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Home My WebLink About01-0762 FX ",- . 'L_; -'-, ,-- ,;, "-,;,f" '.< ~;-b.. ,,",,-""i.<'j~.-i.1!';L'_"" ,,,,.,,,,-,, ""\<~;,' k' "' );'~" ,. :f.;Ii :f. "" "':f. :f. """'''' """':f.:f. . .. .. . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY STATE OF . . . . . KRISTI J. CLARK, Plaintiff . VERSUS . STEVEN B. CLARK, . . Defendant . . . AND NOW, . . . DECREED THAT AND PENNA. NO. 2001-762 DECREE IN DIVORCE AJ~ 2.1. , ;U>07-, IT IS ORDERED AND KRISTI J. CLARK , PLAINTIFF, STEVEN B. CLARK , DEFENDANT, . ARE DIVORCED FROM THE BONDS OF MATRIMONY. THE COURT RETAINS JURISDICTION OF THE FOLLOWING CLAIMS WHICH HAVE BEEN RAISED OF RECORD IN THIS ACTION FOR WHICH A FINAL ORDER HAS NOT YET BEEN ENTERED; . . . . . . The property settlement agreement is incorporated but not merged into . . . the decree. . . . . . . . 0:94- 'Ta~A J. PROTHONOTARY . "" "" "" "" "" "" :f. Of. :l: :f.:f. :f.:f. . ""'~i . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .., "'~ ,~" ~~ kc:;c, .tJd) IIC;Z~ .o,,:}- , [~~""I ^-"~~" ~,-~~,~~ "~ ". "' '1;~"~--~~' '~~..~ ~- '. ' .' :. "-, M~.~~-d-4W~ '?t~~~~~ ""1"..~n!Rl~~~""".." Plfl>\j~lm~"""~1iI'l:~~;m*~Wl'irt~"" .~ 1 " ,~_~!W5Jllli~~ ",,,- ~.' i -, ' - ~ , ~ t" . c. KRISTI J. CLARK., Plaintiff vs. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : No. 01- n2. ~ 1<L-<-- STEVEN B. CLARK., Defendant : ACTION IN DIVORCE NOTICE TO DEFEND AND CLAIM RIGHTS 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 wanled that if you fail to do so, the case may proceed without you and a decree of 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, including custody or visitation of your children. Where 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 at the Office of the Prothonotary, Cumberland County Courthouse. IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER'S FEES AND EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM THEM. YOU SHOULD TAKE TillS 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. Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pa. 17013 (717) 249-3Hj6 c'$"" '" " ,'--, ~~, J ^' ~ '--;~~ . KRISTI J. CLARK, Plaintiff vs. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : No. 01-'7(,).., ~ l.e.- STEVEN B. CLARK, Defendant : ACTION IN DIVORCE COMPLAINT IN DIVORCE 1. Plaintiff is Kristi J. Clark, an individual sui juris, who has resided at 1873 Holly Pike, Carlisle, Cumberland County, Pennsylvania, since 1990. 2. Defendant is Steven B. Clark, an individual sui juris, who has resided at 25334 Beantree Court, Marina Valley, Ca., 92551, since June 1999. 3. Plaintiff has been a bona fide resident of the Commonwealth for at least 6 months immediately previous to the filing of this Complaint. 4. The Plaintiff and the Defendant were married on April 15, 1983 in Cleveland County, Oklahoma. 5. There have been no prior actions of divorce or for annulment between the parties. 6. Plaintiff has been advised that counseling is available and that plaintiff may have the right to request that the court require the parties to participate in counseling. 7. Plaintiff and Defendant have two children together, namely, Joshua B. Clark, dob 6- 17-85, and Jordan S. Clark, dob 8-19-87. 8. Plaintiff and Defendant are both citizens of the United States of America. 9. Neither Plaintiff or Defendant are a member of the Armed Forces ofthe United States of any of its allies. '.'~,! . . . 1D,"'=m " '-. j ,-~ ,-~ '" ;.:; ~- .'