfil) ['n cilll I (,II '(IW" 1111.100' r'n t lOt 1 15 Stalulory Deceased Pension legal Hshld Subtolal Deterred employee plan '"p .m, compensalion ,. State Employer's s_late 1.0. No 17 State wages, tips, etc. ,. Slate Income tax 19 localilyname 20 local wages, tips. elc. 21 local income tax 'n .1_____._ :\;c: 1 ') . ;,;~.) f) 't~. j .,5 j;::' I.':). ;~" () " 1") .- ---- .---------. ------- --_.-------..----- ....-------...--- ------"-------- ----.-....--.--. H__H... H...._ , I 39.1754529 Department of lhe Treasury - Internal Revenue Service ~W.2 Wage and Tax 1996 Statement This information is being furnished to the Internal Revenue Service. If you are required to llIe a tax return. a negligence penalty or other sanction may be imposed on you if this income is taxable and you fail to report it. , . , - "",~. ~,,-- STATEMENT FOR RECIPIENTS OF PA This form shows Ihe lotal unemR,oyment compensation paid to UNEMPLOYMENT COMPENSATION PAYMENTS you In the tax year Indicated. T 1s Is important tax information and Is being furnIshed to the Internal Revenue Service (IRSh- If P~e" you are required to file a rei urn, a ne~ligence penally or 01 af sanction may be imposed on you jf th S income is taxable and C MMONWEALTH OF PENNSYLVANIA the IRS determines thai it has not been reported. For Income DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF UC BENEFITS AND ALLOWANCES tax purposesf unemployment compensation beneUts are HARRISBURG, PA 17121.0001 reported In the calendar year in which they are paid regardless of when the claim for beneflls was flied, No Income !ax was withheld bt The Department of Labor and OMS NO. 1545-0120 FEDERAL NO. 23-6003107 Industry from any of your bene it payments. . . . .. . . ". . . . " "' SOCIAL SECURITY NO. TOTAL PAYMENT TAX YEAR Dear Racl~ent: YOU MAY BE ELIi'3IBLE FOR I THE EAR ED INCOME CREDIT, which Is a 191-4&-14'-10 $1.6&&.00 199& Federal benefit for both married and single parents who worked either full or part time during all of or ~ RECIPIENT'S name, address, zip code part of the year and earned less than the Federa! qualifying amount. If you are eligible, you will either owe less taxes or qualify for a larger tax return. KATHLEEN H GROOM To file for the Earned Income Credit, fill oul and attach "Schedule EIC" to your Federal income tax 1174 KINGSLEV R~ return. For more Information, call the IRS lollltee at j-800-829-1040. CAMP HILL PA 17011-&110 NOTE: If you were overpaid benefits, and repaid the amount, it is still included in the "TOTAL PAYMENT". If the repayment was made in the same year as the OV8dayment, make the necessary adjustment an notation on your Tax Form 1040 or 1 Q40A. Receipts you have from the Instruollons to Reolplent: Plesse make an~ correollons to your address Dept. of Labor & Industrrr may be used as your on lhe allached postcard: delaeh and ma III wllh lhe proper poslage. prool for adjustments cia mad. UC.1Q99G REV 1.97 . . . E 1 4 Department 01 the Treasury-Internat Revenue Service ~@971(1\ ~ U.S. Individual Income Tax Return IRS Use Only Do not wnte or staple in thIs space For the year Ji'ln. 1-Dec. 31. 1997, or other lax year beginning . 1997,ending ,19 I OMS No. 1545.0074 Label Your first name and initial last name Your social security number (See L /q (, 9&. I C/L!IJ A instructions B If a joint return, spouse's first name and initial Last name Spouse's soda! securlty number on page 10.) E : Use the IRS L label. H Home address (number and street). If you have a P.O. box, see page 10. I Apt. M. For help in finding line Otherwise, E instructions, see pages please print R 2 and 3 in the booklet. or type. E City, town or post amee, state, and ZIP code. If you have a foreign address, see page 10. Presldenlial Yes No ~ole,: Checking 22 Add the amounts in the far right column for lines 7 throu h 21. This is your total income .... 23 IRA deduction (see page 16) , 24 Medical savings account deduction. Attach Form 8853 25 Moving expenses. Attach Form 3903 or 3903~F , 26 One-half of self-employment tax. Attach Schedule SE 27 Self-employed health insurance deduction (see page 17) 28 Keogh and self-employed SEP and SIMPLE plans 29 Penalty on early withdrawal of savings 30a Alimony paid b Recipient's SSN ~ 31 Add lines 23 through 30a , 32 Subtract line 31 from line 22. This is our adjust~'Jd grqss ilflcorne F6r Privacy Act and Paperwork Reduction Act Notice, see page 38. ,~'~ o 0 Filing Status Check only one box. Exemptions If more than six dependents, see page 10. 7 Income 8. Attach b Copy B of your 9 Forms W-2, 10 W-2G, and 1099.R here. 11 11 you did not 12 get a W-2, 13 see page 12. 14 15. 16. Enclose but do 17 not attach any 18 payment. Also, please use 19 Form lQ40-V. 20. 21 Ad justed Gross Income If line 32 is under $29,290 (under $9,770 if a child did not live with you), see EIG ;nst. on page 21. <"~. .,- , I~ "~- ~ Yes Will not change your lax or reduce your refund Do you want $3 to go to this fund? . 1f a joint return, does your spouse want $3 to go to this fund? . Single Married filing joint return (even if only one had income) Married filing separate return. Enter spouse's social security no. above and full name here. . Head of household (with qualifying person). (See page 10.) If the qualifying person is a child but nol your dependent. enter Ihis child's name here. . Qualif in widower with de endent child ( ear spouse died. 19 ). (See a e 10.) Yourself. If your parent (or someone else) can claIm you as a dependent on hIs or her tax} ND. 01 boxes return, do not check box 6a. . . .. .......... checked on 6aand6b b 0 Spouse. . . . . . . . . . No. or your c Dependents: (21 Dependent's (3)'Dependent's (4) ,No. of month~ ehlldren on 6e social securi'" number relalionshiplo hvedlnyour who' ~ (1) First name las' name '1 ou home in 1997 at-> . lived wilh you .JOIL~ I. . d1dnelll,"wilh ~ you due to divoree orseparallon (seepage11) Dependents on fie nolenteredabove_ Add numbers entered on Iinesabove,," 5 j 6. d Total number of exemptions claimed [ill Bb Wages. salaries, tips. etc. Attach Form(s) W.2. Taxable interest. Attach Schedule B if required Tax-exempt interest. DO NOT include on line 8a . Dividends. Attach Schedule 8 if requked . Taxable refunds, credits. or offsets of slate and local income taxes (see page 12) Alimony received Business income or (loss). Attach Schedule C or C-EZ Capital gain or (loss). Attach Schedule D Other gains or (losses). Attach Form 4797 ....... . . Total IRA distributions. ~ U b Taxable amount (see page 13) Total penSions and annuities ~ U b Taxable amount (see page 13) Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E Farm income or (loss). Attach Schedule F Unemployment compensation . Social security benelits . I 20. I Other income. list type and amount-see page 15 ............. ................. 9 10 11 12 13 14 15b 16b 17 18 19 20b DD I' b ~ax~bl~ a~ount (s~e pag~ 14) :;j 23 24 25 26 27 28 29 30. '- .-- .- --- 'I ~ Cat. No. 113208 Form 1040 (1997\ I>j Form 1040 (1997) Tax Compu- tation If you want the IRS to figure your tax, see page 18. Credits Other Taxes Payments Attach Forms W~2, W-2G, and 1099-R on the front. Refund Have it directly deposited! .... b See page 27 and filt in 62b,.... d 52c, and 52d. 63 Amount You Owe Sign -- "~, Page 2 33 Amount from line 32 (adjusted gross income) , , . . , ., , 34a Check if: 0 You were 65 or older, 0 Blind; 0 Spouse was 65 or older, Add the number of boxes checked above and enter the total here. 1 35 b If you are married filing separately and your spouse itemizes deductions or you were a dual~status alien, see page 18 and check here . lltem,zed deductions from Schedule A, line 28, OR Enter Standard deduction shown below for your filing status. But see the page 18 if you checked any box on line 34a or 34b or someone larger can claim you as a dependent. ~~ur: - Single-$4,150 - Married filing jointly or Qualifying widow(er)-$6,900 - Head of household-$6,050 . Married filing separately-$3,450 Subtract line 35 from line 33 . If line 33 is $90,900 or less, multiply $2,650 by the total number of exemptions claimed on line 6d. If line 33 is over $90,900, see the worksheet on page 19 for the amount to enter . Taxable Income. Subtract line 37 from line 36. If line 37 is more than line 36, enter ~o. Tax. Se'e pa e 19. Check if an tax from a 0 Form s 8814 b D Form 4972 . .... .. ) 36 37 38 39 40 Credit for child and dependent care expenses, Attach Form 2441 40 41 Credit for the elderly or the disabled. Attach Schedule A . 41 42 Adoption credit. Attach Form 8839 . 42 43 Foreign tax credit. Attach Form 1116 43 44 Other. Check if from a 0 Form 3800 b 0 Form 8398 cD Form 8801 d 0 Form (specify) 44 45 Add lines 4Q through 44 46 Subtract tine 45 from line 39. If tine 45 is more than line 39, enter ~O~ . 47 Self~employment tax. Attach Schedule SE . 48 Alternative n1inimum tax. Attach Form 6251 49 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 50 Tax on qualified retirement plans (including IRAs) and MSAs. Attach Form 5329 if required 51 Advance earned income credit payments from Form(s) W~2 . 52 Household employment taxes. Attach Schedule H, 53 Add lines 45 through 52, This is your total tax , ~ 45 46 47 ~. - 46 ------, 49 -'-::0 50 --, 51 ----, 52 ~ 53 -- .. 54 55 58a 57 56 59 60 Federal income tax withheld from Forms W~2 and 1099 1997 estimated tax payments and amount applied from 1996 return . Earned Income credit. Attach Schedule EIC if you have a u lifyin child b Nontaxable earned income: amount .... - and type" -__ . ___ __ ---_________ -- ;:3J;iJ?f)- _.0./. Amount paid with Form 4868 (request for extension) ., Excess social security and RATA tax withheld (see page 27) Other payments. Check if from a 0 Form 2439 b 0 Form 4136 59 Add lines 54, 55, 56a, 57, 5B, and 59. These are your total payments , .... If line 60 is more than line 53. subtract line 53 from line 60. This is the amount you OVERPAID Amount of line 61 you want REFUNDED TO YOU, , .. Routing number mTITI .... c Type: 0 Checking 0 Savings 61 62a Account number 64 If line 53 is more than line 60, subtract line 60 from tine 53. This is the AMOUNT YOU OWE. For details on how to pay, see page 27 . ... 65 Estimated tax penalty, Also include on line 64 , 65 Under penalties of periury,I declare that' have examined this return and accompanying schedules and statements. and to the best 01 my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) i$ based on all information of which preparer has any knowledge. Here Your signature Date Your occupation Keep a copy ~ 5pouse's signature. . ot this return If a joint return, 80TH must sign. Date Spouse's occupation for your records. Paid Preparer's ~ Date Check if Preparer's social security no Preparer's signature self-employed 0 : Firm's name (or yours ~ EIN Use Only 1f serf~employed) and , ZIP code address ~.. " 8 Control number Copy C For EMPLOYEE'S RECORDS 0 M 5 See Notice on beok of Co B. b Employer's identification number 1 Wages, lips, other compensation 2 Federal income tax withheld ~ ~ ~ ~1~ n -, '1 C mployer's name, address, and ZIP code 3 Social se'ctiri wages 4 Social security {ax \-Vit~ eld I\[)V r,nCEJD BUSUmSS i ,":"1 ., " PPODUCTS, INC, 5 Medicare wages and tips 6 Medicarelaxwth ed' 1901 CHESTNUT S'I'PEH~T ., ~l '"I C 7 Social security IpS 8 Allocaled tips , d Employee's social securIty number 9 Advance EIC payment 10 Dependent care benefits e e'mployee's name: address, end ZIP code 11 ,Nonqualified plans 12 Benefits included in box 1 1\I\TBLEEN H. GROOHE Other\ 1174' RINGSLEY'ROI\D 13 See Instrs.lorbox'13 14 . Pi\ Cr,r'IP HILL 17011 5Stalutory Deceased Pension Legal employee plal1 rep. HShld, 'mp Oelerrecl compensation , 16 Stale Employer's state 1.0. No. ... En. .23.-:2.479.173.... 11 Slalewages, lips,ete. 18 State income lax 19 Localily name 20 Local wages, lips. etc. 21 Local income lax ...6.,.727,..3 _.. ..10.8.3. ~;JJ~ST .~UI( R.. .6.721 ...J!,..... .C~~,. 2:, & W-2 Wage and Tax Statement Department of the Treasury-Internal Revenue Service This information is bein~ furnished 10 the Internal Revenue Service. If you are required to file a lax relurn, a negligence penally or other sanclion may be imposed on you If this income is laxable and you fail 10 reporl il 1997 ....._.~c~,-::- -:::::-;;;;;::;::::::T=-'=-==:;,:~=-::::,: =:.=:-= 8 Control number Copy C For EMPLOYEE'S RECORDS 8 See Notice on beck of Co 8. 1 Wages, lips, other compensation 2 Federal income tax withheld M b Employer's Identification number ~ " ~ ADVI\NCED BUSINESS PRODUCTS, INC, 1901 CHESTNUT STRElElT n1 3 Social securi wages 4 .,- c 5 Medica~e wages an tIps 6 Medicare lax witn e d ~ 7 Social securi i'ps 8 Allocated tips 9 Advance EIC payment 10 Dependent care benefits 11 Nonqualilied plans 12 Benefits included in box 1 13 See.lnstrs.lor box 13 14 Other ., c mpldyer's name, address, and ZIP code " ~ d Empl~yee's sClClal security number e Employee's name: address, and ZIP code 1\I\THLEEN 1,1, GFOOrm 1174 KINGSLEY ROAD CnHP HILL PA 17011 5Statulory Deceased Pension Legal employee plan rep. Hshld. emp. Delerred compensation 16 Stale Employer'S state 1.0, No. 17 Slalewages,lips,etc. 18 Slele Income lax 19 Localllyname 20 local wages, tips, etc. 21localincomelax ... En. .23.-:2A79.173 __.. ..... .023-.3..____ .23. 0.' ~JES:r. .SJI R... .02.3..3 ....... n. 2.3 'j W:'2 Wage and Tax Statement @epartment of the Treasury-Internal Revenue ~ervice This information is bein9 furnished to Ihe Inlemal Revenue Service. If you are reQuired 10 file a tax return, a negligence penally or other sanction may be imposed on you If this income is taxable and you !ailto report 11. 1997 ~.. ~~\" , , I \2\U I)!, II 1-1" I ~ i-' ~ !I' Il"j-.:; 1\5: - I' , Ii; 1111 'I' ;:0 'ill 'i" " ill] I ... liH; ....,0>' ~ i II:j" ~ t." ,i'el. ;; ~ 17 ,~ :;: '" C'l :l> ::0 OJ o Z ,- rn '" '" ....J"" -0 ::0 ;: z 9 >< ... Ie I I~ 1::<:1 t ii,,; "1": 1;1 ^' I I " \ ;'7.t ,! ~ , !'I i' I 1'.."1, ,,- " I . i<,i , ':[1; Ii i II;! I, "T1 ! 0 0 I' ::0 110 3:: ill Z I 9 li"'1 ~ ![1.l, 1,1\: ~ ': i - ~ I(:;:~ lJ ~ II,,,,' .:;: I, _ 11'171 ,0 I rn }Il :;: II-I' ~ '.1" ~!~ '1?1 . ~ ::,,, 0 Ii I Z i t~.~ h1 :1;;1 ~ '~I" j'J 110"" ~.. ~ ,0 ~ rl,i ~co r-- 00 zo ~o' ~...t' N ",' 'S .! ~~ ~ . ~ . O~ "jN: 'io ~o a , ao ~r-- . .fM 'i E "'" 0 . Ol 0 , ~ - ' 0 Ol .- , . ~ '2 , . . ... ! ,~ 0 . ~ '---- ~ 0 . ~ '" ~ M N i'<t . gj '<I' 0: 0 0 0 L{j lf1 lf1 ~ r-- " . . .-4 d , E \.0, i;;: ,'l\.O tJ 8 '<1', ~... E-l~ <J) ~co ,co ~co C 'S...t'1 E'o::Jl ~'<I' .D::~ 0:: o . ~ 0 .; . ~~~ , , 8 t;D:: u ~ 0 w . ~ ~ E-l a: :- . . ~ .. 0 Np'u) D en""::: u ~ ~:E E iu ~3 0 . , '" ~ ~a::r: - w - M ^ ::lUf-l ~~ ~ lf1 ~tI:z , 0 ...IE D '<I' ~ ~ . I1.w ; ;UE-l . :i! 0" 0 .. - 0 EJ:iI ~ u w_. S! 0 _ . D .-4 ~E-l .~ . If.:!; r-l .~ lf1 ~HCI) . -. 00-= .-4 . N ~H 0 . ~ "'. o~ , S!r::(0:2:: 0 ~IllC 0 M ~t:iMu:l " o ttt3 E E O~<d W N WOM~ w D 0 ~ . , u:!::: -- .- 00 =0. ~. .. _0 .- E~ ~~ ~~ .:;; ~;2 -~ $. '0"; ~e 58 ~f.s ~"~ ~5 ,- ~g ,,~ u.ig 'O~ 2:1 ,-og. .t~ .. OD 5~ -. ~E Eo .0 Dp .0 -0 o. ~~ E5 o~ c~ ;~ ~. ~o . ~ o o ~ N ~ - . ~ .; o~ '<I'~ '<I'~ .-4. , E \.0 ~ <::fl -: >- I ~ .-4~ O\~ .-4w . ~ :EQ aD:: a D:::>< 0~ >-1 :EUJ 0>-1 ZZ>-1 J:ilHH ~i>::::r: >-1 ::r:'<I'1>< E-lr--~ ~~U .-4 .-4 o r-- .-4 ~ - -- -- ;0 c ~o ~ . .E ~ E ~ ~. ~ . -E ~ .0 0 ~ 00 u W E .. . "~ 0 ;; c ;; <; ~ c , ~ . '" ~ '" . ~ ,; :i:r:i 0 ., x. 0 . ~ c ~ 5 ~" . . ~ ~ II ~ "~ ~ E .. , c u 0 ~ c "c 0 ~ z i~ . ; ~. ~ 0 ~o ~ . 0 ~~ . 0 ~ . . . . 0 . D 0 'p . D ~. ~ " ~ .. 0 o~ c ;.2 , c ~ " "0 . ., . ~ ~ "'. c .. . u 0 . 0 . . on 0 '" , e ~ ~ . lf1. ",. 09 O. r-lS lf1~ NC , " , MW ~~ 1><'" . o r-- ('01l)Cl;l o::JlO ~~ ,- ,^ , ~- ., '. ~M ~ ~ . ~ e Control number I I OMS No, 1545-0008 0000290 b Employer's Identification number 1 Wage$, lIps, other compensation 2 Federal income tax withheld 23-2388403 987.52 90.00 c Employer's name, address, and ZIP code 3 Social security wages . Social security tax withheld WINDOWS & MORE, INC. 1080.63 67.00 541 BRIDGE STREET 5 Medicare wages and tips 8 Medicare lax withheld NEW CUMBERLAND, PA 17070-1931 1080.63 15.69 7 Social security tIps 8 Allocated tips d Employee's social security number 9 Advance ErC payment 10 Dependent care benefits 191-46-1440 e Employee's name, address, and ZIP code 11 Nonquallfled plans 12 Benellts included In box 1 KATHLEEN GROOME ,. See lnstrs. for Form W.2 " Other 1174 KINGSLEY ROAD D <13,\\ CAMP HILL PA 17011 15 Statutory Deceased Pension Legal Hshld, Sublotal Deterred emptoyee plan lOp emp, compensallon 0 0 0 0 0 0 0 16 St~te Employer's state 1.0. No. 17 State wages, tips, etc. 18 Slate Income lax 19 Locallly name 20 Local wages, lips, ote 21 Local Income lax _J'l\_J.________._____________________ ____tQ_~_9_,_9)_ _____~rr,p_ WS 1080.63 10.80 ......n..nn_ .. - -- -.. -. _....- -... ------...--.....-- I E W 2 Wage and Tax 199 7 ~ . Statement Copy 1 For State, City or Local Tax Department or Copy D For Employer , ~ lf1. M. .-4; , o ~ .co ~'" . , o o .E $ ;; . 0 v.; .3 ~ N 1; :i . o o lf1 ' ~ \.0. ",,% co. ",g . , $! ;;; , 0 U) .3 :::: ?;: 00 gLfllfl . ' , .,j1..01..O go:;t'<c;tI .,jOOOO g.<;jio;;;fl , , c . , . :; ~ . ~ ~ .~X . EU~ G> ~OE-i :;' ~...:i 3 ~ ~ ';" go\OO-l $ ~.-10 ~ - " Department of the Treasury-Internal Revenue Service For Paperwork Reduction Act Notice, see separate Instructions. '. "~.....;........... ~. "-'"",._._"~ ~ ' ......d.... "I 1 Wages, tIps, other compo 2 Federallncolt,e tax Wlth~ 420.44 .41 , Social security wages , Social security tax wfthheld 420,44 26.07 5 Medicare wales and lips . Medicare tax wfthheld 20,44 6.10 : II Control Number I Depl COTp.! rEmplayer use o5~ GROlee 02T c Employer's name, address, and ZIP code MOVIE MERCHANTS INC 48 CENTRAL BLVD CAMP Hill, PA 17011- Batch# 00066 b Empl,er'. FED 10 number d Employee's SSA number 5-1686211 191.46.1440 7 Social security tips II Allocated tips . Advll"ce EIC payme"t 10 Depe"de"1 care benefitlll :11 No"qulIUfled plll"a 12 Be"effta If'lCluded In box 1 13 See '"alt&. for box 13 14 other 1'5 Stllemp.ID~sedlpe"'Io"Plln legllrep.rShld.emp.feferredeomp. en Employee'a neme, addreaa a"d ZIP code KATHLEEN M, GROOME 1174 KINGSLEY ROAD CAMP Hill, PA 17011- 16 StatalimPIOY&r'aataleID 17 Slate wagea, I pa, elc. PA 25.16e6211 420.44 18 Slate IMoma tax " locality neme 11.78 HAMPOEN T 20 Local wages, Ups, ate. 21 local Income tax 420.44 4.21 . Employee Referehc9CO~., ," W - 2 W;faie':atnn~:.,1. 97 Copy C for Emlllovee', RecOnI& -, -: , - '.;, oM,e ,No. 164S-oooil lY!:l/ VV-"2. C1IIU l:J.uillllhlUi:;) "UIVIIVII.\1i I ~,r~~;:~:",~:,;:-",;,.rf;:~,~,-,,,~:v,,~,,,:,,,'m:",.,,,,_r~_~~~"-:':",~~r"::'_-:""-"~:_""", ,:'.:",',-''',',~'':'"'''_~'',' "~-"', -',-' .'-' liffii3'bj!i6:~ifnlhiiiMn;~itV ~~~il~H i. Includlid wli~yo~f W.2 icih.lp descrlb. portions In !nore deten. ,:."ifji,!I,~lai. !\lalilnajUll68iil~.fAjIIiMfii\iliiol\ .Ikil yoU iiiilval'oflM ~illpiul. ." . . ..... r;~1~!~lH~.~nd_~hg."irtf~~~i~8~\Tm!tf~~tit,hn.i Ud7 piysklK jiiui'AhY adJu&tmenh4 $ubmltted by your 'mpioyer, r.'ii'.;,'~.;!!."aroa.p,y",,: :,.".42iL44 "SocIOISecurliy 2607. pA.Ste'elncorileT.. 