-J '~" t,' " 10. The Plaintiff avers that the grounds on which this action is based are: (a) That the marriage is irretrievably broken; and/or (b) That the Defendant has offered such indignities to the Plaintiff, the innocent and injured spouse, as to render her condition intolerable and life burdensome. WHEREFORE, Plaintiff requests the court to enter a decree in divorce. I verify that the statements made in this Complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. ~4904 relating to unswom falsification to authorities. ~~~~.~ Kristi J. Clark, amtlff Respectfully submitted, Date: ~ -7~()7 Jan Adams, Esquire I . No. 79465 117 South Hanover St. Carlisle, Pa. 17013 (717) 245-8508 ATTORNEY FOR PLAINTIFF '".:. ::,~ \,,:1.i ',,~ ~~;:Wil9.Mxjw);;jh'''';;'''U~-a,''\'''';;I,j;,,,-,-"jIT<~''''',-'1h~~''-I,'',~-,,,,,L,,_,,',,'<A1'1~;;,""'I~L.d~'k"*f.Meli!Jtillc~!lf&j~J..ii<lI::d~.&L! r~ w '-. <:> "" c.. l-\l C). -<; I> ,r:< v, - "~,' " .0 ~" _:-""....IalI~'> ^-"~.~"'~~..'- ~. 0 a CJ C -n -- .." S \,JrT ('1 '-n rnfi1 co z:r.: -- z s: ---- ;"~} (/) -' j -< .<:. ~,:) r' c::; " '< '-' :_U "}....... c~. , Z ~-,.~ ,_-:7__ c) )> <.:) 1"0 L-' rn C ~:~ Z ~ ~ ~ '0 ~ \ ~ ~ j '" <lJ - '-. "<:1 0" C\. '" ~ ~ ~ t r .-, ,,,-'. iiluti; .. KRISTI J. CLARK, Plaintiff : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA vs. : No. STEVEN B. CLARK, Defendant : ACTION IN DIVORCE AFFIDAVIT OF SEPARATION 1. The parties to this action separated on February B , 1999 and have continued to live separate and apart for a period of at least two years. 2. The marriage is irretrievably broken. 3. I understand that I may lose my rights concerning alimony, division of property, lawyer's fees or expenses ifI do not claim them before a divorce is granted. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. ~4904 relating to unswom falsification to authorities. Date: 1,- '5 - C>\ ~~~ ~,lU Kristi J. Clark, PIlIl ff 'I } '.>.1" ~~;ig,.b,~~i&lE"~:IIilf.w.l!;"'r{~Jf~i'!"AN:,-,j-"i'1-';o-l'~";;~!i-.~"kM,_';i;n,*,-;>;';(j;-iJ"]i~~~~IUiO~lllIJl;!llliiijlWHi"'~iI~IIliW- c;-_ ~ ~ ~"'" .,""""" . !t~1 ".. () a c:: ,- -oS: ,~ ....... ., rnCD /'i1 ----' zGJ ::l;l , 2'''' "j'-> 05<;:;: I 'r: ----r ':<::-" ...., '>~0 f-:~c " , :<:;'-' );::' l'J ~::..!() 2:(") ~". ~l'~~ ;;;;:0 c:: Sl' 2' ::;;t ;::;. -, ,:)::-.. (.v :c -< ~ <, ~ -~ . r ,.,~ :t/" , "' ,~" " ""'-"- -' ,,", :mi.: , . KRISTI J. CLARK, Plaintiff : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA VS. : No. 01 - 762 Civil Term STEVEN B. CLARK, Defendant : ACTION IN DIVORCE AFFIDAVIT OF SERVICE OF THE NOTICE TO DEFEND. COMPLAINT. and AFFIDAVIT OF SEPARATION AND NOW, this February 21, 2001, I, Jane Adams, Esquire, hereby certify that on February 17,2001, a true and correct copy of the NOTICE TO DEFEND, COMPLAINT, AND AFFIDAVIT OF SEPARATION were served, via certified mail, restricted delivery, return receipt requested, addressed to: Steven B. Clark 25334 Beantree Court Marina Valley, CA 92551 DEFENDANT J e Adams, Esquire .D. No. 79465 117 South Hanover St. Carlisle, Pa. 17013 (717) 245-8508 ATTORNEY FOR PLAINTIFF ~ - "-,..-'- ~ ,;"-;,, ...",-- . Co;;'pl.rtt\lile"'"1, 2, and3. Also co;"'plele item 4 if Restricted Delivery is desired. . Print your name and address on the reverse so that we oan return the card to you. 'I Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: 3. Service Type o Certified Mail 0 Express Mail o Registered 0 Return Receipt for Merchandise o Ins~red Mail 0 C.O.D. 4. Restricted Delivery? (Extra Fee) 0 Yes -''1:..'("10:2 ( ,L ~l oS" "I~OOoo\??Sb8 ci.lo.! Domestic Return Receipt . 102595-99-M-1789 ~B,~~ ~S-2,"6L\ &~~ f11~~\)~cA . "\ )..SS-I 2. Article f'Ju"1ber (Gopy'Jrom service lapel) ',,, PS Fonn 3811., July 1999 " C. Signature x -.. D. Is de Ivery address different from item 1? If YES, enter delivery address below: ~es \:0 ____Ji -;-"".;r- , ~, . ,,,,t_; '_..w~ ~ -.- ~ - ~~ _I ,d ... , . , , KRIST! J. CLARK, Plaintiffi'Petitioner IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE STEVEN B. CLARK, Defendant/Respondent NO. 01"762 CIVIL TERM IN DIVORCE DR# 30671 PacseS# 312103462 ORDER OF COURT AND NOW, this22nd day of May, 2001, upon,consideration,ofthe attached Retition.fur, Alimony Pendente Lite and/or counsel fees, it is hereby directed that the parties and their respective counsel appear before R.I. Shaddav on June 11.2001 at 9:00 A.M. for a conference, at 13 N. Hanover St., Carlisle, PA 17013. after which the conference officer may recommend that an Order for Alimony Pendente Lite be entered. YOU are further ordered to bring to the conference: (l) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by Rule 1910.IW (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. BY THE COURT, George E. Hoffer, President Judge Mail copies on 5-22-01 to: Petitioner < Respondent Jane Adams, Esquire Lindsay Baird, Esquire R (JL Date of Order: May 22, 200 I YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LffiERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 ,," I ~~~',;("l;\"""-S'*"( -~"1-l\ '::;';}~H*!\l;o<_*iLl@!i~~mlMillfuilfl;ift!ip:r;'>;ik4-",<~"k', '''i2N,j,,'Ait_'dHl,:'~lx:..ill,~.J:r ,,,.b,,J~~~HO_ '",""_'" """~,,, _~__,__ ,__,<=~ "._',"""- "'_',.,,,,,,,,,,,,_o.--,,_,~,-,, ,..,-, ,,,,- ,.." ~~~~r~~ ~,,,,.1~ , '" '\{," 'C;NI\J::H 'iJ:~\l\i \1/\'-.;., "-"::"'11"'\'1 II \\'n'~,(\ ,,:1:'-,;;\1 j" 1\.lJ, "_ I.,' 'G::i -,"'-~' .r:' .,.... 1 \ ej' ',;V l'T,J l,f,') A.i.PI "--," - Imtilll- -'''~~->_ ;j,.i ~ .a~"h_ ~. I~ , . __ l"~ --" - .' AMERICANS WITH DISABILITIES ACT OF 1990 The Court of Common Pleas of Cumberland County is required by law to comply with the Americans with Disabilities Act of 1990. For infonnation about accessible facilities and reasonable accomodations available to disabled individuals having business before the court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing. ,,; '"--"~-. ";,C ."-..~ , . -~-" "-' "__ . ,.. _", ,_ _J"_"",_'.' "",,"_, ,;.<, ~ KRISTI 1. CLARK, Plaintiff : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA vs. : No. 01 - 762 Civil Term STEVEN B. CLARK, Defendant : ACTION IN DIVORCE PETITION FOR ALIMONY PENDENTE LITE. AND NOW COMES, Plaintiff, Kristi J. Clark, by and through her Attorney, Jane Adanls, Esquire, and respectfully represents that: I. Plaintiff is Kristi A. Clark, an adult individual, who has resided at 40 I Garland Drive, Carlisle, Pa. 17013 since February 27, 2001. 2. The Plaintiff's date of birth is February II, 1958 and her social security number is: 185-38-5974. 3. Defendant is Steven B. Clark, an adult individual, who has resided at 25334 Beantree Court, Moreno Valley, CA, 92551 since June 1999. 4. Defendant's date of birth is January 26,1956 and his social security number is: 441- 48-1720. 5. The Plaintiff and the Defendant were married on April 15, 1983 in Oklahoma. 6. Plaintiff has heretofore filed a complaint for divorce as of the above caption. 7. Plaintiff lacks sufficient property to provide for her reasonable means and is unable to support herself through appropriate employment. 8. Plaintiff requires reasonable support to adequately maintain herself in accordance with the standard of living established during the marriage. , , ).:, ',;>' '" J~ ", _r' ~ , . .. 