11 7B '" \'- ""1 "'." '. '. ' JaxWlthheld . Box 18ofW-2 . Box 4 of W-2 local Income Tax 4.21 Box 21 of W.2 SUIiSDI Box 14 01W.2 Fed, income TllX Withheld Box 2 of W.2 ,41 Medicare Tax Wl1hheld Box 6 of W'2 6,10 2. Your Gross Pay Was Adjusted a. follows to produce your W-2 Statement, Wages, nps, other PA, State Wages, HAMPDEN T Compensation Tips, Etc, Local Wages, Box 1 of W-2 Box 17 of W-'2. Tips, Etc. Box 20 of W-2 420.44 420.44 Social Security Wages Box 3 of W.2 Medicare Wllges Box 5 of W-2 Gross Pay Reported w ~ 2 Wages 420,44 420.44 420.44 420.44 420.44 420,44 420.44 420,44 3. Employee W~4 Profile To change your Employee W-4 Profile Information, file 8 new W-4 with your payroll dept. KATHLEEN M. GROOME 1174 KINGSLEY ROAD CAMp HILL, PA 17011- Socia! Security Number: 191-46-1440 Taxable Marital Status: SINGLE Exemptions/Allowances: FEDERAL: 0 STATE: LOCAL: 0 C 1997 AUTOMATIC DATA PROCESSING_ INC -V-FOLDANODeIACHHeRe~ STATEMENT FOR RECIPIENTS OF PA This form shows the total unemployment compensation paid to you by the UNEMPLOYMENT COMPENSATION PAYMENTS Department of Labor andlndustry in the tax year Indicated, and the amount Payer: of Federal Income tax Withheld Of you requested tax withholding). This is COMMONWEALTH OF PENNSYLVANIA Important tax Information and Is being furnished to the Internal Revenue DEPARTMENT OF lABOR AND INDUSTRY Service ORS). If you are required to file a return, a negllgence penalty or BUREAU OF UC 8ENEFlTS AND AUDWANCES other sanctIon may be Imposed on you ~ this income is taxable and the IRS HARRISBURG,PA 1712J.ClOOl determines that n has not been reported. For Income lax purposes, unem- ployment compensallon benefits are reported In the calendar year In OMS NO. 1$45-0120 Fed&r81IQ NO. 23<<lQ3107 which they ere paid, r~gerdle" 01 When Ihe clall1l lorbenem,' wss mod, . i ': .. . . . . . . ;- .. . . - ~ SOC, SEC. NO, I TOTAL PAYMENT TAX WITHHELD I TAXYR. 191.46.1440 1$ 272.00 $ ,DO I 1997 Oear Reolplent YOU MAY BE ELIGIBLE FOR THE EARNED INCOME CREDIT, which is a Federal ben. REC1PIENT'S name, eddress, zip code eftt for both married and single parents who worked either full ar part time during an af or part af the year KATHLEEN H GROOM and earned less than the Federal qualifying amount. 1174 KINGSLEY RD If you are eligIble, you will either awe less taxes ar qualily for elerger lax telurn. To file for the Earned CAMP Hill PA 17011.6110 Income Credit, fill out end attach "Schedule EIC' to your federal Income tax return. For more informa- lion, cali IhelRS tali Iree ell.BCJO.B29.1 040 NOTE: If you wera overpaid benefils, and repaid Ihe emount, ~ is ,1i11 included In Ihe 'TOTAl PAYMENT". lithe repayment was made In the same year as the overpayment, make the necessary adjustment and noletion on your Tax Form 1040 or 1040A, Receipts Instructions to Reclplent: Please make any corrections to your address on you have Irom the Dept. 01 Lebor & Industry may be the attached postcard; detach and mall It with the proper postage. used as your proof for adjustments claimed. <D ~ ifj a: '" ~ " " 1.- o. B Dedaration~ []]J[] --.:~ ITIITI -[]] IRSUseOnl --Oonotwriteorsta lelnthlss ace. Form 8453 U.S. Individual Income Tax Declaration OMB No. 1545.0936 for Electronic Filing Fortheyear January 1 ~ December31, 1998 1998 Department of theTreasury ~ See Instructions l Your first name and Initial Last name Your social security number Use the A KATHLEEN M. GROOME 191-46-1440 B IRS label. E If a Joint return, spouse's first name and initial Last name Spouse's social security no. OtherNlse, l please H Home address(numberand street). If you havea P.O. box, see Instructions. Apt. no. ... IMPORTANT ... print or E 1174 KINGSLEY RD You must enter type. R City, town or post office, state, and ZIP code your SSN(s) above. E CAMPHILL, PA 17011 Telephone number(optional) I Part I I Tax Return Information 1Wh0le dollars onlv\ 1 To!allncome (Form 1040, line 22; Form 1040A, line 14; Form 1040EZ, line 4) 1 16,114 2 To!al!ax (Form 1040, line 56; Form 1040A, line 34; Form 1040EZ, IinelO) . 2 271 3 Federal income tax withheld (Form 1040, line 57; Form 1040A, I1ne35; Form 1040EZ, line 7) 3 263 4 Refund (Form 1040, line 66a; Form 1040A, line 410; Form 1040EZ, line 11a) 4 1,646 5 Amountvou owe (Form 1040 line 68' Form 1040A line 43' Form 1040EZ IInel2) 5 I Part III Declaration of Taxpaver (Slcn onlv after Part lis comDleted,) 6a~ I consent thai my refund be directly deposited as designated In the eleclronlcportlon of my 1998 FedelallncomeTax return.1f! have filed a Joint return, this is an Irreyocable appointment of th e other spouse as an agent to receive th e refund. A bO I do not want direct deposll of my refund or I am not receiving a refund. T T AW cO C 2 I authorize (1)the U.S. Treasury and Its designated Financial Agentsto Inillate an ACH debit (automatlcwllhdtawl)enlry to my H G financial Institution acoount designated in the electronic portlon of my 1998 Federal Income tax retuln for payment of my Federal C A o N taxes owed, and (2) my financial Inslllutlon to debit the entry to my account. t also aulhorlze the flnanclallnslitullons Involved ~ 0 In the processing 01 my electronic payment of taxes to receive eonfldentlal information necessary to answer Inquiries and resolve B 1 Issues related to my payment. 0 o 9 !I I have filed a balance due return, I understand that if the IRS does not receIve full and timely payment or my tax liability, 1 will remain liable F 9 F R for the tax liablllty and all applicable Interest and penalties. III have filed ajoint Federal and state lax return and there is an error on my state o H return, I understand my Federal return will be rejected. R E M R Under penalties of perjury, I declare that the Information 1 have given my ERO and the amounts In Part I above agree with the amounts on the S E W corresponding I1nes of the electronic portion of my 1998 Federal Income tax return. To the best of my knowledge and belief, my return ,Is true, 2 cotrect, and complete. I consent to my EROsendlng my return, this declaration, and accompanying schedules and statements to the IRS. ! also consent to th e IRS sending my ERO and/or transmitter an acknowledgement of receipt of transmission and an Indication of wh ether or not my retuln Is accepted, and, if rejected, the le8son(s) lor the reJection. If the processing 01 my return or relund Is delayed. lauth orlze the IRS to disclose to my ERO andlor transmitter the reason(s) lor the delay, or wh en the lefund was sent. :~;,:::"~NL y 0". ~ ~~,~~;,~~.L ~IO;OI "'",0, 80TH moo' ';'0 Declaration of Electronic Return Originator (ERO) and Paid PrepaTer See Ins!ructlons, Date I declare that I have reviewed the above taxpayer's return and that the entries on Form 8453 atBcomplete and corlect to the best 01 my knowledge. If I am only a collector, 1 am not responsible lor revieWing the return and only declare that thlsform accurately rellectsthe date on the return. The tal/payer will have signed this form before , submit the return. I wUl glvethetaxpayer a copy of all forms and Informatlon 10 be flied with Ihe IRS, and have rollowed all other requirements In Pub. 1345, Handbook for Electronic Return Originators 01 Individual tncomeTax Returns. II I am also the Paid Pteparer, under penalties of pelJury I declarethat I have examined the above taxpayer's return and accompanying schedules and statements, and to the best of my knowledge and belief,they are true, correct, and complete. This Paid Preparer declaration Is based on all Information of which t have any knowledge. ERO's Use Onl \ ERO's ~ sl nature r Firm's name 'yours If self- empl eo) and address Date 2/1/99 ASTERN TAX HARRISBURG, Your social security number PA Under peOllnles of perjury, I deelarethat I have examined the above taxp er's retufn and aceompanying sehedules and statements, and to the best of my knowledge and belief. they ale true, correct, and complete. This declaration is based on all Information 01 which I have any knowledge. Preparer's Paid sl nature PrepaTer's Flrrn'sname (oryours U 0 I If self- employec) se n and address KBilI ' For Paperwork Reductlcn Act Notice, seelnstructlcns, Date Preparer's social security no. ., EIN ZIP code Form 8453 (1998) Form 8453D (1998) FD84530.1V 1,91 ".'. "~ - , .- ~, c, ." ,-~ rOOf,' Earned J'ncome C.redit Worksheet- - Line 69a (keeo forvourrecordsl KA.THLEEN M GROOME 191- 46 -14 40 Caution: If you were a household employee who did not receive a form W- 2 because your employer paid you less than $1 ,000 In 1998 or you were a minister or member of a rellglC)usorder, see Special Rules on page 24 before completing this worksheet. Also see Special Rules If Form 1040 includes any amount paid to an Inmate In a penallnstltuition. 1, Enler the amount from Form 1040, line 7 ... . . . . . . . . . . . . 2. Uyou received a taxable Mholarshlp or fellowship grant that was not reported on a W- 2 form, enter the amount here. 3, Subtract line 2 from line 1 ......................,.,.,.",.,...."."...,. 4. Enter any nontaxable earned f"come (see the next page). Typesofnonlaxable earned Income Include contributions 10 a 401 (k) plan, and military housing and subsistence. These should be shown In box 13 ofyourW. 2 form . . . . . . . 5. If you were self- employed or used Schedule C or C- EZ as a statutory employee, enter the amount from the worksheet on the next page. . . . . . . . . . . . . . . , . , , . , , . , . , . , , , . , . . , . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . , . 6. Add lines 3, 4, and 5 .. . . .. . .. .. .. .. .. . .. .. .. .. .. .. .. . .. .. .. .. . .. .. .. .. ..' ..... 7. Look up the amount on Iihe 6 above in the EIC Table on pages40-42 to find your credit Enterthecredithere .... ................................ s. EnteryourmodifiedAGI (see this page) ............. ...... ..... 9. Is line SIess than-- . $5,600 If you do not have a qualifying child? . $12,300 If you have at least one qualifying child? o Yes. Go to line 10now. ~ No. Look up.the amount on line 8 above in the EIC Table on pages40.42 to find your credit. Enter the credit here 10. Earned Income credit. . If you checked "Yes" on line 9, enter the amount from line 7. . If you checked "No" on IIne9,enterthesmallerofline70rline9 ............ Next: Take the amount from line 10above and enter it on Form 1040, line 59a. AND If you had any nontaxable earned income (see line 4above), enter the amount and type of that income in the spaces provided on line 59b. AND Ccmplele SchedUle EIC and a!lach It to your return Only liyou have qualifying child. Note: If you owe the alternative minimum tax (Form 1040, line 51), subtract It from the amount on line 10above. Then enter the result (if more than zero) on Form 1040, line 59a, Alsc, ,eplacetheamounton line 10abovewllh the amounlentered cn Form 1040, line 59a, lffiling a joint return and yourspousewasalso self- employed or reported Income and expenses on Schedule C or C- EZ asa statutory employee, combine your spouse's amounts wRh yours to figure the amounts to enter below. 1, If you are filing SchedUle SE: 8. Enterthe amount from Schedule SE, Section A, line 3, or section B, line 3, whichever applies . .1a. b. Enter the amount, tfany, from ScheduleSE,Sectlon B, line 4b .......... ............ .1b. c. Addtlnes1aand 1b '''. ....... ........... ..... ...........1c. d. Enterthe amount from Form 1040,l1ne27 ..................... ..... .1d. e.Subtractline1dfromlc.. ........ ... ........... ...................1e. 2. If you are NOT required to file Schedule SE (for example, because your net earnings from 5elf- employment were lessthan $400), complete lines 2a through 2c. But do not Include on these lines any statutory employee Income or any amount exempt from self- employment tax as the result ofthe IiIlng and approvalo1Forrn4029 orForrn4361, a. Enter any net farm profit or (loss) from Schedule F I line 36, and farm partnerships, Schedule K-l (Form 1 OG5), Une 15a .............. ............................... .. 2a. b. Enler any net profit or (loss) 1rom Schedule C, line 31, Schedule C- EZ, line 3, and Schedule K-l (Form (065), line 15a (other than farming) . . . . . . . . , . ,.. ............."............. ... 2b, c,Addlines2aand2b.Enterlhelotalevenlfalcss .....".,......... .,.' 3. If you are filing SchedUle C orC- EZas a statutory employee, enter the amount from line 1 of Schedule C or C- EZ 4. Add lines 1 e, 2c, and 3. Enterlhelolal he,e and on line 5cilhewo,ksheelon page 23 even If a loss. If the resultisa loss, enter It in parenttheses and read the Caution below ..... . . . 1. 2, 3, 16,114 o 16,114 4, o 5, 6, o 16,114 7, 1,654 8. 16,114 9, 1,654 . . . . . . . . . . . .10, 1,654 . .2c. .3, 4, Caution: If line 5 of the E:arned Income Credit Worksheet Is a loss, subtract It from the total ofl1nes 3 and 40fthat worksheet and enterth~ result on line 6 ofthatworksheet.lfthe result Is zero or less, you cannot take the earned income credit. " " EIC Chklist (1998) FDEICQUA-1V1,2 ~ ~."~ .c-. ~ .Jii"_ IRS USE ONLY 01011998 29 OMB 1040Pc FORMAT U.S. INDIVIDUAL INCOME TAX RETURN 1998 NO. 1545-1309 PAGE 01 OF 01 KATHLEEN M<GROOME 191-46-1440 30 1174 KINGSLEY RD CAMPHILL PA 17011 PPECF N SPECF FS 4 6A-SELF X DEP RES 01 6D-TOTAL 02 DEPD INFO 6C1--JAMIE<GROOME----- 6C2----------173688269 6C3--DAUGHTER--------- 6C4------------------X 1040 PAGE 1 7----------------16114 22---------------16114 33---------------16114 1040 PAGE 2 34---------------16114 36----------------6250 37----------------9864 38----------------5400 39----------------4464 40-----------------671 43-----------------400 48-----------------400 49-----------------271 56-----------------271 57-----------------263 TOTAL INCOME TOTAL PAYMENTS LINE 22 LINE 64 59A---------------1654 64----------------1917 65----------------1646 66A---------------1646 PREP-LEONARD SCHWARTZ- FIRM-H AND R BLOCK EAS ADD--5072 A JONESTOWN- -ROAD------------- CSZ--HARRISBURG PA 171 -12-0000---------- PEIN--------43-1632899 POCC-CLEARICAL-------- 6A------------------12 ADD INFO PDI---------1000000000 SEI------------------- SC------------------01 DIR DEP INFO 66B----------031300834 660-----------90086228 66C------------------C SCHEDULE EIC - 43 1A---JAMIE<GROOME----- 2A----------------1982 4A-----------173688269 5A---DAUGHTER--------- 16114 1917 TOTAL TAX REFUND LINE 56 LINE 66A 271 1646 Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. For Information Only - Do not File Your Signature Date For Information Only - Do not File Spouse's Signature Date Preparer's Signature For Paperwork Reduction " 02011999 Date Act Notice IRS USE ONLY OF 01 Statement, see Taxpayer PAGE 01 Notice 974 01011998 29 " " _"H' . ~iIJ.'Wli<iw Child Tax Credit Worksheet - line 43 Do Not File KATHLEEN M GROOME .. KeeDforvourrecords. 191-46-1440 1, $400.00 X 1 , Multiply and enter the result 1, 400 .. Enter number of qualifying children (see page 31) ~. Are you filing Form 2656, 2556- EZ, or 4663, or are you excluding Income from Puerto Rico? ~ No. Enterthe amount from Form 1040, line 34. } . . , , . . , . 2. DYes. Enteryour modified adjusted gross Income (see page 31). Enter the amount shown below for your filing status: · Married filing jointly, enler $11 0,000 . Single, head ofholJsehold, orqualifylngwidow(er), enler $75,000 16,114 4. . Married filing separately, enter $55,000 Is line 2 more than line 3? ~ No. Skip l/nes4and 5,enter-O- on l/ne6,andgo to line 7. o Yes. Subtract line 3 from Une 2 } 3, 75,000 3, 4. 5, Divide line 4 by $1 ,000.lfthe resull is nol a whole number, round it up to the next higher whole number (for example, round 0.01 to 1) .5, 6. Multiply $50 by the number on line 5 . 6, 0 7, Subtract line 6 from line 1. If zero or less, stop here; you cannot take this credit. 7, 400 8. Enter the amount from Form 1040, Une 40. .8, 671 9, Is line 1 above more than $8007 ~ No. Add the amounts from Form 1040,lInes41, } 42, and 44. Enterlhetolal 9, 0 0 Yes. Enterthe amount from the worksheet on page 33. 10, Subtract line 9 above from line 8 . 10, 671 11, Child tax credit. Enterthe smaller of line 7 orJine 10here and on Form 1040, line 43 . 11, 400 ITiPl Ifllne 1 above Is morelhan $800, you may be able to take the Additional Child Tax Credit. ~ Seepage31. KllA " " .. W.,.\F.,hL f;Tf": I1QCllH I=nr,Tr,~ 1V 1 ?d " - Form 1040A Label ~ -, ~~ ". "" Department of the Treasury - Internal Revenue Service u..s. Individual Income Tax Return .. 1999 IRS UIe Oh - Do not wrRe or Ila Ie In thIs B ace. OMS No {545-0065 (see the YOl./f ArsI Name and Inlllal laslName Your Social S&curlty Number instructions.) KathleEm M GrOome 191-46-1440 If a Jolnl Return, SpOUge'S Flrsl Name and '"Rial La"Name Spou,e'. Social SecurIty Number Use the IRS label. Home Address (number and slreel). If You HaVEl a P.O. SO)(, See Instructions. Apt Number Otherwise, 1174 KINGSLEY ROAD ! Important! ! please print City, Town Of PoBi Office, State, and ZIP Code, If You Have a Foreign Address, See Instructions. You must enler your or type, CAMP HILL PA 17011-0000 SSN(s) above. Presidential Election Campslgn Fund (See Instructions.) Yes No Note: Checking 'Yes' will not Do you want $3'10 go to this fund? _ . . - ... . X change your tax or reduce II alolnt return, does your spouse want $3 10 00 to this lund? - , your refund. Filing 1 "= Single status 2 - Married filing joint return (even if only one had income) 3 Married filing separate return. Enter spouse's social security number above and full Check only one box. Exemptions 4 name here. . . .. ... ~ Head of household (wilh qualifying person), (See Instructions.) If the qualifying person is a child but not your dependent, enter this child's name here . ~ Quali In widower with de endent child ear sOUSe died'" 19 , See Instructions. Yourself. " your parent (or someone else) can claim you as a dependenr on his or her tax retum, do not check box 6a . . . . . . . . . . . . . . . . . . . . . . . 1 I".' j II " I; 5 6. 1 No. of boxe:!l che(:kedon . 6sand6b. b n Spouse , - c Dependents. (2) Dependen!'s (3) Dependen!'s (4) v, No. 01 your quallfylng chrfcfrenon social relationshIp child lor 6cwho: security number to you child lax . lived (1) First name Last name credh with you . 1 " more Ihan JAMIE K GROOME 173-68-8269 Dauqhter . dldnot seven dependents, live with see instructions. you due to divorce or geparatlon. ~ Dependenl.:!l on6c not enlered abo~e ~ Add number9 I 21 d Total number of exemolions claimed. entered on llnesabove. 13 a Social security benefits. . . , . . . . . . 13a 13b Taxable amount 14 Add lines 7lhrough 13b (Iar rtghl column), This Is your retellncome - , . , . . . , - , , 15 IRA deduction (see Instructions) .,.".,.. - . 15 16 Student loan interest deduction (see instructions) . 16 17 Add lines 15 and 16, These are your tota' adjustments . 18 Subtrect line 17 from line 14, This Is your adJusted grosslnceme- BAA For Paperwork Reduction Act Notice, see Instructions. Income Allach Copy B of your Form(s) W-2 here. Also attach Form(s) 1099-R n tax was withheld. If you did not gel a W-2, see Instructions, Enclose, bu1 do not staple, any paymenl. Adjusted gTOSS income .' 7 Wages, salaries, lips, etc. Attach Form(s) W-2 . 8 a Taxabie Interest, Attach Schedule 11f required. b Tax~exempt Interest. Do not include on line 8a 8 b 9 Ordinary dividends, Attach Schedule 1 if required 10aTotallRAdistributlons. . . _ . .. 10a 10bTaxableamount. 11 a Total pensions and annul11es. . . . 11 a 11 b Taxable amount 12 Unemployment compensallon, qualified state tulllon program eamlngs, and Alaska Permanent Fund dividends. . . . . . . . 7 8a 9 10b 11 b 12 13b .. 