'C, .b,,--,- f,. "-_ ,'_ . '__~L ., 9. The Defendant is fmancially able to provide for the reasonable needs of the Plaintiff. WHEREFORE, the Plaintiff requests that this Honorable Court enter an award of Alimony Pendente Lite until final hearing. Date:fj po{) / ane Adams, Esquire I.D. No. 79465 117 South Hanover St. Carlisle, Pa. 17013 (717) 245-8508 ATTORNEY FOR PLAlliTITF ~,;1~-...."d","''';';""" , "~!I!);ffiiJ~''';''''''"iM>'~~H:iID\,,'1~,,!i;:m,~.-.-lrJ:M,i\l,..i'~1't'--'f!'''''''''--- ....' " ~~. - '~~ . ~ ,"" ~~ (") C) \_j c: -:-1 $: :r: -oCC) Xl'" nln', -< Z:;_~~ ;-, Z S::~ .'~, if> ,--'. ( -< L " ~) I~ iJ ~21 '-n :h ts - -, ," -_.-c.. N i\'l C 0 --, Z 1'0 > =< :0 C' -< ~ ~ - ~ . """,,-,"::';ji ~" . \ ... \ < KRISTI J. CLARK, Plaintiff : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYL VANIA vs. : No. 01 - 762 Civil Term STEVEN B. CLARK, Defendant : ACTION IN DIVORCE AFFIDAVIT OF SERVICE. AND NOW, this May 30, 2001, I, Jane Adams, Esquire, hereby certifY that on or about May 12, 2001, a true and correct copy of the PLAINTIFF'S PETITION FOR ALIMONY PENDENTE LITE was served, via certified mail, return receipt requested, addressed to: Steven B. Clark 25334 Beantree Court Marina Valley, CA 92551 DEFENDANT AND Lindsay Baird 37 S. Hanover St. Carlisle, Pa. 17013 Respectfully Submitted: ~~ dams, Esquire LD o. 79465 117 South Hanover St. Carlisle, Pa. 17013 (717) 245-8508 ATTORNEY FOR PLAINTIFF Complete items 1, 2, and 3. Also complete item 4 if RestrIcted Delivery is desired. . Print your name and address on the reverse so tha~e can return the card to you. R Attach this card to the back of the maiJpiece, X or on the front if space permits. 1. Article Addressed to: S~ g, C~t!- ;)S33L1 &evy> ~G+- (nDF-/MO UI7~ CI4 qdrJ ~ice Type ertified Mail o e9lsfered o Insured Mail o Express Mail o Return Receipt for M.erchandise DC.C.D. 4. Restricted Delivery? (Extra Fee) Dyes 2. Article Number (Copy from servIce label) -"7. " , . _ - . ___ A:ro D&(][:)o:::;f).S-ls:6S 7/'06 PS Form 3811, July 1999 Domestic Return Receipt 102595.(10.M.Q952 . 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 on the front if space permits. 1. Article Addressed to: c/A:,,4o'I~ tI~,j 37 $. ~ S+-. ~s/eI'A /7113 2. Article Number (Copy from servIce label) X" .. 0 Agent o Addressee DYes o No D. Is delivery address different from item 1? If YES, enter delivery address below: 3. ~ice Type ~rtified Mail 0 Express Mail o Registered 0 Return Receip~ for Merchandise I o Insured Mail 0 C.O.D. 14. Restricted Delivery? (Extra Fee) 0 Yes 7006 Dh(JOOoz..7 1.3/32.. ""3 102595-00.M-09S2 PS Form 3811, July 1999 Domestic Return Receipt . ' ,., > PO BOX 7 Employer/Withholder's Address BOILING SPRINGS PA ORDER/NOTICE TO WITHHOLD INCOME fOR SUPPORT );:k.b -3;l.'J' 8/993 State Commonwealth of Pennsylvania 7~ 0< 7110305":;- g~i~c~7~~:'r/~0~:m~= 02 });e. PU ~6 r ~i!i!llfJrj/dgf:/K?i(j~~€' Court/Case Number (See Addendum for case summary) 1'/r~S' -.3/.;1 /tJ 3 vP (yc 06fG7/ ) RE: CLARK, STEVEN B. ) Employee/Obligor's Name (Last, First, Mil ) 44J.-48-J.720 ) Employee/Obligor's Social Security Number ) 290J.J.00703 ) Employee/Obligor's Case Identifier ) (See Addendum for plaintiff names associated with cases on attachment) ) Custodial Parent's Name (Last, First, MI) ) @OriginaIOrder/Notice o Amended Order/Notice o Terminate Order/Notice EmployerMlithholder's Federal EIN Number ALLENBERRY INC Employer!\Nithholder's Name J.7007-0007 See Addendum for dependent names and birth dates assooated with cases on attachment. ORDER /NFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee'sfobligor's income until further notice even if the Order/Notice is not issued by your State. $ J., 507.56 per month in current support $ J. 73.00 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in medical support $ 0 . 00 per month for genetic test costs $ per month in other (specify) for a total of $ 1,680.56 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the foliowing to determine how much to withhold: $ 387.82 per weekly pay period. $ 775.64 per biweekly pay period (every two weeks). $ 840.28 per semimonthly pay period (twice a month). $ 1.680.56 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the the allowable amount. The totai withheld amount, and your fee, cannot exceed 55% of the employee's! obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on pg. 2). If remitting by EFT/ED!, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case tdentifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: ~. KElliN -V'NC-SS /9. ~ Date of Order: MAY 2 9 2002 Service Type M D~;~iK~ILED MAY ~ Q 2002 OMBNO.:0970_0154 Expiration Date; 12/31/00 :::JVMiS Form EN-028 WorkeriD $IATT ~ .~ ~ ~ " ~". ~ -,-, i" --. ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If checked you are required to provide a copy of this form to your employee. f, Priority: Withholding under this Order/Notice has priority over ahy other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority, If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding, You must, however, separately identify the portion_of the single payment that is attributable to each employee/obligor. 3.* Repoltillg tile F'ayddt-dDatc of'lJitl,l,ofd;"g. You ltlu&t lepol1 tile pAydateldate of vvitl,l,old;l,g nl,el, se"d;lIg 1I1e pay I Ilt-IIt. The p'ydate!o.to of "itl,I,010i"5 i, tl,o 001' 010 "I,i<l, ',MUlot ,,", "itl,I,.lo f,,,,,, tl,e ""ploy,"', "age<, You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments, 4, * Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support againstthis employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law o!the state of employee's/obligor's principal place of employment You must honor all Orders/Notices to the greatest extent possible, (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S ID: 2316842070 EMPLOYEE'S/OBLlGOR'S NAME: CLARK. STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments. contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding, Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9. * Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C ~1673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxeSi Social SecuritY taxes; and Medicare taxes. 10. * NOTE: If you or your agent are servedwith a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respectto these items. Requesting Agency: DOMESTIC RELATIONS SECTION 13 N, HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by Internet @ Page 2 of 2 Form EN-028 Worker ID $IATT Service Type M OMBNo.:097().()154 Expiratlon Date: 12/31/00 .. .' "u~ ,-- ~- ..- , 'i, ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 271103055 / c2/CVJ~ Plaintiff Name ! KRISTI J. CLARK Docket Attachment Amount 32i3S1993 $ 1,062.56 Child(ren)'s Name(s): ~~~..~jE~~,....,.,. Dii~h;~k;d,~~~~;; ;~~i;.;d;~;~;oll;he~h;ld(;~~;' '.. '.. .' " , identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Chiid(ren)'s Name(s): DOB D If checked, you are required to enroll the chiid(ren) identified above in any health insurance coverage availabie ' through the employee's/obligor's employment PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment PACSES Case Number 312103462/.3~ 7 ( Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 01-762 CIVIL $ 618.00 Child(ren)'s Name(s): DOB 'dli~~:~~:~,~~~:;: ;~~ui;:~ ;;.