14 16,053. 16,053. 17 .. 18 16,053, Form 104M (1999) FDIA1312 ,-11'10199 ,. .' ,-~-..- ~~~I .- Kathleen M.Groorne Form 104M (1999) Taxable 19 Enter the amount from line 18 inc<lme Tax, credits, and payments Refund Have it directly depostted!See instructions and filii" 41b, 41c, and 41d. 191-46-1440 Page 2 16,053, 19 { 8 You were 65 or older 8 Blind l- Enter number of Spouse was 65 or older Blind _ boxes checked . b If you are married filing separately and your spouse Itemizes deductions, see Instructions and check here . . . . . . . . . . . . . , . . . . . . . 20. Check If: ~ 20eD ~ 20bO 21 Enter the standard deduction for your filing status, But see Instructions if you checked any box on line 20a or 20b 01" If someone can claim you as a dependent. . Single - $4,300 . Married filing jolnUy or Qualllylng widow(er) - $7,200 . Head of household - $6,350 . Married filing separately - $3,600 22 Subtraclline 21 from line 19. If line 21 Is more than line 19, enter O. 23 Multiply $2,750 by the total number of exemptions claimed on line ad 24 Subtract line 23 from line 22. If line 23 is more than line 22, enter O. This Is your taxable Income . . . . . , . , , , . . . . . . , . , . 25 Find the tax on the amount on line 24 (see Instruc1ions) 26 Credit for child and dependent care expenses. AtlachSchedule2.............. 26 27 Credit for fhe elderly or the disabled. Atlach Scheduie 3 27 28 Child tax credll (see Instructions) . 28 29 Education credits, A1tach Form 8863. . . 29 30 Adoption credit. Atlach Form 8839 . 30 31 Add lines 26 through 30. These are your total credits 32 Subtract line 31 from line 25. If line 31 Is more than line 25, enter O. 33 Advance earned income credit payments from Form(s) W-2 34 Add lines 32 and 33. This Is your lolal lax . . 35 Total federal income tax withheld from Forms W-2 and 1099 . . . . . . . , . . . . . , . . . . . . . 21 6,350, 22 9,703, 23 5,500. ~ 24 4,203, 25 634, 31 32 33 ~ 34 634, 634, 293. 35 36 1999 estimated tax payments and amount applied from 1998 retum. . . . . . . , . . . . , . . . . . 37 a Earned Income credit. Attach Schedule E1C if you have a qualifying child. b Nontaxable earned income: amount ~ and type ... 38 Additional child tax credit, Attach Form 8812 .. ....., 38 39 Add lines 35l 36, 37a and 38. These are your total payments. . . . . .. ... 39 40 If line 39 Is more lhan nne 34, subtract line 34 from fine 39. This is the amounf youoverpald..,.,....,.. 40 41 a Amount of line 40 you want refunded to you . . . . . . . . . . . 41 a b Routing number ~ 031300834 cType: ~Checklng o Savings d Account number ~ 90086228 42 Amount of line 40 you want epplled 10 your 2000 estlmaled tax, . . , . , . . . . , . . . . , , . , . , , . ., 42 36 37a 1,734, 2,027, 1,393, 1,393, Amount you owe Sign Here Joint relum? Set:! Instructions, Keep a copy for your records, Paid PTeparer's Use Only " 43 If line 34 Is more than line 39, subtract line 39 from line 34, This Is the amount you owe, For details on how to pay, see Instructions. , . . . 43 44 Estimated tax penalty (see Instructions) . . . . , . . . , , .. 44 Under penallies of perjury, I dedare that I have examIned this return and accompanying schedules and statements, and to the best of my knowledge and belfef, they are true, correct, and accufalefv fist air amounts and sources of Income I received during fhe tax yeer. Oeclarallon of preparer (other lhan Ihe taxpeyer)Is based on an Information of which the preparet has any knowledge. Your SIgnature Date Your Occupalkm Daytime Telephone Number (optional) ~ OFFICE WORKER Spouse',. Oecupsllon Spouse's SlgnallNe. " JoInt Return, 80Ih Mum Sign, ""., Date Preparer's ~ Signature SELF-PREPARED Atm'sName Irrrt... (or yours If ,.. self-employed) and Addrass EIN ZIP Code FD!Al3l2 '111,0/99 ., F.or'1',1040A (1999) Schedule EIC (For", 1040A 0' 1040) Earned Income Credit Qualifying Child Information Complete and attach to Form 1040A or 1040 only if you have a qualifying child, OMS No. 1545.0074 Oepartmem of the Treasury Inlema.l Aevenue Servlce Name(s) Shown on Return 1999 43 Your SocIal Security Number Kathleen M Groome 191-46-1440 See the InstructIons for Form 1040A, lines 378 and 37b, or Form 1040, lines 598 and 59b, 10 make sure that (1) you can take the EIC and (2) you have a quellfying child, Before you begin: Caution: . If you take lhe EIC even 1hough you ars not eligIble, you may not be allowed to take the credit for up 1010 years. See the Instructions for details. . 11 will take us longer to process your return and issue your refund If you do nol fill in all lines that apply for each QualifyIng child. . If you do n01 enter the child's correct social security number on line 4, at the time we process your return, we may reduce or disallow your EIC. Qualifying Child Information Child 1 Child 2 1 Child's name Flrstnl!lml!l Ll!Istnaml!l First name Lllstname If you have more than two quallfying children, you only have to list two to aet the maximum credit . . . . . . JAMIE K GROOME 2 Child's year of birth. . . . . . . . . . . . . . . . . . Vear 1982 Year ~ If born after 1980, skip fines 3a If born after 1980, skip fines 3a and 3b; go to line 4. and 3b; go to line 4. 3 tf the ehlld was born before 1981 - 2t Was the child under age 24 at the end of 1999 and DYes. ONO, OYee, ONO, a student? . . , . ...... -'. ... . Go to line 4. Continue Go to line 4. Continue b Was the child permanenlly and tolally disabled DYes, o No, DYes, o No, during any pari of 1999? . . . . . , . . . . . . . . Continue The child Is not a Continue The child is not a qualifying child, qualifying child, 4 Child's eoclalsecurlty number (SSN) The child must have an SSN as defined In the Form 1040A or Form 1040 Instructions unless the child was born and died In 1999, If your child was born and died in 1999 and did not have an SSN, enter 'Died' on this line and attach a copy of the 173-68-8269 child's birth certificate, . . . . . . . . . . . . . ..... . 5 Child's relationship to you g~i\J.".:\~Ple, ~~,d~ught~r: grandchild,. foster .... . . , Daughter 6 Number of monthe chllclllvecl wllh you In the United States during 1999 . If the child lived with you for more than half of 1999 bu11ess than 7 mon1hs, enter '7'. . If the child was born or died In 1999 and your home was the child's home for the enUre time he or she months was alive during 1999, enter '12' ......... . -1d. monlhs - Do not enter more than 12 months. Do not enter more than 12 months. Do you want part of the EIC added to your take-home pay In 20001 To see if you qualify, get Form W~5 from your employer or by calling the IRS at 1-800-TAX-FORM (1-800-828-3676), BAA For Paperwork Reduction Act Nollce, see Form 1040A or 1040 Instructions, Scheduie Erc (Form 1040A or 1040) 1999 FOIA7401 11/11199 , " " " - \ a Control number I I OMS No. 1545-0008 Copy B To Be Filed With Employee's 0000825 FEDERAL Tax Return b Employer Identification number 1 Wages. lips, other compensation 2 Federal income tax withheld 25-1664123 16052.50 292.99 c Employer's name, address, and ZIP code , Social security wages . Social security lax withheld THEO'S FOODS, INC. 16052.50 995.40 119 NORTH DUKE STREET 5 Medicare wages and tips 6 Medicare tax withheld HUMMELSTOWN, FA 17036 16052.50 232.77 7 Social security tips 8 Allocated tips d Employee's social security number 9 Advance EIC payment 10 Dependent care benefits 191-46-1440 ~;;~1E~ttGR~OMEnd ZIP code 11 Nonqualified plans 12 Benefits included in ~ox 1 1174 Kingsley Road " See lostrs. for box 13 " Other Camp Hill PA 17011 " " 15 Statutory Deceased Pension legal Defoured omplo)'l.>fl plan "p compensalloo 16 SI.&~ Employe.r's state 1.0. 00. 11 S\U\t'lo'agt~, \lp\.t\t, 16 S\l\\e Income ~I\l\ \9 locality name 20 lOCalw~s.\ips,e\c. 2\ local i!'(.C!ne \.Qx Ri\.. J~.5::-1.6.~.~.~?~..... ..... 16052.5( 449.4- MIDDL8~ 16052.5( 160.38 .-......-...-..-... ..-......-.....-.. ..._n_.._..... -..... ..'op..n. ..... ..... I '..W 2 \" - Wage and Tax Statement 1999 Department of the Treasury-Internal Revenue Service This information is being furnished 10 the Internal Revenue Service " " / L.~.. " Form 1 040A Label (Se&In9CructIons.} Use the IRS label. otherwise, please print or type. Presidential Election Campaign (See Instructlons.) Filing status Check only one box. exemptions I..i.. ~ " ~. ,- < . . ~---- -. " . . "!t' DElI=>arbnent of the Treasury - Inlema! Revenue ServIce U.S. Individual Income Tax Return!,S) 2000 IRS use only - Do not write or staple In !his spao:. OMS No 1545.0085 Your F11'8t Name MI Last Name Your Social S&curtty Number kathleen M aroome 191-46-1440 If a Joint Return, Spouse's First Name MI lalltName Spouae's Social Security Number Home Address (number and street). If You Have a P.O. Box. See Instructions. ApartmenlNo. .& Importantl .& 10H vallev drive You must enter your social City, To.vn or PostOlllce.1f You Have a Foreign Address, See Instructions. Slate ZIP Code security number(s) above. calabash NC 28467-0000 .. No .. Note: Checking 'Yes' will not change your tax or reduce your refund. Dc oU,or ours useiffiJin a oint retum, want $3 to otothisfund? 1 Single 2 Manied filing Joint return (even ~ only one had Income) 3 Married filing separate return. Enter spouse's social security number above and full name here. . . .. ~ 4 ~ Head of household (with qualifyIng person). (See instructions.) If the qualifying person is a child but not your dependent, enter this child's name here . . ~ 5 0 Qualifying wldow!er) with dependent child (year spouse died .. )" (See in,tructlon,,) 6 a ~ Yourself. If your parent (or someone else) can claim you as a dependent on his or her taxreturn,donotcheckbox6a....................... . 1NO.oIbO,.. ehGCkBd on . 6aand6b. 1 b n Spouse . ~ .................. . ..... . ,. . ......... . . . c Oependents: (2) Dependent's (3) Dependent's (4)>/ , No. ofYQur children on social reletlonship qualifying 6c who: security number to you "'lid"" . lived chRdtax (1) First name Last name credit with you . 1 If more than seven iamie K qroome 173-68-8269 Dauahter . dldnot dependents, lIvewtth see Instructions. you dUll to dlvorteor _on. ~ Depencknta on""'" &nt9red above ~ Add numbers .1 2\ d Total number of exemotions claimed. , , . . . . " , , , , " . . enteNcl on ... . ... . ....... . lines above. 14a Social sacurtty benefits. " . , . , , . , . 14a 14b Taxable amount. 15 Add lines 7 through 14b (far rtghl column). This is your total Income. . . . . . , . . . . 16 IRA deduction (eee InslNctions) , . , " . " . , , . . . . 16 17 Studenlioan inlerest deduction (see instructions) , " , " . .. 17 16 Add lines 16'and 17. These are your total adjustments" . " . 19 Subtract line 18 from line 15, This is your adjusted gross Incoma. . BAA For Oleclosure, P~vacy Act, and Paperwork Reduction Act Nollce, sea Instructions, Income Attach Fonn(s) W.2 here. Also _ch Fonn(s) 1099--R If tax was withheld" If you did nol get a W-2, see instructions. Enclose, but do not attach, any peyment. Adjusted gross income t' 7 Wages, salartes, lips, elc. Attach Form(s) W-2 " 8 a Taxablelntereet. Attach Schedule 1 If required. b Tax-exampt interest. Do nollnclude on line 8e 8 b 9 Ordinary dividends, Attach Schedule 1 ~ required " " . . , , 10 Cepltal geln di'lributions (see InslNctione). , . . . . . 11a Total IRA distributions" , , . . , , 11 a 11 b Taxabie amounl ' 12aTotalpensionsendannulties, , , . 12a 12bTaxableamount. 13 Unemployment compensation, qualified state tuition program earnings, and Alaska Permanent Fund dividends. , , , , " " . . , " , , " . . , . , . . 7 8a 11,036. 9 10 11b 12b 13 14b .. 15 11,036, 18 .. 19 11,036. Form 1040A (2000) FDlA1312 101f6lOO, ~ " " ~- ~ kathleen M groorne form 1040A (2000) Taxable 20 Enter the amount from line 19 Income Tax, credits, and payments If you have a qualifying chlld,attach Schedule EIC, Refund Have It directly depositedl See insbuctions and fill In 42b, 42c, and 42d. AlI10unt you owe Sign here Joint retum? See instructions. K..,p a copy for your records. Paid preparer's use only .. 22 Enter roo standard deduction for your filing status. Sut see instructions if you checked any box on line 21a or;21b or if someone can claim you as a dependent. · Sillgle - $4,400 . Married filing jointly or Qualifying widow(ar) - $7,350 . Head of household - $6,450 . Married filing separately - $3,675 23 Subtract line 22 from line 20. If line 22 is more than line 20, enler 0, . , . . . . 24 Multiply $2,800 by the total number of exemptions claimed on line 6d , , . . . { B You were 65 or older B Blind } Enter number of Spouse was 65 or older Blind _ boxes checked . b If you are married fllin\! seperately and your spouse itemizes deductions, see instructions and check here . , , , , . . . . . . , , . . . , , , . . 21 a Check ~: 25 Subtract line 24 from line 23. If line 24 is more than line 23. enter O. This is your taxable income . . . . . . . . . . . . . . . . 26 Tax (see inslructions) , , . . . . . , . , , . , . , , . , , , . 27 Credit for child and dependent care expenses. Attach Schedule 2 . . . , . , , , . , , , , , , 28 Credil for the elderly or the disabled. Attach Schedule 3 29 Education credits, Attach Form 8863 . 30 Child tax credit (see in:structions). . . . . . . . . . . . 31 Adoption credit. Attach Form 8839, . , , , . . , . , , 32 Add lines 27 through 31. These are your total credits . 33 Subtract line 32 from line 26. If line 32 is more than line 26, enler O. 34 Advance earned Income credit peyments from Form(s) W-2 35 Add lines 33 and 34. This is your total tax , , , , . . . 36 Faderal income tax withheld from Forms W-2 and 1099 27 28 29 30 31 ......20 191-46-1440 Page 2 11,036. ~ 21aO ~ 21bD 22 6,450. 23 4,586. 24 5,600. ~ 25 0, 26 O. 36 32 33 34 ~ 35 311. 0, 0, 37 2000 estimated tax payments and amount applied from 1999 return, , . , , . . 38 a Eamedlncome credit (Ele). b Nontaxable eamedlncome: 37 38. 2,353, amount .... and type .. 39 Additional child tax credit. Attach Form 8812. . . , , , . , " 39 40 Add lines 36, 37, 38a" and 39, These are your total payments. 41 If line 40 la more than line 35, eublreclllne 35 from line 40. This is the amount youoverpald . . . . . . . . . . . . . . . . 428 Amount of fine 41 you want refunded to you . . . . . . . . . . . . ~ b Routing numba, ~ 053101121 ~ cTypa: I!TIChacking o Savings ~ dAcrount number ~ 5194660415 43 Amount of line 41 you want applied to your 2001 estlmatadtax, , . , . , . , . . . . . . . . , , , . , . . ,. 43 44 if line 351s more than line 40, subtrectllne 40 from line 35, This is the amount you owe, Fordetalts on how to pay, see Instructions . . . . , , . , , . . , . , . . . . , . . , . 44 45 Estimated tax penalty (see instructions) . . . . . . 45 Under penaltles of peljury, I declare that I have examIned thls return and accompanying schedUles and slatemenb:;, and 10 the best of my koo.Y\9dge and bellet', theVI,are tru&, correct.,and accuratelY list all amounts and sources of Income 1 received during the tax year. OGcIaratlon of preparer (other than the IBxpQyer) s based on an InfOnnatton of which the preparer has any knoWledge. Your Signature Date Your Occupation Daytime Phone Number ~ waitress Spouse's OCcupation $poUse's Signature. If a JoInt Return, both Must Sign. 0'" O..e Preparer's .. SIgnature ~ 40 2,664. 41 42a 2,664. 2,664. Film" Name ("'\'0<1'8" ... self-empklyed). ~ Addreft. and ZIP Code __~E~!~P~~~~~~_______________________ EIN -- --- - - - - -- - - ---- - - - - -- - --- - -- --- - - ,PhfJlle I No. FDlA1312 1o.r.mOO.. I Form 1040A (2000) .. - lIIil-..ii>" Form 8453-0L 113 04 1 IRS Use Only - Do not write or staple In this space U.S. Individual Income Tax Declaration OMS No. 1545-139' for an IRS e-fl/e On-Line Return For the yeer January 1 - Oecember 31, 2000 ... See Instructions. Declaration Control Number (DCN) 00 - 530008 2000 Department of the Treasury fnlema! Revenue Service Your FIrst Name and Initial LaetName I Your Social Security Number 1191-46-1440 I Spouse', SocIal Security Number I Use the IRS label. Otherwise, please print or type. L A kathleen M B If a Joint Return, Spouse's First Name and InlUel E L roome Last Name Home Address (number and street). If a P.O. box, see Instruetlons. menl Number Important! You must enter your SSN(s above. Daytime Phone Number .l .l H E 1041 valle R City, Town~PostOfftce E drive Stete ZlPCode calabash NC 28467-0000 (910) 575-4004 _ Tax Return Information (whole doliars only) 1 Adjusted gross income (Form 1040, line 33; Form 1040A, line 19; Form 1040EZ, line 4) ............. . 1 1l,036, 2 Totellax (Form 1040, line 57; Form 1040A, line 35; Form 1040EZ, line 10) , , , , . , . " , ... . . . .. . 2 O. 3 Federal Income lax withheld (Form 1040, line 58; Form 1040A, line 35; Form 1040EZ, line 7), ,. . , . ... . 3 311 , 4 Refund (Form 1040, line 57e; Form 1040A, line 42a; Form 1040EZ, line 11 a), . . . . . . . . ... . .... . 4 2,664, 5 Amount vou owe (Form 1040 line 59; Form 1040A, line 44; Form 1040EZ, line 12\. See instructions. ...... . 5 _ Declaration of Taxpayer ~ I consent that my refund be directly deposfted as designated in the aiectronic portion of my 2000 federal income lax retum. If I have filed B joint retum, this is an irrevocable appointment of the other spouse as an agent to receive the refund, b 0 I do not want direct deposit of my refund or I am not receiving a refund, o 0 I authorize the U,S, Treasury and its designated Financial Agent to inftiate an ACH debit (electronic withdrawel) entry to the finsncial institution account Indicated in the tax preparation software for payment of my federallaxes owed on this retum and/or a payment of estimated tax, I further undenlland that thiS authorization my apply to subsequent federal tax payments that I direct to be debited through the Electronic Federal Tax Payment System (EFTPS), In order for me to initiete subsequent peyments, I requestthst the IRS send me a personal identification number (PIN) to access EF'rPS, This authorization is to remain in full force and effect until I notify the U.S. Treas.iJry Financial Agent to terminate the authorization. To revoke a payment. I must contact the U.S, Treasury Financial Agent at 1-888-353-4537 no .later than 2 business days prior to the payment (settlement) date. I aiso authorize the finenciel InstJtutJons involved in the processing of the electronJc payment of taxes to receIve confidential information necessary to answer inquiries and resolve issues related to the payment. If I have filed a balance due retum, I undersland that ~ the IRS doee not receive full and timely payment of my lax liability, I will remain liable for the tax liability and ali applicable interest and penelties. If I have filed a joint federal and state tax retum and there Is en error on my slate retum, I understand my federal retum will be rejected. Under penalties of pe~ury, I declare that the infomialion I have given my intermediate service proVider and/or transmitter and the smounts in Part I above agree with the amounts on the corresponding lines of the electronic portion of my 2000 federal income tax retum. To the best of my knowledge and belief, my return is true, correct, and complate, Sign Here ~ Your s~netunl BAA For Paperwork Reduction Act Notice, see Instroctlona, Date ~ Spou&&'e Signature. If a jolnll"9lUm, both must sign. Date Form 8453-0L (2000) FDIA6001 12/07100 , ,. ., .. """~~ ,"-. . ~" > Form 1 040 Department of the Treasury - Internal Revenue Selvice 1(99\ U.S. Individual Income Tax Return 2001 IRS use only Do not write or staple in this space. For the year Jan 1 . Dee 31, 2001, o(othertax vear beainnina ,2001, endinQ ,20 OMB No. 1545-0074 Label" '. Your First NamEJ MI Last Name Your Social Security Number (See instructions.) Kathleen M Groome 191-46-1440 If a Joint Return, Spouse's First Name MI Last Name Spouse's Social Security Number Use the IRS label. OthelWise, Home Address (number and streel). If You Have a P.O. Box, See Instructions. Apartment No. . Important! . please print or type. 1041 Vallev Drive You must enter your social City. Town or Post Office. If You Have a Foreign Address, See Instructions. State ZIP Code security number(s) above. Presidential Calabash NC 28467-0000 d Total number of exemptions claimed. 