~~;~il;~:~~il~(r~~)">..'." , " identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment Service Type M Addendum Form EN-028 Worker ID $IATT OMS No.: 0970-0154 Expiration Dale: 12/31/00 >ciIli~~;sl,!';ftji!~1JJ:;Jf~~JW-~';:;~~ilm.O<j.<J>;d'f.I'!-_<lli:!ltt"~4',_"~""iJ{"C"\-:lL':I'''">J,";;j;!-;'lli';;;';'''::d.",'''.:i'~r~i<lt~i j' =~"~ ~ -- 1:l1~~~~M~~MEIlii!!!i;1l!ll<V (") ~; -Oij.~ G)~- zL_ ({J~,- G:L,' l~9. :z '2 o t",J ~ --;.. ':~< '....-,) o -I .' S71 -0 '171 --';~ --,"j......-" :~'~; :~"')\ n '-<< -, ~ =< .-" r..;-? r:- ...l , ~ ," ~ "_~,'I '. ~,., " 'LM_'UiI- 'S"- ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT Mh 3d';- S- /193 State Commonwealth of Pennsylvania PI"IC!9E'> Ol. 7/( tJ::;'Orr Co./City/Dist. of CUMBERLl\ND /);<.. 02/tl-ti % Date of Order/Notice 07/26/02 Court/Case Number (See Addendum for case summary) o Original Order/Notice o Amended Order/Notice ....,0 Terminate Order/Notice 51;)/01V~- Ie .;;SO (" 7 I ) RE: CLARK, STEVEN B. ) Employee/Obligor's Name (Last, First, MI) ) 441-48-1720 ) Employee/Obligor's Social Security Number ) 2901100703 ) Employee/Obligor's Case Identifier ) (See Addendum for pJaintiH names associated with cases on attachment) ) Custodial Parent's Name (Last, First, MI) ) EmployerlWithholder's Federal EIN Number PENNFIELD FARMS EmployerMlithholder's Name 2609 ROUTE 22 BOX 70 EmployerMlithholder's Address FREDERICKSBURG PA 17026-0070 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA nON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBER:r.AND County, Commonwealrh of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee'sfobligor's income until further notice even if the Order/Notice is not issued by your State. $ 1,507.56 per month in current support $ 173.00 per month in past-due support Arrears 12 weeks or greater? (Xlyes 0 no $0: 0 0 per month in medical support $ O. 00' per month for genetic test costs $ , per month in other (specify) for a total of $ 1',680.56 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to deterniinehow much to withhold: $ 387.82 per weekly pay period. $ 775 ;64 perbiweekly pay period (every two weeks). $ 840.28 per semimonthly pay period (twice a month). $ 1.680.56per montl1ly pay period. ' REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydateldate of withholding. You are entitled to deduct a fee to defray the cost of withl1olding. Refer to the laws governing the work state of your employee for the the allowable amollnt The total withheld amouht, and your fee, cannot exceed 55% of the employee'sf obligor's aggregate disposable weekly earnings. For the purpose, of the limitation on withholding, the following information is l1eeded (See #9 on pg.2). If remittingby EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: PennsylvanlaSCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADD/T/C)N, PA YMENTS MUSHNCLUDE, THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case "Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: Date of Order: ~YL a 9 2002 7' ~ KG-t/I#A-,I(~9~ --1 ~ml> 1'10 i'i970.o154 /I. 4... Service Type M ' Form EN-028 Worker ID $IATT Expiration Dale: 12/31/00 ,,' <> I"","",,^.' "' , ~"^<f, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS D II checked you are required to provide a copy olthis lorm to your empioyee. .. , , T. Priority: Withholding under this Order/Notice has priority over aiiy other legal process under State law against the same income. Federal tax levies in effect belore receipt olthis order have priority. II there are Federal tax levies in effect please contact the requesting agency listed betow. 2. Combining Payments: You can combine withheld amounts Irom more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion 01 the single payment that is attributable to each employee/obligor, 3,' Repoltil1g tl,< P'rd.teiD.t~ oIWitl,l,oldilog. You n,ust ,~"Olt the p.,date!date of ..ithl,oldilog..l,el, sel,dil,g tI,~ p.,I"et,L T1,e paydato'dAlt of vvill,l,oldh.g i3 lIle date 15.. ,vvl.i_c,I.,~I",ount vvM vv;U.I.eleJ f1QI.1 tl.e el1lpIQy~~'s vvage3. You must comply with the law of the state 01 the employee'slobligor's principal place 01 employment with respect to the time periods within which you must implement the withholding order and lorward,thesupport payments. 4, ' Employee/Obligor with Mu,ltiple Support Holdings: 'If there is more than one Order/Notice' to Withhold Income lor Support against this. employee/obligor and you are unable to honor all support Order/Notices dueto Federal or State withholding limits, you must lollow the law!,lthe stateolemployee's/obliqor'sprincipal place.ol employmentYou must honor all OrdersfNotices to the greatest extent possible, (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working lor you. Please provide the information requested and return a copy of this Order/Notice to the Agency identilied below. WITHHOLDER'S ID:2311372320 EMPLOYEE'S/OBLlGOR'S NAME: CLARK, STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAMEfADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payrnents, contact the person or authority below, '. 7: Liability: If you lail to withhold income as the Order/Notice directs, you are liable lor both the accumulated amount you should have withheld Irom the employee/obligor's income and other penaities set by Pennsylvania State law, Pennsyivania State law governs unless the obligor is employed i"another State, in which case the law 01 the State in which he or she is empioyed governs. 8, Anti-discrimination: You are subject to a line determined underState law for discharging an employee/obligor lrom employment, relusing to employ, or takingdisciplinary action against any employee/obligor because 01 a support withholding, Pennsylvania State law governs unless the obligor is employed in another State, in which case the law 01 the State in which he or she is employed governs. 9.' Withholding Limits: You may not withhold more tha" the lesser 01: 1) the amounts allowed by the Federal Consumer Credit Protection Act (1 5 U.S,c. H673 (b)l; or 2) the amounts allowed by the State 01 the employee'slobligor's principal place 01 employment The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: state, 'Federal, local taxeSi Social SecuritY taxeSi and Medicare taxe's. ' 10. 'NOTE: If you or your agent are served with a Copy of this order in the state that issued the order, you are to lollow the law of the state ihat issued this order with respect to these items. Requesting Agency: DOMESTIC RELATIONSSECfION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have "nyquestions, contact ' WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (71 7) 240-6248 or by Internet @ Page 2 of 2 Form EN-028 Worker ID $IATT Service Type M OMB No.: 0~1()'{)154 ExpirallonDate: 12/31/00 " _.f,_,_,_ ,c, ADDENDUM Summary of Cases on Attachment PACSES Case Number Plaintiff Name KRISTI J. CLARK Docket ' Attachment Amount 32ilSl993 $ 1,062.56 Child(ren)'s Name(s): ~,,',,8,,',,~,HUll" .