7 Wages, salaries, tips, etc. Attach Form(s) W-2 . 8 a Taxable interest. Attach Schedule B if required b Tax..exempt interest. Do not include on line 8a 9 Ordinary dividends. Attach Schedule B if required 10 Taxable refunds, credits, or offsets of state and local income taxes (see instructions). 11 Alimony received. 12 BUSiness income or (loss). Attach Schedule C or C-EZ . 13 Capital gain or (loss). Attach Schedule 0 if required. If not required, check here. .. 0 14 Other gains or (losses). Attach Form 4797 . 15a Total IRA distributions . . . .l1!!l I b Taxable amount (see instrs) 16a Total pensions & annuities. .~I b Taxable amount (see instrs) 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . 18 Fann income or (loss). Attach Schedule F 19 Unemployment compensation . . . . 20aSocialsecuritybenefits.... 120al I b Taxableamounl(seeinslrs) 21 Otherincome ___________________________ 22 Add the am~u~t;i;the fa-;:- right ~Iumn for lines 7 throuah 21. This is ~our total income. ... 23 IRA deduction (see instructions) . 23 24 Stuaent loan interest deduction (see instructions) 24 25 Archer MSA deduction. Attach Form 8853 _ 25 26 MOVing expenses. Attach Fonn 3903. 26 27 On~half of self-employment tax. Attach Schedule SE 27 28 Self-employed health insurance deduction (see instructions) . 28 29 Self-empioyed SEP, SIMPLE, and qualified plans 29 30 Penalty on early withdrawal of savings. 30 31 a Alimony paid b Recipient's SSN _ . ... 31 a 32 Add lines 23 ttuough 310 ' JJ Subtract line 32 from line 22. This is your adju:5ted aross inoome . BAA For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see instructions. FDlA0112 12/10101 Electron Campaign (Seeinstruetions.) Filing Status Check only one box, Exemptions If more than six dependents, see instructions. Income Attach Forms W-2 and W-2G here. Also attach Form(s) 1099-R if tax was withheld. If you did not get a W-2, see instructions. Enclose, but do not attach, any payment. Also, please use Form 1040-V. Adjusted Gross Income .. ~ Note: Checking 'Yes' will not chan~e your tax or reduce your refund. Do OU.or ourspouseiffilin a'0IOtreturn,want$3to otothisfund? . . _ . " . . ... 1 Single 2 Married filing joint return (even if only one had income) 3 Married filing separate return, Enter spouse's SSN above & full name here. . . . .. 4 Head of household (with qualifying person). (See instructions.) If the qualifying person is a child but not your dependent, enter this child's name here . ... Quali in widower with de endent child ear spouse died'" ). (See instructions.) Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax return, do not check box 6a . . . . . . . . _ No 5 6a l- No. ofbo__ checked on . . . 6aand6b. . . .._ No. of your children on 6cwho: 1 b Spouse . c Dependents: (2) Dependent's social security number (4) . qualifying child for child tax credit (seeinstrs) (3) Dependent's relationship to you (1 First name Jameson C Flo d Jamie K Groome x . lived wlthyou " . . did not live with you due to divorce or separation (seelnstrs) . Dependents on 6e not entered above . 2 Last name 242-97-6732 Grandchild 173-68-8269 Dau hter Add numbers .1 entered on lines above. ... 31 7 8a 6,515. I 8bl 9 10 11 12 13 14 15b 16b 17 18 19 20b 21 22 6,000, 12,515. 32 ~ 33 +2[515_ Form 1040 (2001) (" ~ JI " .."--' --"1 ~~ . ~~ ~~'- ~ _. _1ui1Ii.1",,"1- ,~I.I",~~ ",' ,~ "1 l:<!Ii':tl>..;,' Form 1040 (2001) Kathleen M Groome 191-46-1440 Page 2 Tax and 34 Amount from line 33 (adjusted gross income) . ... - - -- - -. . - - . 34 12,515. Credits 35a Check if: D You were 65/0Ider, 0 Blind; o Spouse was 65/0Ider, D Blind. ,L L Add the number of boxes checked above and enter the total here . . ... 35a Standard b If you are married filmg separately and your spouse itemIzes deductions, Deduction 35b D for- or you were a dual-status alien, see instructions and check here. . . . ~ . People who 36 Itemized deductions (from Schedule A) or your slandard deduction (see left margin) 36 6,650. checked any box -37 Subtract line 36 from line 34 - _ . . . . . . . . _ - . ....... . . . 37 5,865. on line 35a or 38 If line 34 is $99,725 or less, multiply $2,900 by the total number of exemptions claimed 35b or who can be claimed as a on line 6d. If Ime 34 is over $99,725, see the worksheet in the instructions. . . . . . 38 8,700. dependent, see 39 Taxable income. Subtract line 38 from line 37. instructions, If line 38 is more than line 37, enter -0- . - - . . . . . . . . . . - - . . 39 O. 40 Tax (see instrs). Check if any tax is from a D Form(s) 8814 b D Form 4972 . 40 O. . All others: 41 Alternative minimum tax (see instructions). Attach Form 6251 41 Single: .. . $4,550 42 Add lines 40 and 41 ........... - ... . .. . ~ 42 O. Head of 43 Foreign tax credit. Attach Form 1116 if required 43 household, 44 Credit for child and dependent care expenses. Attach Form 2441 44 $6,650 45 Credit for the elderly or the disabled. Attach Schedule R . 45 Manied filing 46 Education credits. Attach Form 8863. . . 46 jointly or 47 Rate reduction credit. See the worksheet. 47 Qualifying widow(er), 48 Child tax credit (see instructions). . .. . 48 0, $7,600 49 Adoption credit. Attach Form 8839. . . . . . . 49 Married filing 50 Other credits from a B Form 3800 b 0 Form 8396 separately, c D Form 8801 d Form (specify) 50 $3,800 51 Add lines 43 tI1rough 50, These are your lolal credils . . _ -.... . .. . . . 51 O. 52 Subtract line 51 from line 42. If line 51 is more than line 42, enter -0- . ~ 52 O. 53 Self-employment tax. Attach Schedule SE. - - - - - . _ . . . . . . . . . . 53 Other 54 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 54 Taxes 55 Tax on qualified plans, including IRAs, and otl1er tax.favored accounts, Attach Form 5329 if required . 55 56 Advance earned income credit payments from Form(s) W-2 56 57 Household employment taxes. Attach Schedule H . . . 57 58 Add lines 52-57. This is vour Iotal tax -..... . -.. - ~ 58 o. Payments 59 Federal income tax withheld from Forms W-2 and 1099 59 78, If you have a 60 2001 estimated lax paymenls and amount applied from 2000 relom 60 qualifying 61 a Earned Income credit (Ele). . . -......... 61a 2,219. child, attach I b Nontaxable earned income. . . . .1 61 bl Schedule EIC. 62 Excess social security and RRTA tax withheld (see instrs) 62 63 Additional child tax credit. Attach Form 8812 . .... . 63 64 Amount paid wilh request for extension to file (see instructions) . . . 64 65 Other payments. Check if from. . . . a D Form 2439 b D Form 4136. . . . . . . . . . . . . . . - , . -, . 65 FDlA0112 12/10/01 66 Add lines 59, 60, 61a, and 62 throu9h 65. These are your total payments . . . . . . . . . . . . . . . . . . . - - -....... . ~ 66 2,297, Refund 67 If line 66 is more than line 58, subtract line 58 from line 66. This is the amount you overpaid 67 2,297. Direct deposit? 68 a Amount of line 67 you want refunded to you . -- . - . . ...... . ~ 68a 2,297_ See instructions ~ b Routing number . . . . _ 253171430 ... c Type: !ill Checking o Savings and fill in 68b, ~ dAccountnumber. . . . .1170000174266 68c, and 68d. Amount of line 67 vou want applied 10 .our 2002 estimaled tax 69 I 69 ' , ~ Amount 70 Amount you owe. Subtract line 66 from line 58. For details on how to pay, see instrucrons ~ 70 You Owe 71 Estimated tax oenaltv. Also include on Hne 70 . . . . . . . . . I 71 Third Party Do you want to allow another person to discuss this return with the IRS (see instructions)? . . . . o Yes. Complete the followi~g. IRJ No Designee Sign H Designee's Phone Personalldentlflcatlon Name ~ No. ~ Number (PIN) ~ Under penallias of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. ere Your Signature D,1e Your Occupation Daytime Phone Number Joint return? See instructions. ~ Clerk Keep a copy Spouse's Signature. If a Joint Return, Both Musl Sign. D,1e Spouse's Occupation for your records. ~ I Date I Check if self-employed n Preparer's SSN or PTIN Paid' Preparer's ~ Signature Preparer's Firm's Name Self-Prenared. 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" '0 '0 0 "03 :" Hmo 0 I '&::c r< ,q; 0 w == '2 "" '" 0:;l.0IY: "'rl "'f-; "" H '" C "00 "- :<:ooF<: "-m !~ 0 F<: a. .u 0 i:]1i) E UG\U i:]rl r< U E ~ Z: 0 UJ w E " .0 U ." . :e 0 .. .. . Y' _" . ,. ~- . CERTIFICATE OF SERVICE I, James W. Abraham, Esquire, the undersigned, do hereby certify that I have served a true and correct copy of the foregoing document, by first class mail, on the date indicated below, to the following person(s} : Melissa P. Greevy, Esq. Johnson Duffie 301 Market St. PO Box 109 Lemoyne, PA 17043 DATE: 7/5/02 James W. Abraham, Esq. ,...... I " ., . ~ '\II. .. ~--~ - ._r-l- r b~~_~~ililllim~h1i~olli,:,;~.j;U""'clml.ojml.ali!llilllllimill!il!l ';;- r-. )c- o: ,~ ,- " "' , ? 1"-': {~;J lL! Q ._) 0::( C:-> ,". () ~t n.:. ~:.-.! , (-' CL C ")} ::~j , L{) :> , . ----.. 2~ , I __.J ",-::-.1 ;~; " L__ =l :i{ 1.0 j--- "'-;'-" t1.._ . ....::': 0 c',.) =::> C) u . .. , ... ~ .,," -.""'. "'illIJii1ll~' - " '"' iJilII , ~,.,-~ i ... . . - t. ,....-~". . B(30 (02- lfH Johnson, Duffie, Stewart & Weidner By: Melissa Peel Greevy LD, NO', 77950 301 Market Street p, O. BO'x 109 LemO'yne, Pennsylvania 17043-0109 (717)761-4540 Attorneys for Defendant KATHLEEN M, GROOME, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff NO, 00-2750 v. CIVIL ACTION - LAW THOMAS R. GROOME, Defendant PRETRIAL STA TEMENT PURSUANT TO PA.R.C.P. 1920.33 I. BACKGROUND A, Marriage - September 7,1974. Separatian - May, 1997. B. Children - The parties have nO' minar children. C, Camplaint: (i) Filed by WIFE an May 3, 2000, dacketed to' NO', 00-2750 Civil Term. (ii) Cantested claims - Indignities, Alimany and Caunsel Fees, Equitable Distributian. (iii) Divarce - It is expected that bath parties will agree to' a cansensual divarce pursuant to' !l3301(c) af the divarce cade and file Affidavits af Cansent and WaiveTs af Natice, as the twO' (2) year separatian periad has expired. II. MARITAL ASSETS The marital assets are listed in the Plaintiffs Inventory and AppTaisement, filed cancuTrently herewith. The exhibits attached heretO' demanstrate the value af the assets to' be distributed. ,-- , .=~~,.' III. NON-MARITAL ASSETS The defendant has purchased an 1988 Cougar after the parties separation which is non marital in nature. Defendant believes and therefore avers that Plaintiff owns a 1996 Mitsubishi Eclipse which was pUTchased subsequent to the parties separation, IV. MARITAL DEBTS Marital debts are identified in Defendant's Statement of Inventory and Appraisement, filed concurrently herewith. Defendant's exhibits inventory the marital debts as they are known to the Defendant and provide the value of each. V. WITNESSES A. Expert Witnesses. 1. Unless stipulated thereto, Defendant expects to call the evaluating actuary from Pension Appraiser's, Inc, to testify as to the value of the Defendant's defined benefit pension which report has been included as an exhibit submitted by Plaintiff, B. Fact Witnesses, 1. HUSBAND 2, WIFE 3. Anna Ann Atanasoff, Wife's former employer at Theo's Foods. Defendant reserves the right to call additional witnesses for rebuttal if necessary, based upon the testimony offered at hearing, Defendant reserves the right to supplement this witness list prior to time of trial upon proper notice to the hearing master and opposing counsel. -,'- ',~, VI. EXHIBITS See attached. VII. DEFENDANT'S INCOME Defendant's 2001 Federal Income Tax Return is included in Defendant's Exhibits. Defendant earns $23.56 per hour in his position with United Parcel Service. Filed concurrently herewith is Defendant's Income and Expense Statement. VIII. PLAINTIFF'S EARNING CAPACITY Plaintiff was earning $26,904 per year in 1994, prior to being terminated from her employment with Cumberland Services Inc. She was subsequently convicted for theft by deception, Had she continued to be employed as a book keeper, it is averred that her annual income would be in excess of $30,000 per year, However, she may have experienced difficulty obtaining employment as a book keeper and a salary consistent with her earning capacity as a result of her prior criminal actions. Any alimony award in favor of Plaintiff and imposed on Defendant should not be based on her voluntary reduction in earning capacity and criminal activities, Rather, it should be based on her 1994 earning capacity plus reasonable increases based on experience and inflation. Plaintiff is capable of full time employment which provides health benefits, IX. DEFENDANT'S EXPENSES Filed herewith is Defendant's Income and Expense Report, X. COUNSEL FEES The parties shall each be Tesponsible fOT theiT Tespective attorney's fees and costs. _...- XI. PERSONAL PROPERTY Personal property from the marital home has been divided by the parties in a fashion satisfactory to each of them. XII. PROPOSED RESOLUTION Defendant proposes an alimony payment to Wife in the amount of no more than Five Hundred ($500.00) Dollars per month until Defendant's retirement which may occur as early has his age fifty-five (55), but in any event shall not continue beyond his age fifty seven (57), The amount will be modifiable only based on a substantial involuntary decrease in earning capacity of one of the parties. It would terminate upon the death of either party or Plaintiffs remarriage or cohabitation, Escrowed proceeds from the sale of the marital residence are Forty Four Thousand Three Hundred Seventy Five ($44,375) dollars. Defendant would receive Twenty Five Thousand Eight Hundred Eighty ($25,880) dollars which is: 1. 50 % of the proceeds from the sale of the marital residence, plus 2. $511,00 for one-half of unpaid utilities bills from the period he was not residing in the marital home, 3. $1206,00 as full TeimbuTsement fOT a mortgage payment and utility bills unpaid when the Plaintiff abruptly left the marital home to live in North Carolina, 4. $597.00 as one-half of the home insurance proceeds received by Plaintiff, 5. $1379,00 as 75% of the amount of funds Defendant spent in paying for the painter's labor and expenses for materials associated with the preparation of the marital home for sale. Plaintiff would receive eighteen thousand four hundred ninety four dollars ($18,494) in remaining funds held in escrow from the sale of the marital home, ,,- ~-"J:!~ Defendant would retain the full value of his Defined Benefits Plan. Plaintiff would receive via and Qualified Domestic Relations Order of the amount of Seventy Thousand Seven Hundred Sixty ($70,760) Dollars from Defendant's Central Pennsylvania Teamster's Retirement Income Plan, plus any growth thereon, calculated from December 31, 1997. This figure represents 59% of the marital value of this Retirement Income Plan as of date of separation. Defendant would retain the balance of his Retirement Income Plan. Defendant would retain the 1990 Ford Mustang. Date: if J; 9 16 ~ I JOHNSON, IE, STEWART & WEIDNER : 162098 , -" - ~ ,,~ ," ~'~'- Johnson, Duffie, Stewart & Weidner By: Melissa Peel Greevy I.D. No. 77950 301 Market Street p, 0, Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 Attorneys for Defendant KATHLEEN M, GROOME, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO, 00-2750 v, CIVIL ACTION - LAW THOMAS R. GROOME, Defendant VERIFICA TION I, Thomas R. Groome, hereby verify that the statements made in this Pre-Trial Statement are true and correct. I understand that false statements made herein are subject to the penalties of 18 Pa,C.S, 94904 relating to unsworn falsification to authorities, #, : 162077 CERTlFICA TE OF SERVICE AND NOW, this 29 th day of August, 2002, the undersigned does hereby certify that she did this date serve a true and correct copy of the foregoing Pretrial Statement upon the other parties of record by causing same to be deposited in the United States Mail, first class postage prepaid, at Lemoyne, Pennsylvania, on the date indicated below, to the following persons: James W. Abraham, Esquire 513 N. Second Street Harrisburg, PA 17101 IE, STEWART & WEIDNER elissa Peel Greevy ~'""'I~,-' - - _:., ". ~~" Johnson, Duffie, Stewart & Weidner By: Melissa Peel Greevy LD, No. 77950 301 Market Street p, O. Box 109 Lemoyne, Pennsylvania 17043-0109 (717) 761-4540 Attorneys for Defendant KATHLEEN M. GROOME, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff NO. 00-2750 v. CIVIL ACTION - LAW THOMAS R. GROOME, Defendant DEFENDANT'S EXHIBITS VI. EXHIBITS A, Defendant's 2001 form 1040 Federal Income Tax Return; B. August 10, 2001, Report from Pension Appraisers, Inc. of Defendant's defined benefit pension plan; C. Defendant's 2001 estimated employee defined benefit plan statement; D. 2000 estimated defined benefit statement; E. 19.97 estimated defined benefit statement; F. 1996 estimated defined benefit statement; G, Defendant's Retirement Income Plan 2001 statement; H. Defendant's Retirement Income Plan 2000 statement; I. Defendant's Retirement Income Plan 1999 statement; J. Defendant's Retirement Income Plan 1998 statement; K. Defendant's Retirement Income Plan 1997 statement; L Defendant's Retirement Income Plan 1996 statement; . "' - -'-. ~ , L",,"- M, Select Activity Log dated November 18, 1998 and attached Xerox of Check No, 61949420; N. Select Activity Log dated July 25,1997 and attached copy of Check No, 58098996; 0, Select Activity Log dated October 6, 1999 and attached copy of Check No, 58834451; P. February 27,2001 statement of Timothy Walker regarding painting costs; Q. Receipts from materials to prepare the marital home for sale; R. Copy of Page 2 of 9 pages of a Defendant's credit report indicating unpaid UGI bill; S. Copy of Page 3 of 9 pages of a Defendant's credit report indicating unpaid UGI bills due to Bell Atlantic; T, Copies of utility bills for PP&L, Comcast, Water, UGI, Sewer and September 1, 2000 Mortgage statement left unpaid by Plaintiff when she vacated the marital home; U, Income and Expense Report of Defendant; V. Escrow Account from Commerce Bank as of August 15, 2002; W, Defendant's paystubs for period ending August 3, 2002 and August 10, 2002; X. Kelley Blue Book Trade-In Report 1990 Mustang; and Y. Plaintiff's 1994 W-2, :162103 E Department 0 the Treasury- nternel avenue Service ~@O1 1111 .E U.S. Individual Income Tax Return IRS Use Only--oo not write or staple in this space. For the year Jan. 1 Dec. 31, 2001, or other ta.x year beginning ,2001, ending ,20 " OMB No, 1545-0074 label Your first name and initial Last name ~ Your social security number -' /( /"" i-" 1', "r- (See L .....!~ j""kilf..te'l S ;) ,- 7.0-'1 ))'1 I - l ~:_.';/,.....,jc. VI I" ,.", j'; instructions A on page 19.) 8 If a joint return, spouse's first name and initial Last name Spouse's social security number E , Use the IRS L : label, H H~!Q1,~..;~ddre;ss (number" ~d stre_~t). If y~~ave af ',?' box, see page 19. I Apt. no. . Important! A Otherwise, E /' J ,J '1 /'-', '-v,_" :..I.y L,' i ~-O please print R ~~wn or post office,. state, and ZIP cOdef~Ol.!_ have a foreign a~dress, see page 19. Y QU must enter or type, E your SSN(s) above. Presidential '- '-{ve"d''Vl\Jv,\J r ,() 17J";-0 ~~-- 1040 Election Campaign ll. (See page 19.) 1 ~ ~~~ IR Note. Checking "Yes" will not change your tax or reduce your refund. Do you, or your spouse if filing a joint return, want $3 to go to this fund? ~ \1 You Spouse ~ DYes DNo DYes DNo Filing Status 1 2 3 Check only 4 one box. 5 6a Exemptions b c If mare than six dependents, see page 20. Income Attach Forms W-2 and W-2G here_ Also attach Form(s) 1099"R if tax was withheld. If you did not get a W-2, see page 21. Enclose, but do not attach, any payment. Also, please use Form 1040"V. Adjusted Gross Income r--- Single r--- _,!'v1arried filing joint return (even if only one had income) I,......."... Married flling separate return. Enter spouse's social secufity no. above an,d full name here. ... Head of household (with qualifYing person). (8ee page 1 g.) ,If_~.~e qL!alifyi,ng perso~ is a child but not ~9ur ,dt'?P'e~Q..e,rt, enter this child's name here. .,.. . " , f-- Qualifying widow(er) with dependent child -,year spQ.u~e died .... ).,' (See page 19.) GYVourse'f. If your parent (or someone else) can claim you as a dependent on his .or her tax} return, do not check box 6a . . . . . . . . . . . . . . . Os pause ,J, Dependents: (2) Dependent's {31 Dependent's (4i"if qtialiMng Last name social security nlJffiber relatIonshIp to ctliI11:r<hild la!~1 (1) First name YOU credllseeoilOe20 D D D D , D D 8b Gat. No. 113208 ~b. .llf ,~_q~es ,ch,eCkj;ld:on 68' an~ fib ~o.' :0' y~~r ,,,,tl{)~le1'l pn ~t ~11~: ' . llve,~-wjth y_ou ..00d "~t Itve '\'lth yoil'dbe hi dl~arce ;or sel1.a~~ign, . , (~ee pe!!~ aq) p'epai1d~~~ '~,~ ;~c not en~.~J~d, aM've ~ P;i~ n'.il\~$$ [ZJ entere,d :~n I lil'!es_abt)1(~ ,)I- .'__'-"_','__ (j~ '2 f -L 9 10 11 12 t3 14 15b 16b 17 18 19 20b 21 22 ~ d Total number of _exemptions claimed 7 Wages, salaries, tips, etc. Att~ch fbrm(s) W-2 8a la)<~ble interest. Attach Schedule I? if required b l'ax..exempt interest. Do not incH.!de on Hne 8a 9 Ordinary dividends. Attach ScheqLiJe -S if required 10 Taxable refunds, credits, or offsets of state and tocal income taxes (see page 22) 11 Alimony received 12 Business income or (loss). Attach Schedule C or C-EZ . 13 Capita! gain or (!oss). Attach Schedule 0 if required. If not required, check here" 0 14 Other gains or (losses), Attach Form 4797 , _.".""." 15a Tota! IRA distributions. ~ U b Taxable amount (see page 23) 16a Total pensions and annuities ill!J, U b Taxable amount (see page 23) 17 Rental real estate, royalties, p~rtnershjps, S corporations, trusts, etc. Attach Schedule E 18 Farm income or (loss). Attach Schedule F 19 Unemployment compensation . 20a Social security benefits . I 20a I I' b T ax~bl~ ~ou~t (s~e ~ag~ 2si 21 Other income. List type and amoul1t (see page 27) __.....____...~.....__.__."._.__H_. 22 Add the amounts in the far right column for lines 7 through 21. This is your total income ,.... 23 IRA deduction (see page 27) , 23 24 Student loan interest deduction (see page 28) , 24 25 Archer MSA deduction. Attach Form 8853 . 25 26 Moving expenses. Attach Form 3903 26 27 One-naIf of self-employment tax. Attach Schedule SE 27 28 Self"employed health insurance deduction (see page 3D) 28 29 Self-employed SEP, SIMPLE, and qualified plans 29 30 Penalty on earty withdrawal of savings 30 31a Alimony paid b Recipient's SSN IJo- 31a 32 Add lines 23 through 31 a _ 33 Subtract line 32 from line 2?, This is your adjusted gross income For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see page 72. I Fo'm 1040 (20011 Tax and Credits ['~""""".i' ~~ction [b /1 " 1:: . pe'koP1jG who_ 36 ,:36::' ~'~ Sy I'........cm~c e<.,any I' ...... --.-, .. box on hn<> 3T"lr:~ " ~l 7- Me. or 35b or" .":". :. ~ _..:.l.......l_.....Q- (.. ~~3:7!a!. j;... line. 5d.lllii,1~841..wer~gg,725,ljee ." Wbrksh~~t 0I1I'~ge32+':;'Y":':'i'.'0..."38i' ~. ,,~~,I~~~~.'" '~f~~.':i~~p '1.............~$r~7~,io~:. ..444;7..g!k'$<lk,:,"~)~;i,)p~Ji -----=t-- I <.N !~~te redLie([9'!!":~re.dit~;:9~~ th-&_W\?r~5~~et;::~,~;':Page-',~3e,:":: ..c:";.:.,..,> j,'4'Z;::2 _______..._.+_ Mam"" 48. Chll~iai'fi;?'3it(s;,~fia~f:3i) ................ .......... ," S I". ~~~~lrately, J 49 ..'AdOP.tIQ,~'_,.c~d!t~::_~n3'~h<~9rfna639<." ", -, . ." :(::.:'~ '~~-'-':5...~.O....~...",' . "......-..-..... ...._- ...!~,~9'O"~>.......... 50 Other c\'i>Qit.frql11,."OForl]1~8~QbGFor;'ra3g&.. i~ -'-.-- .. 51 .' ~;;~,f,,1(~i~8~%d~k~~f:.~~r:~~tow~~~~--:"'J,< -- :.... ._._.~~_~~:. Sl.lbtr.actJio?':Jj'l,:'lrorn:j'iri:e:. :4.~.., IUln".,(5:1.Ji:more":than --line 42;,<ei:)ter:::~'o~',\:,,:,:,::< "" s,__~~~..~ 5:1' . HOlJSeho'[&; '~Ioy"'entl""es, Alteoh ,SI'h."OUle H . ' ..J'""",;,c;., '58'. AO\llineS,52 iliwugfj fi/, This Is yourJ'olill tax , tiJ~I~~I*~~~ ~ 1- 64 ArnOtliJt:::~~i_~:::~~itt\_ "": f",f~_~:,~ktfi~:~19~'__,to:_iire, {$e~:page;"'?,~)-'~:::'? 55 . OU"", p~;:i;;~dis;G' na[j'~cim'~4:i9b [JForm4i3a';;',.5Ik 66 Addllnij~:'59,iio,ih,,;~hd 6~itirotigh65,:rh~~~~t~y"l.lt;lOtijfPil1ii..!1is." . ,,;"',. .. i :: '_.;::__-'_::;,:' 'f:, ,'":,,,,",: ":.. ,,:,:::.,,:,,-, <:_:"'_':-"~::',:':":-,'::,:.-'::::,:" "-'-: .__: "'-',.:" ",: _ :":'-:' ,,:':"""'-'_ :':':: .::.::.-'_:" .:'::':'<'!"<,:-"":"".:"-:',,''',: :._"' ,.-' Refund 67 'If tirie-~a,:j~:'i~o'r.e:tftari {ihe '$a~,',~q~ttacf::'li~e ,'5~':Jro'(it, lina 6~;<:fhrs', is;~i~t;;,:af#.gLl~t~otJ'.?ve"rij~p::I'?:, ~~~~? ~n~ ~68: ..~T~t;;~~l;~:~C:I:Q:t~4tor'id5'~'b'f~p~;~j[:K~rmii(t~f:~~JI~~ ~~!; ~~~'OOd ~ dP,c~o~Wj.V~~b,~';L+.J......kJ:J,...i '.' i . .J-..Lcl"J""J . .11' [ ".LL.J,," , , _E.~....._ A."n~,.lin~.,bdine':.G?-~~?\~_wan~~plleiH?:~ou.t::~.e$tlmatt)d ta)t::~""~"",__':"'l." ::~':::", '. Amount 70. '.AI]10. U:~{~..'.!i'.OW.'.~S,j!>ihlct. '!Iri~fj.~;f.tbiii'f'ri~5l!r.F'~~.<:I"1~i.l5,g\1ll\?'k'lo.~ip"V;."",,;p~ij'i;'.!>g',,!-:;': You Owe _.?l E:.tlm.I\18't",,,pel1a:r{iAlsO'~c1tJ.deccnlln.i'O,;;,;j""if'1';7".1.... .... .... ......1 Third Party " Do YOu;~iI!it]r>;iIli9'!j:anbli\.i.p<irs9~;td;B~i!q~~tr;!t:~~f~0 'Ivit~.tl)~'~~ti;tiepii~~;~lt,;gi'Y~!~ Designee Designe.;~);. "PlI\in.,. liP, ."'if name ...' .. nQ:'::;--''':). ( ) Sign Ui1der pen,altle~'l){ prn1ury, I qeclar~ that 1 f1av~ 'ia-xair11ned thls :~t~rn: ana ~P;9mp:fUlY!I1Q '.?C~,(J1i~~::; Here bellef, th~}'}~~:tn~e" COrH~d, and. ~cmpI6te-. ~t;-'Cl~~lon ~f praFrer:(('th~rU'i~'1: ,~~Xm.\~;J~fI~~,::~~:,;. ;-. Your signature I Dale Y{;IlJr occupa.tion ~ Sp;;:;;;;';';".,n",~~""-~j;;;;;-;;;;;:;;:b;;il:;-;;;;;;t "gn, 1.0.;';_-- Spau';;';-;;;';;Up;;;~;;--'" ~~~~.l 'i~~:.,:~~~'} Other Taxes Joint return? See page 19, Keep a copy for your records. 34 35a I .:~~7~.' I _:~~ .-..-.....: ........--..-...- ---. "~,I I C)~3> ~t Paid Preparer's Use Only P!'&parf;l"::> ... slgrraturo ,. ".'.'.'.'"_'.'"'.'_'.'.'._w__.~."'_.'.'.'._'.__.'.'._........_ '....._......_... ~~~D;~s,F~~I';:J~plcyed), ... .._.___....._....._....~_...._w_..__.~._.....~_...____... address. and llP cod!;: , _ Oat", Phor'le fW. tem, ...10lf~L(200'} ."""--'" ~ ~ ~" ~~ ;1 'I ,~ j ;1 :, I ~) 1 ;[ ~ :1 C\/ l I 'I I J :1 ',I ~I '" . i~ .~ \II ~ . ~ .. ~ "0 .~ jl~ 'i.. ]g.... ~ ~ . " u o ;;; = ~" O' i1 . c . D m :~: :8 """ .5 ;'0<1 =e,., 0'" ~ . " oil ~ ~ Ii " . ~ c . ~ " o ~ no II ~ o II> ~ " o .. o c ,. ~ O~ ,~o . . ".. 00 ':i1~ ""tn 0' . ~ . ;< ~;;; " . '" €O 0:: m 1ft l o ~ .~ ~- cO 0 :a:;l g &0 a- ~; ~ l!! U\ m ~ ]j . 8 " '" ~ , " . E ~ . ~ ~ . "- ~ . = .. , ~ . c ~ ~ is ::: :!: M B c . ~ m ~ ,..~ ~ ~.~~ II> ~_;' ~ si~! ~ l~.~ ~ j~~e oS f!~ 'I ~.. .. .. .. .. jiJL 1 Jl Ii-If < ~"'- ~.~u_~__~".,.. ~'!fB~ 'I ;1 , \1 1 :1 I ;j :1 :1 1 :1 ',I ;I ) 1 I ~.-g . " I ~ = .~~ lij1l ~l .~. ~ ',.1 ~ l! /0 'Ul I ~~ 'J: .*,'.~ ~I 11 ., .Q 0 1 o o 1ft '" N .. ~ . .. ~ Ul <.>w ~z . > "8 ffi>a:I Q. VJ~~ i;;;j ..J1l.0 W .. <.>w "'''.. ...." n...l z" OWl- W..lZ 1-"" ~ ..l Zlnl- ",In" . 3 0- N ~ c . :i . ~ ~ " ,; ~ c o '. . ;;- ~ w . o In .. .. , o ~ Q.N lJ'IUJ~;:: 0%0::..-1 o 01-" ",,,,n. "0 o.Z "'30 W,. en,.,. .. .. "'..<.> ON" :zOO"" I-~" ,. ~....M~ <-'~i 1 ~ , 1 .l 0::1 { :z 0 ~ , Z. Go c ~~I J-.f :g:::lIl1. ~~ C ~ ~ 1 ~ ~ I 8 '" g:l~ Jl';I'; .~ ~ ~lnl .5 \j o ~ l' m ii..-lI..-l8 "'":cuo 0';' ;::~';l,a ; "'" :":01 0 . ~.:~: : ro ~ 1.~~lln ~ ~.~ I No.;.[ ~ 1 I !::I Jl':1 'oil"" . "'I B~ ~ 1 ~ I t:: 1 . 1 il-I __.0 1';1 ,0 m CDl 'r~1 ~ !1 1 :!! 8 I . II> . , C " > " CC .. E . " T '" ;;: " . ~ " " " " . . r " g- o l! ci ~gl "'" .."'I oN )ii..rl {51 w . ~:I ~ ~ o o '" E . e l! J!! !J) ~ I- " c " . '" ~ '1 ;: E & J~"r,.-." ~- ~-"""-' - ,~ ~<~L' -a,......'.'... \l\ RECEIVEQ BY IIlAtII , ~Pb . qf/''7/~1 V @ PENSION APPRAISERS INC. P.O. Box 4396 · Allentown, PA 18105-4396 1-800-447-0084. Fax 610-770-9342 E-MAIL: penapp@pensionappraisers.com WWW: hUp:/ /www.pensionappraisers.com August 10, 2001 Melissa Peel Greevy, Esq. 214 Senate Avenue, Suite 105 Camp Hill, Pennsylvania 17011-2336 RE: Present Value of Thomas R. Groome's Defined Pension Benefit File No. 08-06-01-054-2394G no"" ^t+................\! ,"'":!.............". .... "......1 /-\ l...,III\,;:,iJ "-'4,'O"~y y_ We have determined the present value of Thomas R. Groome's defined pension benefit by the GATT Method as of August 6, 2001 to be $20,832.89. This valuation was developed and prepared in conformity with the requirements of the Actuarial Standards of Practice No. 34. These Standards were developed by the Pension Committee of the Actuarial Standards Board of the American Academy of Actuaries. The purpose is to set standards for Members and Other Persons Interested in Actuarial Practice Concerning Retirement Plan Benefits in Domestic Relations Actions. Pension Appraisers, Inc. relies on the requestor to provide the information necessary to value pensions. In some cases, information not provided by the requestor may be obtained from plan summaries on file in Pension Appraisers, Inc.'s offices. All information received from the requestor is reviewed for practicability and reasonableness. Any information in question is verified with the requestor, when possible. Any deficiencies in data may materially affect the results of the appraisal. Pension Appraisers, Inc. utilizes the fractional rule allocation method in valuing all pensions for equitable distribution purposes unless otherwise stated. BIRTH DATE: December 1,1952 SEX: Male MARRIAGE DATE: September 7,1974 VALUATION DATE: August 6,2001 PENSION PLAN: Central Pennsylvania Teamsters Defined Benefit Plan DATE EMPLOYMENT STARTED: September 1,1977 (Assumed date pension holder began participation in the plan) DATE BENEFITS STOPPED ACCRUING: December 31,1986 (Assumed date pension holder ended participation in the plan) ASSUMED DATE MARRIAGE ENDED: May 15,1997 (Assumed) AGE WHEN BENEFITS COMMENCE: 57 Years "Valuators of Defined Pension Benefits for Equitable Distribution" ""__n"~=' ~". " ......,~-~" GATT Actuarial and Mortality Tables Method August 1 0, 2001 Thomas R. Groome - # 08-06-01-054-2394G Page 2 MORTALITY TABLES: 1983 Group Annuity Mortality Tables INTEREST RATE ASSUMPTIONS: 5.52% 30-Year U.S. Treasury Bond Constant Maturity Rate for the Month of the Date of Valuation. ASSUMED MONTHLY BENEFIT: $227.08 Monthly penSion benefit 'the'pension:hoider 'would receive at retirement age with a fully vested pension based upon compensation and plan provisions as of December 31, 1986. REDUCTION FOR NON-VESTING: 1.0000 Represents a reduction for the probability of seNice to 100 percent vesting as equal to the portion already completed. REDUCTION FOR MARITAL COVERTURE FRACTION: 1.0000 Represents that portion of the value of the benefits attributable to the marriage. The numerator of the fraction represents the total period of time the pension holder participated in the plan during the marriage and the denominator is the total period the pension holder participated in the benefits program. PRESENT VALUE BEFORE REDUCTIONS: $ 20,832.89 Reduction for Non-vesting: Reduction for Marital Coverture: x 1.0000 1.0000 x VALUATION FOR EQUITABLE DISTRIBUTION: $ 20,832.89 ~.Ii"" , ~ N......_'. THE CENTRAL PENNSYLVANIA TEAMSTERS DEFINED BENEFIT PLAN MAILING ADDRESS: P.O. BOX 15223 STREET ADDRESS READING, PA 19612-5223 2001 ESTIMATED EMPLOYEE BENEFIT STATEMENT GROOME THOMAS R 1824 NEWPORT RD DUNCANNON PA 17020 I. BIRTH DATE 2. SPOUSE NAME 3. SPOUSE BIRTH DATE 4. SPOUSE SOCIAL SECURITY NO. 5. REPORTED DATE OF HIRE 6. AGE WHEN HIRED 7. VESTED STATUS 8. DEFINED BENEFIT PLAN LEVEL 9. LAST CONTRIBUTING EMPLOYER 10. BENEFITS ACCRUED THROUGH II. ESTIMATED NORMAL RETIREMENT DATE 12. ESTIMATED ACCRUED BENEFITS: DEFINED BENEFIT SERVICE 8 YEARS 1055 SPRING STREET WYOMISSING, PA 19610 4/2002 SOCIAL SECURITY 208-42-4774 12/01/1952 KATHLEEN GROOME 07/11/1953 191-46-1440 09/01/1977 24 100% VESTED I UNITED PARCEL SERVICE INC 12/31/1986 01/01/2010 NORMAL BENEFIT $227.08 THIS STATEMENT IS AN ESTIMATE OF YOUR ACCRUED BENEFIT, PAYABLE IN THE FORM OF A SINGLE LIFE ANNUITY AT NORMAL RETIREMENT AGE. IT IS SUBJECT TO VERIFICATION AT THE TIME OF RETIREMENT, AND DOES NOT TAKE INTO ACCOUNT THE EFFECT OF RECIPROCAL PENSIONS. THE BENEFIT LEVEL LISTED ABOVE ASSUMES THAT YOU WORKED AT LEAST 1,000 HOURS AT THAT LEVEL DURING YOUR LAST YEAR OF' },AR'l'ICIPA~'ION UNDER THE DEFINED BENEFIT PLAN. ~ .....~.~ ~.~ _,L .'. . . . ,~ 2000 Estimated Defined Benefit Statement 208-42-4774 GROOME THOMAS R RR 2 BOX 2329 DUNCANNON PA 17020-9638 1. BIRTH DATE - 12/01/1952 2. SPOUSE NAME - KATH:E.EEN GROOME 3. SPOUSE BIRTHDATE - 07/11/1953 4. SPOUSE SOCIAL SECURITY NO. - 191-46-1440 5. REPORTED DATE OF HIRE - 09/01/1977 6 . AGE WHEN HIRED - 24 7. VESTED STATUS - 100% VESTED 8. DEFINED BENEFIT PLAN LEVEL - I 9 . LAST CONTRIBUTING EMPLOYER - UNITED PARCEL SERVICE INC 10. STATEMENT REFLECTS BENEFITS ACCRUED THROUGH - 12/31/1986 11. ESTIMATED NORMAL RETIREMENT DATE - 01/01/2010 12. TOTAL ACCRUED BENEFITS VESTING SERVICE B~rnFIT SERVICE THRU STMT YR THRU RIP START BASIC BENEFIT 22 YEARS 8 YEARS 227.08 CF6 - Main Selection CF7 - Year Selection - 05/01/2001 ~" ~ ~- ~"-". THE CENTRAL PENNSYLVANIA TEAMSTERS DEFINED BENEFIT PLAN 1055 SPRING STREET WVOMISSING, PA 19610 MAILING ADDRESS: P.O,'BOX 15223 READING. PA 19612-5223 1997 ESTIMATED EMPLOVEE BENEFIT STATEMENT 3/25/98 GROOME THOMAS R 210 SENATE AVE APT 121 CAMP HILL PA 17011 SOCIAL SECURITY 208-42-4774 1. BIRTH DATE - 12/01/52 2. SPOUSE NAME - KATHLEEN 3. SPOUSE BIRTH'OATE ~. 7/11./53" 4. SPOUSE SOCIAL SECURITY NO. ~ 191-46-1440 5. REPORTED DATE OR HIRE ~ 9/01/77 6. AGE WHEN HIRED - 24 ., 7. VESTED STATUS - 100r. VESTED 8. OEFINED BENEFIT PLAN LEVEL m I 9. LAST CONTRIBUTING EMPLOYER ~ UNITED PARCEL SERVICE INC 10. STATEMENT REFLECTS BENEFITS ACCRUED THROUGH - 12/31/1986 11. ESTIMATED NORMAL RETIREMENT DATE - 01/01/2010 12. TOTAL ACCRUED BENEFITS VESTING SERVICE 19 YEARS BENEFIT SERVICE 19 YEARS BENEF 1 T EARNED $227.08 THIS STATEMENT IS AN ESTIMATE OF YOUR ACCRUED BENEFIT, PAYABLE IN THE FORM OF A SINGLE LIFE ANNUITY AT NORMAL RETIREMENT AGE. IT IS SUBJECT TO VERIFICATION AT THE TIME OF RETIREMENT. AND DOES NOT TAKE INTO ACCOUNT THE EFFECT OF RECIPROCAL PENSIONS. THE BENEFIT LEVEL LISTED ABOVE ASSUMES TliAT VOU'WORKEO AT LEAST 1.000 liOURS AT THAT LEVEL DURING YOUR LAST YEAR OF PARTIC.lPATlON UNDER THE DEFINED BENEFIT PLAN. -'""~" ~~~ ~- ~~ '''''''''' . I -~: 1996 Estimated Defined Benefit Statement 2/22/97 208-42-4774 GROOME THOMAS R 1174 KINGSLEY RD CAMP HILL PA 17011-6110 1. BIRTH DATE - 12/01/52 2. SPOUSE NAME - KATHLEEN 3. SPOUSE BIRTHDATE - 7/11/53 4. SPOUSE SOCIAL SECURITY NO. - 191-46-1440 5. REPORTED DATE OF HIRE - 9/01/77 6. AGE WHEN HIRED - 24 7. VESTED STATUS - 100% VESTED 8. DEFINED BENEFIT PLAN LEVEL - I 9. LAST CONTRIBUTING EMPLOYER - UNITED PARCEL SERVICE INC 10. STATEMENT REFLECTS BENEFITS ACCRUED THROUGH - 12/31/1986 11. ESTIMATED NORMAL RETIREMENT DATE - 01/01/2010 12. TOTAL ACCRUED BENEFITS VESTING SERVICE BENEFIT SERVICE BENEFIT EARNED 18 YEARS 18 YEARS 227.08 CF6 - Main Selection CF7 - Year Selection -- ~ , fi'I/Iil__"e", THE CENTRAL PENNSYLVANIA TEAMSTERS RETIREMENT INCOME PLAN 1987 MAILING ADDRESS: P.O. BOX 15223 STREET ADDRESS READING, PA 19612-5223 2001 ANNUAL EMPLOYEE BENEFIT STATEMENT 1055 SPRING STREET WYOMISSING, PA 19610 4/2002 GROOME THOMAS R 1824 NEWPORT RD DUNCANNON PA 17020 1. BIRTH DATE 2. SPOUSE NAME 3. SPOUSE BIRTH DATE 4. SPOUSE SOCIAL SECURITY NO. 5. REPORTED DATE OF HIRE 6. VESTED STATUS 7. ESTIMATED NORMAL RETIREMENT DATE SOCIAL SECURITY 208-42-4774 12/01/1952 KATHLEEN GROOME 07/11/1953 191-46-1440 09/01/1977 100% VESTED 01/01/2010 8. DETAILS OF ADDITIONAL MONIES POSTED TO YOUR ACCOUNT FOR THE YEAR 2001 THAT WERE RECEIVED BY 03/08/2002: EMPLOYER MONTH HOURS TOTAL DOLLARS ------------------------------------------------------------------------------------- UNITED PARCEL SERVICE INC JAN. ,2001 841.53 UNITED PARCEL SERVICE INC FEB.,2001 841.53 UNITED PARCEL SERVICE INC MAR. ,2001 841.53 UNITED PARCEL SERVICE INC APR.,2001 841. 53 UNITED PARCEL SERVICE INC MAY. ,2001 841.53 UNITED PARCEL SERVICE INC JUN. ,2001 841. 53 UNITED PARCEL SERVICE INC JUL.,2001 841. 53 UNITED PARCEL SERVICE INC AUG.,2001 841. 53 UNITED PARCEL SERVICE INC SEP.,2001 841. 53 UNITED PARCEL SERVICE INC OCT. ,2001 841. 53 UNITED PARCEL SERVICE INC NOV. ,2001 841.53 UNITED PARCEL SERVICE INC DEC.,2001 841.53 TOTAL...................................................... .10,098.36 9. LATE CONTRIBUTIONS/ADJUSTMENTS TO PRIOR YEARS 10. DETAIL OF ACCOUNT ACTIVITY: .00 A. ACCOUNT BALANCE AS OF 12/31/2000 B. ADDITIONAL MONIES RECEIVED DURING 2001 C. NET EARNINGS ADDED DURING 2001 D. ACCOUNT BALANCE AS OF 12/31/2001 $166,157.04 * INCLUDES #9 10,098.36 -5,528.19 $170,727.21 II. GROSS ANNUALIZED RATE OF RETURN FOR THE TOTAL PLAN FOR 2001 12. NET ANNUALIZED RATE OF RETURN FOR THE TOTAL PLAN FOR 2001 (AFTER INVESTMENT AND ADMINISTRATIVE EXPENSES ARE DEDUCTED) NOTE: NET EARNINGS ARE ACTUALLY CREDITED TO YOUR ACCOUNT BASED ON QUARTERLY RATES OF RETURN AND BECAUSE CONTRIBUTIONS ARE RECEIVED THROUGHOUT THE YEAR, THE NET ANNUALIZED RATE OF RETURN CANNOT BE USED TO VERIFY THE "NET EARNINGS ADDED" AMOUNT ABOVE. YOUR ACCOUNT BALANCE ABOVE IS SUBJECT TO ADDITIONS, DELETIONS AND CORRECTIONS. -3.1 % -3.4 % --" "~ ~" ~ ~" 1L~;' 2000 Annual RIP 19B7 Statement 05/01/2001 20B-42-4774 GROOME THOMAS R RR 2 BOX 2329 DUNCANNON PA 17020-9638 1. BIRTH DATE - 12/01/1952 2 . SPOUSE NAME - KATHLEEN GROOME 3. SPOUSE BIRTHDATE - 07/11/1953 4. SPOUSE SOCIAL SECURITY NO. - 191-46-1440 5. REPORTED DATE OF HIRE - 09/01/1977 6. VESTED STATUS - 100% VESTED 7. ESTIMATED NORMAL RETIREMENT DATE - 01/01/2010 9. LATE CONTRIBUTIONS/ADJUSTMENTS TO PREVIOUS YEARS - .00 10. DEVELOPMENT OF ACCUMUlATED BALANCE FROM A. ACCOUNT BALANCE AS OF 12/31/1999 - B. CONTRIBUTIONS RECEIVED DURING 2000 - C. NET EARNINGS ADDED DURING 2000 - D. ACCOUNT BALANCE AS OF 12/31/2000 - 12/1999 TO 12/2000 : 156,218.46 * INCLUDES #9 10,098.36 159.78- 166,157.04 RATE OF RETURN OF TOTAL FUND FOR 2000 CF6 - Main Selection 11. GROSS - .50 % 12. NET - CF7 - Year Selection .20 ~ o - -~,~ . ~~~ "~.-~ ~ ~ "" ._, .'--<, - ~~ THE CENTRAL PENNSYLVANIA TEAMSTERS RETIREMENT INCOME PLAN 1987 1055 SPRING STREET WYOMISSING, PA 19610 MAILING ADDRESS: P.O. BOX 15223 READING, PA 19612-5223 1999 ANNUAL EMPLOYEE BENEFIT STATEMENT 5/2000 GROOME THOMAS R 210 SENATE AVE APT 121 CAMP HILL PA 17011 SOCIAL SECURITY - 208 -42 -477 4 1. BIRTH DATE - 12/01/1952 2. SPOUSE NAME - KATHLEEN GROOME 3. SPOUSE BIRTH DATE - 07/11/1953 4. SPOUSE SOCIAL SECURITY NO. - 191-46-1440 5. REPORTED DATE OF HIRE - 09/01/1977 6. VESTED STATUS - 100% VESTED 7. ESTIMATED NORMAL RETIREMENT DATE ~ 01/01/2010 8. DETAILS OF ADDITIONAL MONIES POSTED TO YOUR ACCOUNT FOR THE YEAR 1999 THAT WERE RECEIVED BY 3/31/2000. EMPLOYER MONTH HOURS TOTAL DOLLARS ------------------------------------------------------------------------------------- UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE INC UNITED PARCEL SERVICE ;rNC UNITED.PARCEL SERVICE INC UNITED PARCEL SERVICE INC JAN. ,1999 FEB., 1999 MAR. ,1999 APR. ,1999 MAY. ,1999 JUN., 1999 JUL., 1999 AUG. ,1999 SEP., 1999 OCT..; 1999 NOV., 1999 DEC" 1999 798.19 798.19 798.19 7 9 8 . 19 7 9 8 . 19 798.19 798 .19 841.53 841.53 841;53 841. 53 841.53 TOTAL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 9, 794 . 98 9. LATE CONTRIBUTIONS/ADJUSTMENTS TO PREVIOUS YEARS - .00 10. DEVELOPMENT OF ACCUMULATED ACCOUNT BALANCE FROM 12/1998 TO 12/1999 A. ACCOUNT BALANCE AS OF 12/31/1998 - B. ADDITIONAL MONIES RECEIVED DURING 1999 - C. NET EARNINGS ADDED DURING 1999 - D. ACCOUNT BALANCE AS OF 12/31/1999 - 141,700.91 9,794.98 4,722.57 156,218.46 * INCLUDES #9 11. ANNUALIZED RATE OF RETURN EARNED ON THE TOTAL FUND FOR 1999 - 3.6 % NOTE: NET EARNINGS ARE ACTUALLY CREDITED TO YOUR ACCOUNT BASED ON QUARTERLY RATES OF RETURN, THEREFORE THIS RATE CAi'lNOT BE USED TO VERIFY THE "NET EARNINGS ADDED" AMOUNT ABOVE. YOUR ACCOUNT BALANCE SHOWN ABOVE IS SUBJECT TO ADDITIONS , DELETIONS AND CORRECTIONS. .'. ...,~-" .,~....'\MC;: THE CENTRAL PENNSYLVANIA TEAMSTERS RETIREMENT INCO~E PLAN 1055 SPRING STREET WYOMISSING. PA 19610 MAILING ADDRESS: P.O. BOX 1S223 READING. I'll. 19612-5223 1998 ANNUAL EMPLOYEE BENEFIT STATEMENT 5/04./99 GROOME THDI~AS Fl 210 SENATE AVE APT 121 CAMP HILL PA 17011 SOCIAL SECURITY - 208-42-4774 1. BIRTH DATE - 12/01/52 2. SPOUSE NAME - KATHLEEN GROOME 3. SPOUSE BIRTH DATE - 7/11/53 4. SPOUSE SOCIAL SECURITY NO. - 191-46-1440 5. REPORTED DATE OF HIRE - 9/01/77 6. VESTED STATUS - 100% VESTED 7. ESTIMA-rED NCm.1AL RETIREMENT DATE - 01/01/2010 8. DETAILS OF ADDITIONAL MONIES POSTED TO YOUR ACCOUNT FOR THE YEAR 1998 -rHAT MERE RECEIVED BY 3/31'1999. EMPLOYER MONTH HOURS TOTAL DOLLARS .----'----------------.---------------------------------------------------------------. UNITED PARCEL SERVICE INC .JAN..98 UNITED PARCEL SERVICE INC FEB,. .98 UNITED PARCEL SERVICE INC MAR...9B UNITED Pl\RCEL SERVICE INC APR... 98 UNITED PARCEL SERVICE INC MAY..9a UNITED PARCEL SERVICE INC JUN..98 UNITED PARCEL SERVICE INC JUL. .98 UN !TED PARCEL SERVICE INC AUG..98 UNITED PARCEL SERVICE INe SEP-..98 UNITED PAF!CEL SERVICE INC OCT..98 UNITED PARCEL SERVICE INC NOV..98 UNITED PARCEL SERVICE INC DEC..91l 659.52 659.52 '737.52 '137.52 737.52 '737.52 '737.52 798.19 798.19 798.19 798.19 798.19 TOTAL......~............................................... B.997.59 9. LATE CONTAIBUTIONS/AD.JUSTMENTS TO PREVIOUS YEARS - 190..6'5 10. DEVELOPMENT OF ACCUMULATED ACCOUNT BALANCE FROM 12/1997 TO 1?'1998 : A. ACCOUNT BALANCE AS OF \2/31/1997 - B. ADDITIONAL MONIES RECEIVED DURING 19qB - C. NET EARNINGS ADuED DURING 1998 - o. ESCROW TRANSFER 1998- E. ACCOUNT BALANCE AS OF 1.2/31/1998 - 120.881.04 8.99'7.59 3.769..34 3.0S,2.g4 141.700.91 ,. INCLUDES 1!19 11. ANNUALIZEO RATE OF RETURN EARNED ON THE TOTAL FUND FOR 1998 - 6.6 % NOTE: NET EARNINGS ARE ACTUALLY CREDITED TO YOUR ACCOUNT BASED ON QUARTERLY RATES OF RETURN. THEREFORE THIS RATE CANNOT BE USED TO VERIFY THE "NET EARNINGS ADDED" AMOUNT ABOVE. YOUR ACCOUNT BALANCE SHOWN ABOVE IS SUBJECT TO ADDITIONS.OELETIONS AND CORRECTIONS. ~. .~. ~ . " ~ 1... ~ " ~ -~ THE CENTRAL PENNSYLVANIA TEUISTERS RETIREMENT INCOME PLAN 1055 SPRING STREET WYOMISSING. PA 19610 MAILING ADDRESS : P.O. BOX 1522.3 READING. PA 19612-5223 1997 ANNUAL EMPLOYEE BENEFIT STATEMENT 3/31/98 GRDOt4E THOMAS R 210 SENATE AVE APT 121 CAMP HILL PA 17011 SOCIAL SECUPITY - 208-42"-'/+ 774 1. BIRTH DATE - 12/01/52 2~ SPOUSE NAME - KATHLEEN GPOOME 3. SPOUSE BIRTH DATE - 7/11/53 4. SPOUSE SOCIAL SECURITY NO. - 191-46-1440 5. REPORTED DATE OF HIRE - 9/01/77 6. VESTED STATUS - 100% VESTED 7. ESTIMATED NORMAL RETIREMENT DATE - 01/01/2010 8. DETAILS OF EMPLOYER CONTRIBUTIONS POSTED TO YOUR ACCOUNT FOR THE YEAR 1997 THAT WERE RECEIVED BY 2/10/9S. EMPLOYER MONTH PD FOR HOURS PAID TOTAL DOLLARS ~___._______.~_____w._____~.__~~.,.._________~_______._____~_~_________.. _____._.m______~.h.. UNITED PARCEL SERVICE INC JAN..97 UNITED !'ARCEL SERVICE: INC FEfh.97 UNITED PARCEL SERVICE INC t4Afh .97 UNITED PARCEL SERVICE INC APR..97 UN I TED PARCEL SERVICE INC I<lAY.,97 UNITED PARCEL SERVICE INC JUN.,97 UN 1 TED PARCEL SERVICE INC JUL.,97 UNITED PARCEL SERVICE INC AUG...,97 UNITED f'.AflCEL SE"VIC" INC SEP..97 UNITED PARCEL SERVICE INC OCT<II'I97 UNITED PARCf~L SERVICE INC NOV..97 UNITED PARCEL 5E.RVICE INC DEC..97 621,,39 621.39 621.39 621.39 62 r.. 39 62 l-ll 3'9 621.39 621.39 621.39 ()21 ''II 39 621.39 621~39 TorAL.~~~.~.~&~.~~..~~.~~.9...4~..~~~.$.~~...~$...~.4~~~*~~ 1.456~68 9. LATE CONTRIBUTIONS/ADJUSTMENTS TO PREVIOUS YEARS - .)U 10. DEVELOPMENT OF ACCUMULATED ACCOUNT BALANCE FROM 12/96 TO 12/97 : A. ACCOUNT BALANCE AS OF 12/31/1996 - B. CONTRIBUTIONS RECEIVED DURING 1997 - C. NET EARNINGS ADDED DURING 1997 - D. ACCOUNT BALANCE AS OF 12/31/1997 . Q2.,759'$ 86 7,456.68 20,47,3",85 1.20,6Q{)-.39 .* INCLUDE 5 119 lIe ANNUALIl~D ~ATE OF RETURN EARNED ON THE TOTAL FUND FOR 1991 21.1 ., " NOTE: NET EARNINGS ARE ACTUALLY CREDITED TO YOUR ACCOUNT BA5LD ON QUARTERLY RATES OF RETURN. THEREFORE THIS RATE CANNOT BE USED TO VERIFY THE "NET EARNINGS ADDED" AMOUNT ABOVE. YOUR ACCOUNT BALANCE SHOWN AECVE IS SUBJECT TO ADDITIONS.DELETIONS AND CORRECTIONS. ---~ =,"-~.~ -~" ., ~~ 1996 Annual RIP Statement 208-42-4774 GROOME THOMAS R 1174 KINGSLEY RD CAMP HILL PA 17011-6110 1. BIRTH DATE - 12/01/52 2. SPOUSE NAME - KATHLEEN GROOME 3. SPOUSE BIRTHDATE - 7/11/53 4. SPOUSE SOCIAL SECURITY NO. - 191-46-1440 5. REPORTED DATE OF HIRE - 9/01/77 6. VESTED STATUS - 100%" VESTED 7. ESTIMATED NORMAL RETIREMENT DATE - 01/01/2010 9. LATE CONTRIBUTIONS/ADJUSTMENTS TO PREVIOUS YEARS - 10. 12/95 TO 12/96 74,267.40 7,031.99 11,460.47 92,759.86 DEVELOPMENT OF ACCUMULATED BALANCE FROM A. ACCOUNT BALANCE AS OF 12/31/1995 ~ B. CONTRIBUTIONS RECEIVED DURING 19 96 - C. NET EARNINGS ADDED DURING 1996 - D. ACCOUNT BALANCE AS OF 12/31/1996 - ~"~i:-" 3/03/97 .00 * INCLUDES #9 11. ANNUALIZED RATE OF RETURN EARNED ON THE FUND FOR 1996 - 14.20 CF6 - Main Selection CF7 - Year Selection l} o .kii~", , . "L . Select Activity Logs Claim Key: 58 37 MP 11638~1l998))] Requester: ROSST Policyholder: Groome, Thomas & Kathleen M Print Date: May 22, 2001 Claimant: N/A Print Time: 8:18 AM Date: 1998-11-18 Time: 09:41:59 Creator: OaR Assignee: OOR Cov: Claimant: ~,~ ~~ 10{ -# 532. LJ9 eK '*' b / - 9 <(If '/2.0 0220 INVESTIGATION: CAUSE & ORIGIN - Groome, Thomas R & Kathleen M returned call to '1:;11. sh~ stated that her son, marshall- age 21, is in the marine corps stationed at camp lejeune, nc, he was overseas on deployment and a box containing some 'ofher personal. belongings as well as his was stolen, . ehe had given him her camcorder and he had some tapes and c,d.'s in the box, he still considers his parent's address his permanent residence and all of his records lists their address as his home address. his driver's license has their address on it. she will fOIWard the inventory, -~ ~~"'--............. _...~"', _I . ~ - "'~ - ~" . i~_,,;, "\' '..llo It. l\t~T' 1'" t.aU)(lM)i . ~. \ ....,1"10\..,:1 I' , ,"\ \{"',, t.. .'\1," ,: ," ~'-"f)f.II.,,J.';Eit.... J.~iC.;:I):"I" 1,"".1.I.U.1It "'1.\':" ,~."..nt ,~.... $->.J2,49. .' ::l" p.,:... ..' "".,..~- .' "1'( . ..' ""'1 , ...:..1 . ",~ ,::m<:.. .hl949,uO '. 1 \Il"1J .".'Ii ... . :1' :l'.I(.J ,ii.> ~/. ..~,.. ''''',. .;';.l..~" !~~t~ .. ,,:,~~ "''''S~ <'; S;~ ',Nitt . ,":'t~ ..0/ " .'--' .'\.." ." .., 1.'.1,',,1.. .... < ".' .__ _ S i 2Iolil.~~ J ,-:1 ,".- v, .. '. ~ :~ ..... ''''1 '':''; ~~ ,~ 't. ~ ":I"~ .~.~:~ ,'.~.;il. \"'~ ',;.'/~ ~.';,~ ,..:.~., . . "~','1' ** TOTRL PRGE.02 ** ~~"" ~. ". " Select Activity LOj!s .' Claim Key: 58.37 MP l16384~1' .' Requester: ROSST Policyholder: Groome, Thomas R & Kathleen M Print Date: May 22, 2001 Claimant: N/A Print Time: 8:21 AM Date: 1997-07-25 Time: 13:28:57 Creator: HOOVERM Assignee: HOOVERM COY: Claimant: 0240 EV ALUA TION OF DAMAGES: DAMAGE EST - Groome, Thomas R & Kathleen M SCOPED DAMAGE WITII PH, WATER THAT CAME FROM TOILET OVERFLOW HAS DAMAGED THE mE FLOOR AND THE WOOD MOLDING AROUND IT, THE DOOR PANELS ALSO SPLIT, I WROTE BOEC~OTAL OF EST IS $363,6. 9, AFTER PH'S $100 DEDUCTmLE I AM ISSUING THEM A CHECK FO 263.69 SENDING A COpy OF EST, THERE IS NO SUB OR SALVAGE OPPOR11JNITY a: Ii .5 J- 09g 9~6 " j , !;..l..". " ~ ..... .,~-. ".,. .. 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'"' . . :,: +,;~';',:, ~,:~;~~~~: I...... '1"'. ~ ,'. .:' " :!: ...~.::L.::~ ......:.,... ':" : ..; ',t., ::. 'J' ..: . ." : ;.:'~ I .;.;.... ,.; , . '. . '..i' ':;':: ,'. .",: . ~. ' ". '. : ~~. :.... j~;~~{~} '. .t....".... ...!ki: ",'.,." '.\: ~ : '.. .',' ". , , 919;5, ZH :1 ., jllillll~"" !. " ......:. ~_i, .' " ." .. .' .... ...;.<~ , -'- ~ ~ ~ I~ , , ~" " . ",., Select Activity Lo~s Claim I{ey: 5837 MP 11638(iQ02199;)1 . Requester: ROSST Policyholder: Groome, Thomas R & Kathleen M Print Date: May 21, 2001 Claimant: N/A Print Time: 1:52 PM Date: 1999-10-06 Time: 21:00:19 Creator: GffiSONR Assignee: GffiSONR COy: Claimant: 0220 INVESTIGATION: - Discussed claim wIPH. Water entered room thru window, Wall, carpet damage. Got room info. No cvg for contents. 5- /- 9J 5 -I s- C; 7 :if 3 79. J. f cJ:-dl 6J- 33lfl.fS-1 ~ I.,~~f~ ;j' ~~Y\ ~ ~ ',", . ~ 9'~<L p,~ ~ kij soRJ ~ -to diUCll..UL. c.JC'-D t.uY\.o.l...)O-A-L 'SO a.,bCl\Nl.... 3 . )OS:SeA.. ~JU~ Cop<-{ 17 .$J.rl C~I bS2.-/")...~g """- "<.~... , c -'..... ,-, '--"--"'''''fOCCCl-lNil .......... NAT10Nff1OE l/ISUIWiCE ENTElll'AtsE P 0 lOX. 1106 COLUIIIUS 011 4Gtll-lIQ11 1.8QO.m.41411 EltT 2700 MoCK'" 001832 PAY EX.\9TLV: Par T. Tha Ol~lr ell . TllaMS R ~ KA TitLE EN 1\ GROOIIE \\74 KINGSLEY ROAD tAMP HILL PA 17011-8110 ..- 1WMIIGAIi. .JQI" a'lI ~saa~~~s~~ ~O?2~~~qi7~ e~ g ;if - :I': 9 9 W C'~"1l ~~"::d'? 1(1-14-!:ISt <l;.lNC&:. . ~,~,~.\)~~ o;e'''-)~\:a,'' f:~~i:\~O'-~'i~i~ 1 J+:iiW I.OU J:\' 'J~v,j.f'..lJ'~"'" ~ ;Z J" ::1l:' o \ . . . 4.; b':.j; o ..0 -.\ 'IJH( ~, ;'iIlr1~ C7~41:a9a7 l&lUm ::;!"':7i;"fi~ i !-QI'"'t:.J~~~ \, ~~ t "\ :. ~: =: '.: j r ....i faVl i - 05122/2001 oe:5S AM "'...'_...'uv......oillCi.c.lXlI:\MId------ $*395.24* 74.11;2 7U 1hIiI" ill, ....",...,.., ....... 1JId"'" CII'l .". . i ~f/!,. ".ff" OD~OSal,b" ,"00000 3li'i 21,," r~ , . :-=:- .ro... . ,~ ,....., ,,'" n . .,:, .. ~'1 1 j: '". .') " ... , ' '~ \ . .:-;:~ <., .., ..n o $.:\ (\ 10.) 9J ~ CDVallDICIMSKay 19951027081901 Bank II ?0ooooo101 Acc.1I llOOOOOOOfOS8.l6 SarlalNum 005Il!l311/:1 tJ NATtONWlD. E Cll8ck No: Sl.83445 I INSURANCE Date: 10-07-99 ..........,..... ~ ~ NIl CMMc -"IG Oqt Ref: ~ $7 lIP 111384 fO.Oa-1M 01 ..13.411 . .-THREE HUNDRED HI_ETY NINE AHa 24/100 DQLLARS....r...........~..............~......t...................... SequellCll 0028743481 , lA1oc8lIon CD Paldllata 1011411999 -...._Al'P~C8.... . . . . - .., .... J." ~J i:.j <::> <: ..... - - $399.24 . . ,-..'Z.. Post.lt" brand fax transmittal memo 7671 ~ ~m Co. Dept, Co. Fo'" - . -" . . February 27,2001 Timothy Walker 70 Caravan Court Middletown, PA 17057 717 -944-2628 $ 500,00 Grand Total The above amount to include two coats of ceiling paint, two coats of wall paint Also included in above amount are two coats of oil trim paint on nine interior doors and trim, nine windows and frames, as well as, crown and floor molding on entire fIrst floor. The square footage is approximate at 1,200 sq. ft. All supplies to be provided by customer. All preparation of walls to be completed by customer with the exception of caulking wood to walls. Thank. you for your,f~iness! /},' Al k/~ Tk~yV~lker . ,-~ _ "~_":""",O_;;I' " THE HOME DEPOT 4120 6000 CARLISLE PIKE, MECH. PA 17055 JERRY ANDERSON MANAGER (717)795-9602 HOME DEPOT 4113 4200 DERRY ST HARRISBURG, PA 17111 STORE NANAGER SCOTT SAURS 717-558-8105 SALE 4120 00007 13909 03/18/01 11 891 02:44 PM SALE 4113 00007 33998 03/18/01 11 265 01:00 PM 9H6... ~..... ~.. ) ~ ~~<;;! ~'" ~*'@ 765096852512 SHOE 765096852512 SHOE 765096852512 SHOE 076178104048 MASK TAPE 731161011061 ROLLER BOX 731161011061 ROLLER BOX 731161011061 ROLLER BOX SUBTOTAL 36.45 TAX PA 6.000 TOTAL CASH CHANGE DUE : "~.~) "'~" :~~, ,~ , ~ @ h. ~ ____......._~ 1.51 1.51 1.51 1.95 9.99 9.99 9.99 36.45 2.19 $38.64 40.00 1.36 02"367398194 GL1516 GAL 077089143300 3PK RLLR C 030699157112 fASTENERS 030699157112 fASTENERS 731161005350 ROLLER BOX SUBTOT AL 39.50 TAX PA 6.000 TOTAL CASH CHANGE OUE 21.97 5.96 0.79 0.79 9,99 39.50 2.37 $41. 87 42.00 0.13 11111111111111111111111I111111111111111111I111111111111 4113 07 33998 03/18/01 9105 GREAT CAREERS BUILT HERE APPLY IN PERSON OR CALL 1-877-WORK-4HO WE INSTALL CARPET!! 11111111111111111111111111111111111111111111111111'11111 4120 07 13909 03/18/01 9128 GREAT CAREERS BUILT HERE! 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Dlf 046878580947 HOSE NOZZL 078477824474 SWITCH IVV 071514024288 TWINE 078477151273 OUTLET 078477151273 OUTLET 078477151273 OUTLET 078477232057 DUPX RECEP 078627405829 HOSE 078477151273 OUTLET 078477232057 DUPX RECEP 078477151273 OUTLET 078477151273 OUTLET 078477151273 OUTLET 078477772713 SP SWITCH 078477772713 SP SWITCH 078477772713 SP SWITCH 078477772713 SP SWITCH 078477772713 SP SWITCH 078477772713 SP SWITCH 078477151273 OUTLET 078477151273 OUTLET 078477232057 OUPX RECEP 078477151273 OUTLET 078477151273 OUTLET 078477151273 OUTLET 079000308744 SURfACE MO 078477493106 TGGLE PLAT 078477493106 TGGLE PLAT 078477493106 TGGLE PLAT 078477493106 TGGLE PLAT 078477493106 TGGLE PLAT 078477493212 DUPLEX PLA 078477493212 DUPLEX PLA 078477493212 DUPLEX PLA 078477151372 WALLPLATE 078477493212 DUPLEX PLA 078477493212 DUPLEX PLA 078477493212 DUPLEX PLA 078477493106 TGGLE PLAT 078477493212 OUPLEX PLA 078477493212 OUPLEX PLA 078477493212 OUPLEX PLA 078477493212 OUPLEX PLA 078477493212 DUPLEX PLA 078477493212 DUPLEX PLA 016744610184 ES36X47 WH 016744610184 ES36X47 WH SUBTOTAL 105.77 TAX PA 6.000 TOTAL CHECK 181926367 AUTH CODE 931459 3.92 3.29 6.84 1.98 0.35 0.35 0.35 0.86 10.97 0.35 0.86 0.35 0.35 0.35 0.51 0.51 0.51 0.51 0.51 0.51 0.35 0.35 0.86 0.35 0.35 0.35 1.93 0.36 0.36 0.36 0.36 0.36 0.36 0.36 0.36 0.62 0.36 0.36 0.36 0.36 0.36 0.36 0.36 0.36 0.36 0.36 29.95 29.95 105.77 6.35 $112.12 112. 12 . 1111111111111111111111111111111111111111111111111111111 4113 02 03349 12/02/00 1902 THANK YOU fOR SHOPPING AT THE HOME DE~T-- WAREHOUSE PRICES - DAV IN, DAV our WE INSTALL CARPET ~/ ) d- Co ~ ,'i \ / ~~'~, 6~'6~1 : X33H3 69'6~1 :300 33KUlua 69'6~1 W8 Ja'1~1 Ln L~'O LI'l ona OL '~I 6L'I WI 96'S L~'E 6L'1 6L"1 8~'L 8S'E 88'0 88"8 8!:'l 9l'a 66'0 6&'0 66'0 anI La'a WI an 6n :lUIOl sal 33IOhKI , OSS8E m 'lU101aOS IHn SM3H3S ij31109 E~E9E IHM Sn3ij3S ij31109 E~E9E 10U3 SHIKIUd 1'01 06~E~ 9n g 81 103 H Hsnl~ 39NIH Eaa~~ 86'8 g SI Xla lUIK0103 aOKX Lla~9 U ij3HIUHlS ij311n9 59511 Moa13 wnlU ij311n9 8SS1l 13 HOOD 3IIUM03Hd 6sas~ IUHJ IJ310ijd ijOOO ~sas~ U ij3KIUHlS H311n9 S~Sll U H3KIUHlS ij31109 S9SI1 89'9 g 11 lU3 ij3110ij 9NIijdS ~8~09 d ON3 wnlU ij31109 ~LSII UJOK3 wnlU ij31109 89Sll U30N3 wnlU ij311n9 ~~Sll dI1S wnlU H311n9 ~9Sll ~S'O g ~ ua 100dS NnlU In9 89S1l HUH N300IH H311n9 6SE9E KUH K300IH ij311n9 6SE~E HUH N300IH H311n9 6SE~E hW3ij3hIS3HOU lU9 9S~8a IH3ijijnJ KIUH311nd SLsaL H9Iija HSINI~ lIUN 8SlG~ 88'1 g ~ ijUlS/HU313 ,,~/l a S~LE6 M 181 wnlU ij31109 lSSll on g 01 80'lE Lal/Gal KIUIS !8l ~~EE lO-81-ao 8GE~al Erwso~os ,<< S31US -31US- a~S9-99L (L lLl S ".::'3If.'IO...... - .,- 0.'1 4' " --< - 00 '" -l .... " > c... <: :>: en en .... m gs:c ~::e::~ - Q"" '" ~>'" .... ~ gl'T1 --<'" - W """ "'< ...= W 0... ~ ~:I .~ 0:>:0 ..- ..0 c::o c:: N- '" ..en "'c:: 0== 0 "'..... g;J ~C "'.." ....o ",,"'0 ..- "'... .. ~ ~3 '" '" 0 .o'" ~..~~ ..... "''''' en= c:: N Z '''IT\ "'''' '" 0 0 ~~:>: W ~n """" ~ --<no W- z*" ~~i'~ 0 i!; ~c "'''''''' N= ('''H'''l -t -HI) 0 '" "" 0 $G1~~ai~Q 0 >'" > ~ .....~ ~:X:i!=-aci~tri ~~~ .......... ~. IT\ --;!rrtrrl @)~ ~./~) ;:lCI ~"'O !~~ .....- en N W _ !iC ...- c en .... "w .....- c:: WN ..... -l :Cl-t-t 0 '" 0 ...0 ..... OZ:>: 0- 0 .... "". '" 0 ~"" ~t::J:X: N_ ~ >J:. .o "'>0 0_ .......... ... ........ ""<"" ... ... 0..... , o '" - "W WN ....... ~.~,N. --<0 ~O(nNW(n""" ON . C::C "'... ~ ~C n--<'" = :"'OCoOCDmu:' ..... o "" - -a 0 "" 0 -- ......OWWCH,,o)...... ,.0 --< tE~~Ym~R~~T !7043 c-----.' ""'" s;..' \ V \ \:j D. 1. Y. DATE: 01/27/01 TIME: 1:46 PM 1-0100 E03/10490 10-014 * INDICATES SALE PRICE SALES NU~lBER SIZE PRODUCT DESCRIPTION QTY PRICE VALUE 291-3739 18 IN VALUE LINE TRAY-18" P,'eferred pL(i;\;omer 201.. /.. ,~'->L',' 1 7.49 * 7.49 -I. 50 -------- Thank You --------- receipt required for refund SUBTOTAL 6.0001. SALES TAX(I-38001) CASH TENDERED CHANGe; DUE TOTAL 5.99 0.36 -10.00 3,,6~ $6,,35 . , ~ "-',~,,- ',l~iiiI ~I.......... ~~ REPORT ON: GROOME, THOMAS R. PAGE SOCIAL SECURITY NUMBER: 208-42-4774 DC6256455 SEARS # 287047984722 >INCLUDED IN BANKRUPTCY< UPDATED 09/2000 BALANCE: $0 OPENED 07/1995 MOST OWED: $805 CLOSED 08/1996 STATUS AS OF 08/1996: UNRATED IN PRIOR 04 MONTHS CONTACT SUBSCRIBER: SEARS 13200 SMITH RD 2 OF 9 REVOLVING ACCOUNT CHARGE ACCOUNT INDIVIDUAL ACCOUNT PH#: CLEVELAND, OH 44130 BC9616003 DISCOVER FIN # 6011002710177338 >CHAPTER 7 BANKRUPTCY< UPDATED 09/2000 BALANCE: $0 OPENED 02/1996 MOST OWED: $2140 CLOSED 06/2000 STATUS AS OF 06/2000: UNRATED REVOLVING ACCOUNT CREDIT CARD AUTHORIZED ACCOUNT CREDIT LIMIT: $2000 CONTACT SUBSCRIBER: DISCOVER FINANCIAL SERVI PH#: (800) 347-2683 WILMINGTON, DE 19850 Z1353001 UGI CORP # 218191183647 OPEN ACCOUNT UPDATED 12/1999 BALANCE: $83 INDIVIDUAL ACCOUNT OPENED 08/1987 MOST OWED: $146 STATUS AS OF 12/1999: PAID OR PAYING AS AGREED >IN PRIOR 48 MONTHS FROM DATE VERIF'D 2 TIMES 90 DAYS,< > 5 TIMES 60 DAYS, 6 TIMES 30 DAYS LATE< > MAXIMUM DELINQUENCY OF 90 DAYS OCCURRED IN 01/1998< CONTACT SUBSCRIBER: U G I CORP OF READING PH) 375-4441 READING, PA 19611 BC4283002 FULTON BANK # 5418701100028867 REVOLVING ACCOUNT >CHAPTER 7 BANKRUPTCY< VERIF'D 07/1999 BALANCE: $0 PARTICIPANT ON ACCOUNT OPENED 09/1989 MOST OWED: $2526 CREDIT LIMIT: $2500 CLOSED 09/1996 STATUS AS OF 09/1996: UNRATED CONTACT SUBSCRIBER: FULTON BANK LANCASTER P.O. BOX 4887 PH#: LANCASTER, PA 17604 DZ235027L MBGA/HECHING # 52060679629 REVOLVING ACCOUNT >INCLUDED IN BANKRUPTCY< UPDATED 02/1999 BALANCE: $570 PARTICIPANT ON ACCOUNT OPENED 01/1986 MOST OWED: $570 CREDIT LIMIT: $0 CLOSED 10/1996 >PAST DUE: $570< STATUS AS OF 10/1996: UNRATED CONTACT SUBSCRIBER: HECHINGERS PH#: (800) 631-9700 POB 103000 ROSWELL, GA 30076 ~_......,-""'-....._,~- ~.- ~~ .~".~~ REPORT ON: GROOME, THOMAS R. SOCIAL SECURITY NUMBER: 208-42-4774 ADVERSE }~.C-eotlNTS, CONT. PAGE 3 OF ," >COLLECTION RECORD< . ,_,.,'X.e2834001 '-----,c SYSTEMS # 41982U24 'PLACED FOR COLLECTION< UPDATED 01/1999 BALANCE: $159 PLACED 11/1997 MOST OWED: $159 >STATUS AS OF 01/1999: COLLECTION ACCOUNT< SUBSCRIBER: I C SYSTEMS P X 64378 > OLL RECORD< YC28340 IC SYSTEMS 6 >PLACED FOR COLLECTION< UPDATED 12/1998 BALANCE: $190 PLACED 08/1998 MOST OWED: $190 >STATUS AS OF 12/1998: COLLECTION ACCOUNT< SUBSCRIBER: I C SYSTEMS PO BOX 64378 CO CORD< YC2834001 IC SYSTEMS # 4199390337 >PLACED FOR COLLECTION< UPDATED 12/1998 BALANCE: $79 PLACED 08/1998 MOST OWED: $79 >STATUS AS OF 12/1998: COLLECTION ACCOUNT< CONTACT SUBSCRIBER: I C SYSTEMS PO BOX 64378 . ~""" 9 INDIVIDUAL ACCO BELL ATLANTIC TELE INDIVIDUAL ACCOUNT BELL ATLANTIC TELEPH 1-6333 ,MN 55164 INDIVIDUAL ACCOUNT BELL ATLANTIC TELEP QU6755004 MEMBERS 1ST # 4121449991156634 REVOLVING ACCOUNT >INCLUDED IN BANKRUPTCY< VERIF'D 10/1997 JOINT ACCOUNT OPENED 07/1992 MOST OWED: $10000 CREDIT LIMIT: $0 CLOSED 08/1996 STATUS AS OF 08/1996: UNRATED CONTACT SUBSCRIBER: MEMBERS 1ST FCU 5000 LOUISE DR PH#: (717) 697-1161 MECHANICSBURG, PA 17055 "" ,- . I. _ ~~ - Additional bills left when Kathleen moved out of the marital home: PP&L Comcast Water UGI Sewer Mortgage due 9/1 $347.90 $103.30 $118.00 $ 34.54 $ 79.53 $624.89 $1206.19 . h~ .~J ~iUf# I) GU sr,,,,, Billing Summary for Service to: THOMAS R GROOME 117. KINGSLEY RD CAMP HILL PA 17011 Rate Classification: Residential Heating Billing Period: 08111/2000 to 09/12/2000 (32 days) Estimated Read "Your current charges include State taxes totaiing $ 1.77. ,.....,.,->>lL___~, Past Bill Information - The account balance on your last bill was ,..,....",.., Payments "...."........"""........"......,,,,,.................,,,,..,,,..... Late Charge ................".............',..."",...........",.........".." Your baiance as of 09/14/2000 (due now) """"..." $ 34,12 0,00 0.42 34.54 f..-.......,~~. '=.'"'''''.''''.''''''''' """.'~t.",_."" .c...... '.".' i,y..U~:.9ln..~;l\twn.~eJ .'liv..!itm.;u. :"~}):tti."",;;,, 218191183647 If you have any gu.stlor please call us at 717-232-1811. or write POBX 13009., Reading, F 19612.3009, Please contact us by October 6 NPN 218 1911836 471 Average CCF Per Day . "m - !II - III II 5,10 4,59 4,08 3,57 3,06 2.55 2,04 1.53 1.02 "0,51 0,00 . . . . . .. . 80NDJFMAMJJAS 1999 Months 2000 . = Estimated Usage Average Last Year This Year 0.38 700F CCF/day 0.41 Daily temperature 760F , .' Current Bill Information - UGI Customer Charge ""'....".......""........,....,.."....,,.............. Charge for gas used ...........".."".."....".."....",........""". PA State Tax Surcharge ."......"....."""".............."""...., Pipeline Surcharges "...."..."""..............""""................ PA Sales Tax ....................,........................"....""......"."", Total Current Charges (due by 10/06/2000) """"" Total Amount Due "............"..".."...."..........."."......".... 9,00 11,16 -1.01 -0.01 1.15 20.29 $ 54.83 ~\) (0/3 ck.:fj 9~<O Meter. Reading Information Meter Number Previous Reading 1131412 3B55 (company) . Present Reading 3867 (estimated) CCF Used 12 Messages from UGI . Please pay your bills promptly or your credit history may be affected. . ~elp prevent pipeline damage. accidents and service disruptions. If you see someone digging near your home please call UGI. If you pay at a payment agent please take your entire bill. Make check payabie to UGI. Keep this part for your records, Important Information is on the back of this bill, - "'~ - !:Ik~,' . - )> .... 0 0 i ()~I ~ .... )> co ( I s::~: ." .... m .I> !!1"tJ:r:1 Z m :r:C: ~ 0 :::! r- s:' . ". r 0- "' -0 m r 0 (")~ .... ~ (if ::tir! Z :i ..... 1>.... 0 ..:.. -'o.~. (J) 3:-J 0 en .......<. ~ \1.1> 3: :;tl dI emf ~z m 1> iT; ...a.c: J:" .. "T1 Jl u. m: )> Hl-i C ! z rz ;ll (.l) c r.. . fT1 )> i,;""l . . ~ \1r .. 0 I>fT1 ;ll ~ -< 0 ." 0 m .... 7.1 3: Z -J \;l fil .I> )> 0 IV ~ .. . ... 0 0 0 Z ~~ Jl m ",0.- "T1 -".- , r-. Z c ! Cr-Ci) (J) i!jg" m c;; "" o~~ ~oo E:; "" zo I ! . c ... m c W , - f ! Joi..~!--- "T1 , 0"'0 "T1 l ,.,./, .c 1= C~O ~ .... J-J-:...i-'" ." ~ 0 '''' J ~ii ;..; OHIO 1>.1> OZO :m rr-J .. ':!l . :".{iOO-{ \;le 1>rJ: 1(;5 CC '"<:l'1?l Iz fT1. __ -<0 '0 .. C [-l 7.17.1., I:;:: OCiZ 111 IE:; "". 0; [~ i> .. tiC)! IV I~ "TJ " .. ." l>l tt!~ I1l .. I~ Wt.! " " 0 C :I< -I 0 I~ :t: H I~ .- 1,;; .. t:I '<II t..?!v -I 1- 11= t-J">O .~ I- . . IZ ...W .... ,G) t>lW ..... Ie 0 I!; lie ... 'm , 0 0 , . '"., ,_:, '/'>':;~_v ,-- ':;, ;'"::,, .<':~-'; . '"<",,. '-,','r-' r " ;. '-: ':, , ,PPL.Utilities . ~rk" Service For: THO~SGRQOME 1174K,INqSlJl'(RD' CAMP HILL PA 17011 Questions ahout . this bill? Please COntact us by Oct 31 at 1-800,342-5775 or write to: Customer SerVice . 827 Hausman Rd. Allentown, PA 18104-9392 wwW'l'plweb.coin - ~~ -~ " , . ,i,' "':'~I~:'-:+::' pp .;~~~: " N t'3gt:. J. ::;1;~1;?i!~*i:Jl:'" :\.1&:: in:". ..... 'l1rit. . '-.. ,:~;~;l:1!!:~',li~' 13460-76007 'i:'!l:+.':~; ii:':~::: '&1::'" ....::ca ....:Oi:: ",," in ~lImmary Pa~e Balance as of Oct 10, 2000 $ 347,,0 Charges: TotarPPL UTILITIES Charges $ -87,15 Total Charges $ 260.75 -.'......"..'..."...... , ,', ' " ", - . ".. -.. '-.. . . . "~',;" '-'. '. . Account Balance $ 396,11 Electric' Use This graph.shows yourelectnc use over the last 13 months. 'I'ypes of Meter Readings: Actual _ Estimated _ Customer D 42 KWH - Average Per Day Meter Reading Information e er 3S . OcllO Actual 71837 Sep 8 Actual 71328 28 32 Da s 1 e ~ Average' Oct 1999 2000 21 T'\V'nerature 62F 62F K Per Day 25 16 14 Yearly Use: Total A vera~{ 7 Use Month) , Nov 1998 - Oct 1999 9160 76: 0 Nov 1999 - Oct 2000 9911 821' ONDJ FMAMJ JASO 1999 Months 2000 -~-----------~--------------------~---~--~---------~-------~----~--------------~----------------~--~----------------~---------~~.-------------.- Other important information on back -+ -.... , ,. ~ , - PPLUtilities. . Electric Service For: THOMAS GROOME 1174 KINGSLEY RD CA!vlP HILL PA 17011 . PPL Utilities Customer Service 827 Hausman Rd, Allentown, PA' 13104-9392 1-800-342-5775 www.pplweb.com -'".. " """,- Page 3 ..,... ....\'f("dl' tA&'~it:l'l'\fubi;i.':::'J"""" '-ll, ' P'p":'~rf{~-- . " . , " ~ sg" ieii':ca 13460-76007 .":Qt:wrll'i , ,.- Total from Last Bill $ 347.90 $ 347.90 Current Charges Chal)les for - PPL UTILITIES Residential Rate: RS for Sep 8 - OctlO Distribution Charge: Customer Charge 200 KWH at1.79600000~ per KWH 309 KWH at1.59400000~ per KWH Transmission Cha'Xe: 509 KWH at 0,37700000~ per KWH ,Transition Charge: . 200KWH an.798oo000~ per KWH 309 ~WH at1.59400000~ per KWH GeneralIon Charge: . Capacitv and Energy 200 KWH at 4,826000001<' per KWH 309 KWH at 4.238000001<' per KWH P A Tax Adjustment Surcharge af 0.05000000% Total PPL UTILITIES Charges Other Charges for PPL Utilities Payment Plan Adjustment Payment Plan Amount Total of Other Charges 6,47 3,59 4.93 1.92 3.60 .4.93 9,65 13.10 0.02 -150.36 15.00 Billing Details Amount You Still Owe as of Oct 10, 2000 $ 48,21 $ -135.36 -................:.........'.' ., .' - . \ -,.. .-.... .' . . -. . . Account Balance $ 396.11 General Information Ne~t meter reading on or aDout No" 8 Generation prices and charges are set by the elec1ric generation supplieT you have chosen: The Pubfic Utility Commission regglates distdoution prices ~nq servi~es, The Feqeral Energy Regulatory-Commission regulates transmIssIon pnces and servIces, The Transition Charge includes an Intangible Transition Charge (ITq and the applicable gross receipts tax which together amount to $7,33. The ITC isa pe.rnsage,.Charge aJlPToved by the PuStic Utility Commission which PPL collects as agent lor PPL Transition Bond Company LLC and which that company uses to service debt incurred to recover a portion of PPL's stranded costs, The_gross receipts tax, which is collecteo for the Commonweal1h of Pennsylvama, is equal to 4.4% of the ITC, For your convenience, you can now Q,ay your bill using y,our Visa, MasterCard Discover or American Express Card, Call Bill Matrix at 1-800-672-2413. BillMatrix will charge your credit card a service fee for making this paym'ent. Save postage and late charges - sign up for Automated Bill Payment. Keep tight bulbs and fixtures clean, Dust and dir1 absoTb light and can reduce fight output by as much as half. ~~ I,~-~ ~~ __,,6,=.......~ " '~i"<Ulllk!i1I....-.~"'~ -f""M~I-", , , , , , , , . , . , . . . . , . . , , , , , i J. : ~' : it if 1 i , ii i S : .~ : 1;; it : ~ , :i : 0 :~ :~ . ~ : ~ , ~ ! -; : :~ : ; , , , , , , , , , , , , , , , , . , , , , , , . ...~unffl_~jE~'?1 .-= g" a ; . ft . :"". II .' . .~. - . "';'. '" = !~ ti' ~r " ET. " !'" ~ 2 0 g~ !:.= " ~ f . l;l s e1r ~ . '" [~ '" r- g t" 0 .., ~ 0 6'1 0 :r .0 ~ ~- = - ~ ;!- '" ~ =" ~ r~ h ~ " ~ r . Ii l'-g rr e " g- o . Ii .. ~ . p ; [ !l!: 0 [ I>" 0 m a ~ ~,e ~ f~ ~ I:l: o . ...:l! :;, c" f Q.g g ~~ i ~! -.. ~l s_ . Q.~ .. iff 0 '" c . Ii I!. 0 m II> ... : Ii g, !': . I;; ~ '" : 0> [ ~ : 0 : .. .... ~ ~ 0 '" .. .. '" .. E: ... ... 0 ~ !i! !i! c !!l !.o c , .- , Fo~ SerVice 'To:.- Thomas Groome ~~~~:":':'Prior :Balance------------~.-- . '. '.' _,. . ... 1174KingsleyRd Balanc;efromlaslbill.. .... $111.49 Account Number: 24-0632059,4 Paym",riis 'prior to Oct 09, :<000.. Trianks! . 00 Premise Number: 24-0373523" . Totat"prior b;:dance, Oct 09, .2000 .., 111.49 , , ,', , ':' ," ' '~~~,M~~rr~rit Water Charges--,"';-~-" --------------- . BiflillgPeriod & Meterlflformation... Service Charge' 9.75 Billing Date: Oct 09. 2000 . . Water Vo!umej$.0048B4X 3,800) 18.48 Billing Period:.Sep 07 to Oct 05 (28 days) . Total water cliarges, Oct 09, 2000 . 28.23 Next reading oniabout: Nov 06, 2000' ------Other Current Charges-.:..------ ___________________ Rate Type: Residential StateTaxSurcliarge-Water - . 12 . DSI - Chiu-ge. . .29 . Meter re"dingsin current billing. I'.e.r.icd: .' Total other charges, Oct 09, 2000 .17 Meter Number N042571.708 ~ a 5i8-inch meter:' _ Present~actu~1 . . . 16 I:sD.o'" . '. TotaJ/i.ccount Balance ~~~~1;{i~~~'" ::-.\::!:,WZgo;;~;'::~~;l;~i~f~i,~~j~~(~~At:ff~aY:~..~ttg.r.~~~~.~.~ ..' . ,;Y\;;j;i~;\;;'C . .. '-. - .,> '","',,~ " .. 'T:', ,>". '. 139.89 $118.001 I: . ,. ....,'-~ I i i '1: " , . ,'.,:;. ':,~ . """~', . '>'~:.' ~i'~':'i/"::~')::~\;; :;: i\,.~:.:""'. ' 'w';" ., f .'.-....::.,;'>:i.:.:,/: t,:::r,jj)f:;~i~~f~~!'~':~~(!~!("l~::~;~~':1::,t:T.'.' ","~", ,," - .'," ,I" , Messages to you from Pennsylvania - American . Any portion (.fthis water bill which IS not paid as of II/DB/OO wilt be subjectlo a 1.5D%penalty, On any gl\'en day. you may find Pennsylvania-American Watar Company meler readers walIdng from door to door in your commumty reading meters, These dedicated emptoyees walk several miles each day to complete their jobs. As such, they wanted to extend their appreciation to those customers who make sure the meter pits are not covered by leaves or glass in the fall and those who clear a path to tile meter reading devices in the winter when there is snowfalt on the ground. Your efforts do not go unnoticed by our staff, and we thank you for making a difference. !' Questions? Call 1-800-717-7292 Weekdays-8:15 am to 6:30 pm Saturday-8:15 am to 2:00 pm.' . E1J1ergencies: 717-774-2420 PAWC. 852 Wesley Dr,. Mechanicsburg. Pa. 17055-4436. . InternetY(~,p~w~:~omo:",::.._",-"' @' ~-' '"._. " .' .:-;;~ .." '.' -....:. _ + :'.;.. _:.;__~ A~~, ~., . .1<:9B , . ......._~- -~~ 0-' "-'''_"",,",_f',- J, Fulton Bank People dedicated to your success," . . [- ;;;. -~T M;;:;.~7. v.. --;;"t --.. .-.1?~ '$~~:'.. -. .=. -c'.$ 'II,., t- . .... ..r-v-- -.-. -..." p,lt-Ja.n.~ '. _ ~ . _ :.'::_< ;....::;:.....;;; ~m ~;.,...;.. -- -.. "___~ . ....... '. . .'. -'---, _._. .._...... .........'\'l"U~...~ ....., '~--~. ". '- "--,--. ',,, -- ~ , :t~ . ._~ "'-'$;m." '1 jJ3~l!!J)'j;~'{~~t ':DI110~"II'; ,:'''1.1,'1''-11.'1.'.. ~D..i.I':~"~' " . _--:-...._...._~a.__..... __ _",,:,j 9120S/i6]60 . ",-'-', '71:'01' . :j:-...~.,~~~~,,;,:~~; 1'...(' " i.,g,.I<:r/ , . ?:: ilK:- a~U"~LO ... 7'7 ,........."-'10- . - ~.. ~..~- - .~..._.!I: <<IUIIUr..U.; IU.. l!'Ula>> 1:1".1.1 "~ aDaao...Olo". 913 915 OS/21/00' f - -- ---~ :-' ,_: .'... :f"i,!'tlllilPt_,:.fit:..'..;r::..:","'.......'.'. ltf ..... .., . .' ..~ ~--- .,.,,;;.:::!/. ~'."", ! =~ ..~:~~~-~$~i~l '-~'JV .':]3. """'1 l~ID1':,!!= lalq i!r...!.~~-"J cmtlDDIi"?~ . -- _._'~. --'-- - - -~.~. ~ -.. ..~. .. ... .-~ -.CD1UDU.UC' _~"lI 916 OS/lS/00 ~- ~-:.;;'~~" i~'~~I-';'l ":;!:. '.' ~'''''~I ..i:f::. ~__..-....lbC ~~ ~~=-~! GCIIIO~"i!IS:_ la~'l i!.~~~~_;~=~~!i~~ 64.72 923 09/0S/00 67.13 i , 917 .OS/25/00 52.59 !.-/ \ I Member ED.I.C. www.fultonbank.com , -~ .~~ - ~~-~ ",-- . :><llo3 3: bJlI . JlJ::l' rTO ... ~~ ~~ I-i lD'" if lD i:lGl ii ... 3: rT 'Gl lQ ... III GlO lQ 0;0 It 08 ~ OlD 8 ..... .. lD rT ...0 0 0 0 "",j , - l'71 "\ ~ ~ 0 ('\ ~ -r > ~ ~ .,S) n L 0 -II e: tn w@ IT" 0 .... .... ~~ "'"' N en . ~q,jI '" '" Z "" . 0 C>> '" ... '" 0: II 0 0 0 0 0 S:::!1~ 0 IT" 05<.< nJ 0 o. ;:l.t:.ltll ~ ... ... ~:3o C>> ...... ...... ~O':3 ..n ... . O' '" .... f1I el..f1I 0 ...... ...... ~ 0 0 0 0 0 0 0 . .... :. 0 '" 0 en N- IT" ... .... tn . . "'"' ... "'- "" ... ... "" "'... ~~ . .1... - ..:iY " " Plaintiff Name: Defendant Name: Docket Number: PACSES Case Number: .~ (? I O)..c;~ =- Other State ID Number: Please Note: All correspondence must include the PACSES Case Number. INCOME and EXPENSE STATEMENT THIS FORM MUST BE FILLED OUT . (If you are self-employed or if you .are salaried by a business of which you are owner in whole or part, you must also fill out the Supplemental Income Statement which appears on the last page of this Income and Expense Statement. INCOME STATEMENT OF T/fo"",.a~ \(.. G, (I-ol.Jo(lllC- I VERIFY THATTHE STATEMENTS MADE IN THIS Income and Expense Statement are true and correct. I understand that false statements herein are subject to the criminal penalties of 18 Pa.C .A. ~4904, relating to unsworn falsification to authorities.. . ~. 11-24o~ <" Date' Employer ( ) An 7''i{) ~,<J(l..c!..H. ~ {l..VI c...C }/fJ ftIlrS(!,Vf/..6 P/J ( //.J'-( INCOME: Address /?cJ../ S. /9 t!L sr7. Type of Work 7),1.. I V ~r-- Payroll No. C>~.? Ic!-o , Gross Pay per Pay Period $ ! { Co O. Pay Period (wkly., bi-wkly., etc.) GU k C'-l I ... " Plaintiff Name: Defendant Name: Docket Number: PACSES Case Number: Other State ID Number: Please Note: All correspondence must include the PACSES Case Number. INCOME and EXPENSE STATEMENT THIS FORM MUST BE FILLED OUT (If you are self-employed or if you are salaried by a business of which you are owner in whole or part, you must also fill out the Supplemental Income Statement which appears on the last page of this Income and Expense Statement. INCOME STATEMENT OF I VERIFY THAT THE STATEMENTS MADE IN THIS Income and Expense Statement are true and correct. I understand that false statements herein are subject to the criminal penalties of 18 Pa. C.s.A. 94904, relating to unsworn falsification to authorities. Plaintiff or Defendant Date INCOME: Employer Address Type of Work Payroll No. Gross Pay per Pay Period $ Pay Period (wkly., bi-wkly., etc.) Itemized Payroll Deductions: See paystub Federal Withholding $ Social Security $ Local Wage Tax $ State Income Tax $ Retirement $ Savings Bonds $ Credit Union $ Life Insurance $ Health Insurance $ other Deductions (Specify) $ $ Net Pay per Pay Period $ O<~ """'~..:- -. Income and Expense Statement PACSES Case Number: 817102950 (Fill in Appropriate Column) OTHER INCOME WEEK MONTH YEAR Interest $ $ $ Dividends Pension Annuity Social Security Rents Royalties Expense Account Gifts Unemployment Compensation Workmen's Compensation IRS Refund Other Other TOTAL $ 0 $ 0 $ 0 TOTAL INCOME $ (Fill in Appropriate Column) EXPENSES WEEK MONTH YEAR Home $ $ $ Mortgage/Rent 500. Maintenance 2,000. Utilities Electric 75. Gas 200. Oil 750. Telephone 100. ~ - - . Income and Expense Statement PACSES Case Number: (Fill in Appropriate Column) OTHER EXPENSES WEEK MONTH YEAR Hospital Medicine Special Needs - (Glasses, Braces, Orthopedic Devices) Education Private School Parochial School College Religious 400. Personal Clothing 500. Food . 150. Barber/Hairdresser Credit Payments: Credit Card 50. Charge Account Memberships . Loans Credit Union Miscellaneous Household Held Child Care Papers/Books/Magazi nes 30. Entertainment 100. Pay TV 35. I Vacation I I 500. \ - ~~-.hll,i= ~ <~'- ::~'1 " '. Income and Expense Statement PACSES Case Number: 817102950 (Fill in Appropriate Column) EXPENSES - (Continued) WEEK MONTH YEAR Water $ $ $ Sewer Employment Public Transportation $ $ $ Lunch 50. Taxes Real Estate $ $ $ Personal Property 275. Income 600. Insurance Homeowners $ $ $ Automobile 1,200. Life 860. Accident Health Other Automobile Payments $ $ $ Fuel 3,000. Repairs 1,000. Medical Doctor $ $ $150. Dentist I Orthodontist I _.~..- . " ~._" , " Income and Expense Statement PACSES Case Number: 817102950 (Fill in Appropriate Column) EXPENSES - (Continued) WEEK MONTH YEAR Gifts 1,000. Legal Fees 200. Charitable Contributions 750. Other Child Support Alimony Payments 500. Other $ $ $ Ownershin* PROPERTY OWNED DESCRIPTION VALUE H W J Checkina Accounts <1;2 000. X Savinas Accounts Credit Union StockslBonds Real Estate Other TOTAL Coverane* INSURANCE TYPE COMPANY POLICY # H W C Hospital Blue Cross Other Teamster H & W Medical same Blue Shield Other Health! Accident Disabilitv Income Dental Oth"r I I * H - Husband W - Wife J - Joint C - Combined .... ~~. "-;;,.; " \ Income and Expense Statement PACSES Case Number: 817102950 SUPPLEMENTALINCCOMESTATEMENT A. This form is to be filled out by a person (1) who operates a business or practices a profession, or (2) who is a member of a partnership or joint venture, or (3) who is a shareholder in and is salaried by a closed corporation or similar entity. B. Attach to this statement a copy of the following documents relating to the partnership, joint venture, business, profession, corporation or similar entity: (1) the most recent Federal Income Tax Return, and (2) the most recent Profit and Loss Statement C. Name of Business: Address and Telephone Number: D. Nature of Business (Check One) (1) Partnership (2) Joint Venture (3) Profession (4) Closed Corporation (5) Other E. Name of accountant, controller or other person in charge of financial records: F. Annual Income from Business: $ (1) How often is income received? (2) Gross Income per pay period: (3) Net Income per pay period: (4) Specified deductions, if any: _4.~ ~~- . ~ Commerce flBank Commerce Bank/Harrisburg N.A 100 Senate Avenue Camp Hill Pa 17011 8880937.0004 THOMAS R GROOME MELISSA PEEL GREEVY POBOX 109 LEMOYNE PA 17043 ~w Page 1 of 1 STATEMENT DATE 05 318 842 ACCOUNT NO. CYCLE-014 *W* CHECKING *** NOW ACCOUNT NUMBER 0513181842 PREVIOUS STATEMENT BALANCE AS OF 07/16/02 .......... .....,...,.... PLUS 1 DEPOSITS AND OTHER CREDITS. ,.... ,. '.......... LESS 0 CHECKS AND OTHER DEBITS. '.."..,.,..,...,..., CURRENT STATEMENT BALANCE AS OF 08/15/02 ..... "" ,.......... ,.... NUMBER OF DAYS IN THIS STATEMENT PERIOD 30 ***' CHECKING ACCOUNT TRANSACTIONS *** DATE DESCRIPTION 08/15 INTEREST PAYMENT DEBITS CREDITS 27,35 *** BALANCE BY DATE *** 07/16 44,348,48 08/15 44,375.83 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE 23-2324730 119.12 *** INTEREST EARNED THIS STATEMENT PERIOD DAYS IN PERIOD .....,.......,........... INTEREST EARNED ..,..................... ANNUAL PERCENTAGE YIELD EARNED (APY)..., *** 30 27.35 0.75% 44,348.48 27.35 .00 44,375.83 - , --uJli7.J .. WORK LOCATION 0934 FOR 1719 1 FEDERAL STATUS A II 00 TOTAL TAXES 2 CHECK NO. 0000703067 S A S IPIO US OS CURRENT PAY RATE' 23.16 REGULAR 23.56 24.00 OVERTIME 35.34 "1. 91 OPTION DAY 23.56 16~0 CURRENT TOTALS Y-T-D TOTALS N TAXES FICA 75.76 FICA MEDICARE 17 . 71 FEDERAL TAX 180.82 ST TAX- PA 34.21 DADPB1ll NR 12.22 TOTALS 320.72 DEDUCTIONS UNIONDUE 776 59.00 UNITEDWAY '02 5.00 TOTALS 64.00 565.44 279.54 376.96 1,221.94 38,009.39 2,~56.58 51.14 5, 61.18 1,064.27 380.08 1,480.09 400.00 165.00 WClRKUlCATION 0934 FOR 1719 1 TAX 1.0, FEDERAL STATUS. 208-42-477 II 00 PERIOD END . TOTAL EARNINGS 08. 1 002 E RNIN S o RE HURS OSS CURRENT PAY RATE 23.16 REGULAR 23.56 32.00 REGULAR 23.16 8.00 OVERTIIIE 34.74 1.22 OVERTIME 35.34 6.73 CURRENT TOTALS Y-T-D TOTALS II 00 TOTAL TAXES 6 sc TAXES FICA 75.6t FICA MEDICARE 17.6 FEDERAL TAX . 180.1 ST TAX- PA34.11 DAUPHN NR 12.1 TOTALS 319.7 DEDUCTIONS UNITEDWAY '02 5.08 TOTALS. 5.0 2,432.19 568.82 5,541.32 1,098.417 392.2 753.92 185.28 42.38 237.84 1,219.42 39,228.81 1,573.04 170.00 .::. -.-., " .4."" ~- -~-_. " " ',~ Kelley Blue Book Used Car Values Page I of2 Kelley Blue ..11. Tb,e Trusted Resoare'll New Car Prid ng BuHd! it Cel' ,Incentives' My Carls Vahle Us.d 'Caf Retail F.."" Prk" Quat. Iluy " u.act C,,,, , SoHI Y<>L1rCar MOl",'cyd.. FhHH1Ci:rng Insurance Lemon Check :, W,a1"rantie:s '; Ao;e,S5;[)I'~:eS Car R€::vi eW!5 Ca:r Previews: O-&tis:i on Guides Advice. ~ About kbo Home . ',-' '",-"- - ' .~,--. -';).'_..,:;;~/''-~'''I ',' : ,. '--, - ;;;-';""':;",f::,'~")"-~ ;,} I '" ",: E,!e~yonc. ~~slaHistory' ,c'- ,. ~" . ",' ~_."C", ,-"" _,,' ,,-"' ,. _, ,,'.' _,~' ," :._.,' ,'-';;";2, _,,~.:} _ .",",,,",' 1990 Ford Mustang GT Hatchback 20 Buy a New Car Buy a Used Car llsJ:Y('-ljrC<lLf-9L:;?!'IJ~QJ11ine fre_e.leJJ1.9.n..C!tec;k Financina Quote Jnsurance Quote 'N<lIC<lnJ:y..QYQte f'!'IY-!J:1entC!'Ilc;YJQJ:.9r Engine: va 5.0 Liter Trans: 5 Speed Manual Drive: Rear Wheel Drive Mileage: 99,000 Equipment Air Conditioning Power Steering Power Windows Power Door Locks Cruise Control AM/FM Stereo Cassette Flip-Up Roof Rear Spoiler Alloy Wheels Consumer Rated Condition: Fair "Fair" condition means that the vehicle probably has some mechanical or cosmetic defects, but is still in safe running condition. The paint, body and/or interior need work to be performed by a professional in order to be sold. The tires need to be replaced. There may be some repairable rust damage. The value of cars in this category may vary Widely. A clean title history is assumed. E;ven after significant reconditioning this vehicle may not qualify for the Blue Book Suggested Retail value, Trade.ln Value $1,565 Trade-in value represents what you might expect to receive from a dealer for this consumer owned vehicle. Keep in mind that the dealer must then absorb the cost of making the vehicle ready for sale, advertising, sales commissions, arranging financing and insurance and standing behind the vehicle for any mechanical or safety problems. G.et a Private Party Value. GS!.t Invoice & MSRP on New Car http://www.kbb.comlk. "Ikw,kc, ur?kbb;906187 &;t&39;Ford; 1990%20Mustang& 13 ;FO;D4 8/29/2002 \ o~_ a Control number 00-GROK500 Void ., l~-.".~ ~-~"--, b Employer's identification number 23-2293735 "'"-"'"', ,~ ' ~~ ~- ."~~ OM8 No. 1545-0008 Copy B To Be Filed with employee's FEDERAL tax return 1 Wages, tips, other compensalion 2 Federal Income tax withheld 26904.28 2669.44 c Employer's name, address, and ZIP code 3 Social security wages 4 Sociel security tax wIlhheld >). ".i.: CUMBERLAND SERVICES INC 26904.28 1668.07 ,,;; . jh , P 0 80X 693 ~~N:: .. .~. -,-, S Medicare wages and tips 6 Medicare tax withheld CAMP HILL PA ,17001-0693 26904.28 390.22 7 Social seculily lips 8 Allocated tips d Employee's social security number 191-46-1440 e Employee's name, addresS, and ZIP code KATHLEEN M. GROOME 1174 KINGSLEY ROAD CAMP HILL PA 17011 9 Advance EIC psyment 10 Dependent care benefits 11 NonqualWK>d plans 12 Benefits included in box 1 13 See Instrs. for box 13 14 Other SUI 40.46 / / 5S!aIUlory Deceased Pension lo,. 942 Sublolal Deferred employee plan .p. .mp. compensation . . - 1751atewages,tips,eIc. 18Staleincomelax 19 locality name 20 LocaIwages,fips,etc. 21loca11ncometax 26904.28 753.32 WEST SH 26904.28 269.04 1994 ~ ,,,,.m, >'-'c'"="~="""'-'''"'"''''-\ill'.'''J!''''l!Io,,:,,~!I'!lli\i]I!IIII~lmITm!1TII!11'!I!II!~1~_~iliii;~i~m~II:I'lIp~''i'r'<7Ni')'f(\'j,'''':m'"'''''-;'''_"!'''~'''''U!~I" 11'1""'''1 f.'_~:;. -.' t :... ~".'.~ :. t.~:. . Department of the Treasury tnternal Revenue Service f.:'..... This infonnatlon is being furnished to the Internal Revenue Service. i',. L/) ,,,,,,._--~,--,,,,,,,,,,,,:,,,s,,,,,,_,,,,_,,,,,,~( " , "c , ~ l1ll~>ild KATHLEEN M. GROOME, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 00 - 2750 CIVIL THOMAS R. GROOME, Defendant IN DIVORCE ORDER OF COURT AND NOW, this 2-~~ day of ~~ 2002, the parties and counsel having entered into an agreement and stipulation resolving the economic issues on October 25, 2002, the date set for a pre-hearing conference, the agreement and stipulation having been transcribed, and subsequently signed by the parties and counsel, the appointment of the Master is vacated and counsel can conclude the proceedings by the filing of a praecipe to transmit the record with the affidavits of consent of the parties so that a final decree in divorce can be entered. BY THE COURT, .J. cc: James W. Abraham Attorney for Plaintiff Melissa Peel Greevy Attorney for Defendant ~ ~ /()-.J-'1- oJ.-. ~ - . IIIIIIl'" - =~~ . ,- FILED-OfFICE or" T>lr- ''''''(''1' ,rl'"'T^R'>1 ~ ,,' ',':. "-~':.>-' :~u,\-~) r\ I 02 OCT 28 0),1 2: t:;l r I, ~ '.' ~ CUlv;;:!!CI../O );\1; (Oi "!!ll,r,'V '_'- "..... ,. '...." ,-,'-/~,I.: I PENNSYLVA~~IA \ I ,r , ".~I ~~ .,..,.., ',' ~ _J ~~i!OI!~~~!fit,II'!'!-~I,~!i_Il!!lI_r~!J][ltlJ., -,~~ijl -. ~ " c . , i , J . I ' ~ KATHLEEN M. GROOME, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Vs. NO. 00 - 2750 CIVIL THOMAS R. GROOME, Defendant IN DIVORCE THE MASTER: Today is Friday, October 25, 2002. This is the date set for a pre-hearing conference; however, counsel have appeared with the parties and have engaged in a conference to settle this case. Present in the hearing room, are the Plaintiff, Kathleen M. Groome, and her counsel James W. Abraham, and the Defendant, Thomas R. Groome, and his counsel Melissa Peel Greevy. The parties were married on September 7, 1974, and separated in May 1997. They are the parents of three children; all of whom are emancipated. The complaint in divorce was filed on May 3, 2000, raising grounds for divorce of irretrievable breakdown of the marriage and indignities. The Master has been provided affidavits of consent and waivers of notice of intentions to request entry of divorce decree signed by both parties and dated today so therefore the divorce will be able to proceed under Section 3301(c). The Master's office will file the affidavits and waivers with the Prothonotary. The complaint also raised economic issues of - ~ equitable distribution, alimony, alimony pendente lite and counsel fees and expenses. As previously noted, the parties engaged in negotiations today to attempt to settle this case and have resolved the outstanding economic issues. We are here in the hearing room for the purpose of having counsel put an agreement on the record in the presence of the parties resolving all of the economic claims. The agreement as stated on the record will be considered the substantive agreement of the parties not subject to any changes or modifications except for correction of typographical errors which may be made during the transcription. Consequently, when the parties and counsel leave the hearing room today after the statement of the agreement on the record, the parties will be bound by the terms of the agreement even though there is no subsequent signing of the agreement affirming the terms of settlement. However, the parties and counsel are going to return later today to review the agreement for typographical errors and then affix their signatures affirming the terms of settlement as stated in the agreement on the record: Following the receipt by the Master of the completed agreement, the Master will prepare an order vacating his appointment. Counsel will then be able to file a praecipe transmitting the record to the Court requesting that the Court ~ ~ ~ enter a final decree in divorce. Mr. Abraham. MR. ABRAHAM: Thank you, Mr. Elicker. 1. The parties are waiving any claim for counsel fees. The only claim was with Plaintiff, Kathleen M. Groome, and the parties shall be responsible for their own attorney fees. 2. Except as otherwise stated in this agreement, wife and Defendant husband, Thomas R. Groome, have divided their tangible and intangible personal property to their mutual satisfaction and neither party will make any claims against the others' tangible or intangible personal property in their current possession. 3. As to the former marital residence, wife shall receive all sales proceeds from the sale of the marital residence in a lump sum. Wife shall be fully responsible and liable for any and all tax consequences as to said proceeds. Wife shall receive the proceeds within ten days of this agreement. 4. As to husband's defined benefit plan pension, that pension plan shall become the sole and separate property of husband. 5. Wife shall receive the amount of $38,130.00 from husband's retirement income plan with the Teamsters through his employer which shall be contained in a QDRO as prepared by wife's attorney and approved by husband's attorney. Wife shall be entitled to growth and/or interest on the $38,130.00 from the retirement income plan as of the date of the divorce decree to the date of distribution at a rate of interest provided by the plan. 6. As to alimony, wife shall receive alimony in the amount of $500.00 per month from husband until husband reaches the age of 59 1/2. The term and amount of alimony is modifiable only if husband is partially or totally disabled as verified by a physician at which time alimony is modifiable. Alimony shall otherwise terminate upon the death of either party, remarriage or cohabitation of wife. 7 . shall As of the entry of the decree in divorce, each party be responsible for their own medical insurance coverage. 8. Except as herein otherwise provided, each party may dispose of his or her property in any way and each party hereby waives and relinquishes any and all rights he or she may now have or hereafter acquire under the present or future , 1 , . laws of any jurisdiction to share in the property or the estate of the other as a result of the marital relationship including without limitation, statutory allowance, widow's allowance, right of intestacy, right to take against the will of the other, and right to act as administrator or executor in the other's estate. Each will at the request of the other execute, acknowledge, and deliver any and all instruments which may be necessary or advisable to carry into effect this mutual waiver and relinquishment of all such interest, rights, and claims. MR. ABRAHAM: I am sitting here with Kathleen M. Groome, the Plaintiff. Kathleen, you heard me dictate the agreement of the parties, do you have any questions? MS. GROOME: No. MR. ABRAHAM: Do you fully understand and accept the terms of the agreement as dictated? MS. GROOME: Yes, I do. MS. GREEVY: I am with Thomas R. Groome, the Defendant in this action, and he has been present for the negotiations and for the dictation of this agreement. Do you understand the terms of the agreement? MR. GROOME: Yes. MS. GREEVY: And do you have any questions that you would like to ask about the agreement at this time? MR. GROOME: No. MS. GREEVY: And are you willing to accept the terms of this agreement? MR. GROOME: Yes, I am. ~ ,- ~- , -j,~ 1 I acknowledge that I have read the above stipulation and agreement, that I understand the terms of settlement as set forth herein, and that by signing below I ratify and affirm the agreement previously made and intend to bind myself to the settlement as a contract obligating myself to the terms of settlement and subjecting myself to the methods and procedures of enforcement which may be imposed by law and in particular Section 3105 of the Domestic Relations Code. WITNESS: DATE: (0 ~)-r'"(j"L. If!gfu)YI1~ athleen M. Groome James W. Abraham Attorney for Plaintiff I~h{!o\.. Melissa Peel Greevy Attorney for Defendant '~'r&i;; . , . ~ MIiK 1 _ ."u, KATHLEEN M. GROOME Plaintiff v. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA. ;1-750 NO. 00 - r5'ffi MAR 1 0 2004 v THOMAS R. GROOME Defendant CIVIL ACTION - LAW DIVORCE ORDER AND NOW, this if! day of ~ , 2004, in consideration of the attached Stipulation For Entry Of Qualified Domestic Relations Order entered into by the parties hereto, it is hereby ordered and decreed that the Stipulation shall be entered as a Court Order and said Qualified Domestic Relations Order shall be implemented in accordance with the terms and conditions stated therein. BY~~ \Stt~~ 1j'~1~ J. . ? I." I ~~-~.,.."..,,- - ~~ U"_".~ . ~ -, -,,~ ,~ .~- " FiLED-OfFiCE Or~ THe: PDnTI_j!"!~l',T'''Q\! . ..~ I II'.Jf. I\.;!~V., \i, 1 2oa411Af~ II PH 1.1: 20 )- <> ~~ ~l\j j~ lJ t:(';: j;\T'/ PL},::\!S\'Lv/~:\f:~;~" ~ . . - ",._""~ IIlIllmr~'_~~~W!'Wil~_~~iIim]!~W!I~-It~p~ ,~r"*""'/l'f,fI . -~ - ~ . ~.- ~~~ "-..liI;~,:. " '< , " KATHLEEN M. GROOME plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND couNTY, PENNA. v. NO. 00-2570 THOMAS R. GROOME Defendant CIVIL ACTION - LAW DIVORCE STIPULATION FOR ENTRY OF OUALIFIEDDOMESTIC RELATIONS ORDER AND NOW, come the parties hereto, Plaintiff, Kathleen M. Groome and Defendant, Thomas R. Groome, pursuant to the agreement of the parties entered before the Master, E. Robert Elicker, III, dated October 25, 2002 and incorporated, but not merged, into the Decree in Divorce entered on November 5, 2002, the parties hereby agree and stipulate as follows: SECTION I - IDENTITY OF PARTIES: The name, address and social security number of the parties are as follows: 1. Participant: Thomas R. Groome SSN208-42-4774 l824 Newport Road Duncannon, PA l7020 Alternate Payee; Kathleen R. Groome SSN 19l-46-1440 PO Box 1793 Shallote, NC 28459 2. The parties were married on September 7, 1974 and were divorced on NovernlJer 5, 2002. The parties raised claims of equitable distribution of marital property pursuant to the Pennsylvania Divorce Code. 1 ~~ .~ , SECTION II - PLAN TO WHICH THE ODRO APPLIES 1. Teamsters This QDRO Payee: This QDRO applies only to' the Central pennsyl vania Pension Fund's Retirement Income Plan 1987 ("Plan"). requires, that the Plan, on behalf of the Alternate (a) Shall segregate and separately account for the sum of Thirty Eight Thousand One Hundred Thirty Dollars ($38,130.00), plus interest according to the Plan; and said amount shall be credited with a pro rata portion of Plan gains, lOl3ses and expenses from September 30, 2002 through the date of distribution. (b) Under the terms of the Plan, payment of the benefit to the Alternate Payee can commence when the Participant reaches his "earliest retirement date" as that term is defined in Section 206 (d) (3) (E) of ERISA and Section 4l4(p) (4) of the Internal Revenue Code. 2. The Alternate Payee may elect any form of payment available to participants under the Plan, other than a joint and surVivor annuity with respect to the Alternate Payee and a subsequent spouse. The Alternate Payee may file a Beneficiary Designation Form to designate the person who will receive her benefits if she were to die prior to payment of her benefits. SECTION III l; This Order is intended to constitute a qualified domestic relations order within the meaning of section 414 (p) of the Intern~l Revenue Code of 1986, as amended and section 206(d) of the Employee Retirement Income Security Act of 1974, as amended, and shall be interpreted in a manner consistent with such intention. 2. The Court of Common Pleas of Cumberland County, Pennsylvania, shall retain jurisdiction to amend this Order to the extent necessary to establish or maintain its status as a qualified domestic relations order. 3. It is recognized that the Alternate Payee may elect to Commence receiving benefits before the Participant retires. If the Alternate Payee so requests, the Participant will cooperate with tne Alternate Payee in sUbstantiating a claim or application to the Fund and shall provide documentation or information reasonably necessary to establish their eligibility for benefits. 2 '. "-'I I I I I ! I ! I I ! , I ! :1 'i I i il :~ i 'j ! i I ! ~~ ~,- -~ >~. , > "". , . WHEREAS, by their notarized signatures attached hereto, signed in counterpart, and intending to be legally bound hereby, the parties hereto, Plaintiff, Kathleen M. Groome, Alternate Payee, and Defendant, Thomas R. Groome, Participant, respectfully request that this Stipulation be entered as an order of court. WITNE~ ~h'..2/fJ. ~ KA HLEEN M. GROOME, Alternate Payee STATE OF tJOy-\-h eanlULrA- COUNTY OF 'B~\.lI'\."I.','t.k--> On this 2.f"l9 day of ~(Urdf,- , 2004, before me the subscriber, a Notary Public, in and for said State and County, came the above-named person, Kathleen M. Groome, satisfactorily proven to me to be the person whose name is subscribed to the within instrument, and acknowledged the above instrument to be her act and deed, and desired that the same might be recorded as such. SS: WITNESS my hand and Notarial Seal: ~ S. V\\~ NOTAR~LIC MY COMMISSION EXPIRES: "1-':>--0'" 3 d,_~d.,; " ~- ~" " ~ ~ I., fii .. ' A . ~ . . ~ . . '. WHEREAS, by their notarized signatures attached hereto, signed in counterpart, and intending to be legally bound hereby, the parties hereto, Plaintiff, Kathleen M. Groome, Alternate Payee, and Defendant, Thomas R. Groome, Participant, respectfully request that this Stipulation be entered as an order of court. /fL ()...---- STATE OF lulfsiv.o., i { (j J, I SS : COUNTY OF /tN)J-Ell tllUl : On this .Jt;5 day ofJUd./c(~/c/ , 2004, before me the subscriber, a Notary Public, in and for said State and County, came the above-named person, Thomas R. Groome, satisfactorily proven to me to be the person whose name is subscribed to the within instrument, and acknowledged the above instrument to be his act and deed, and desired that the same might be recorded as such. hand and Notarial Seal: NOT MY . Notarial Seal Le KIistee K.MY818, NotaIy Puolrc Myl!lOyneeom .Boro, Cuml.lenancll"~,_. IIlJSSIon~Oec -'''1 Member, Pennsylvania .~~_~ 2, 2006 '-'IIOIl or Notariae 3 .~ ., . .f l!l1lliiilJ1IdiIlilI~i%ljtlJijj]!ili;;&~iiIt~'lIliJljlllilWM~wtlWZili"-'l.wj;ji:"'i~llI!t~~i..:0:d. .' . ~.A ~. . - IfIIiiltl - ~- :JI~?- ,k"ll > ~ .c 0 "'" 5:; = 0 = ~ or- .] :~ {J1 ::E: --I :I:~ :r ;;0 nl.:n l~ I ' -oF;; C"}/;~" , '-D :00 r:: 0' -10 ~~'; ". ~=H' ::c 2(~ :2 '2 On"! ." =2 C> 5J <:::> --.;;:: '-R~ "I ! 4 .