~"",'"""BS""""""':""""",~,'",~",,""~R~""",:,,,,""""'" ..,'"",',',' ',',.." I<I:,,",,~~ -~~;&II; ,...'::..:-:....::.:::',...:.',.:...::..::.:.:::.::':"'.,:':::"::';., Defendant/Obligor: CLARK, STEVEN B. 271103055/dl;).8 r DOB " , 06/17/.8,5 '.:,::".'IlIl/i!l1117 PACSES Case Number Piaintiff Name KRISTI J. CLARK Docket Attachment Amount 01-762 CIVIL $ 618.00 Child(ren)'s Name(s): 312103462 PD&'f1./ DOB ....,...' .., ..,., . 'v,'.....'...'...'.....,'.'..,' :,.::..:..:..'.'.,0.",. ':. ::':' :.: '. ::. ,": ': :::: ::y :,:::::,': ::::: ::::: :,:" ::' . :;" ~.;, :":': . ., . .. . . " . " "'. .. .. .. ,. :::: :,:: :.::: '.,: ':::':: :::: : '.: :'" / ':':",: .' '.. . Olf checked, you are required to enroilthe child(ren) "" identified above in any-health insurance coverage available through the employee's/obligor's employment. 'dli:~~~~~:~:"~~~~;;;;~~;~~;~'~~;~II;~:~h'il~;;;~) identified above in any health insurance coverage available through the employee'slob/igor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. Addendum Form EN-028 Worker ID $IATT Service Type M OMB No.: 0970.0154 Expiration Date: 12/31/00 o 00 .tIit ,_II.jlJ~"iI!/t!i"jUjjc~bTh.-\;ljlmrii#.i"j~$lilii~iimill~bjlmi1b\li;1r<i!L)K,1;;/li<,'l,:."j,i" "'''''lik:!i'''''iI~R~iIMI _.'~~~ji ~_;;;l -"~ ~ B'iiU -".I 'I , I rl' i \'1 1,! ,I ~I I I t. II II II II I' I 0 ,.". ('i c: "'''':1 -n g. (~ .... -C(.c ..--- ; ..U rnf'!' ,- -7 -'1'\ W '-'7j zc- {~ \ ~~:~- (-.::) - " l;:,~ -'0 ~ ~~~~ ~> <~,; 2") ~.'" r,":::)rn :>c -:-':;;:;i Z ~' -~ :Q -~ ... ,~.. , -, ~" ,-." .",' ] - ~_""",""i'.' DR30671 P ACSES ID 312103462 KRISTI}. CLARK, Plaintiff/Petitioner vs. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : DOMESTIC RELATIONS SECTION : CIVIL ACTION - LAW STEVEN B. CLARK Defendant/Respondent : NO. 01-762 CIVIL TERM ORDER OF COURT AND NOW, this 13th day of August, 2001, based upon the Court's determination that Petitioner's monthly net income/eanling capacity is $N/A per month and Respondent's monthly net income/eanling capacity is $NI A per month, it is hereby Ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit, $275.86 per month payable monthly as follows; $248.86 per month foralimony pendente lite and $27.00 per month on arrears. First payment due with respondent's fIrst pay in September. Arrears set at $0.00 as of August 13,2001. The effective date of the order is September I, 200 I. This order is based upon the parties' stipulation and agreement of August 9,2001. Arrears on the Alimony Pendente Lite order are to be $1,667.94 on September 1,2001 pursuant to the parties' agreement. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.g 3703. Further, if the Court [mds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and its discretion make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. ;!A,-,~.. . Said money to be tunled over by the P A SCDU to: Kristi J. Clark. Payments must be made b}"check or money order. All checks and money orders must be made payable to P A SCDU and mai~: PASCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the defendant's P ACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. ~ - _ _ d k , _ ,~l , . ~~. Umeimbursed medical expenses that exceed $250.00 annually are to be paid 86% by the respondent and 14% by petitioner. The petitioner is responsible to pay the first $250.00 annually in unreimbursed medical expenses. Respondent to provide medical insurance coverage. Within thirty (30) days after the entry of this order, the Respondent shall submit 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 allY 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. This Order shall become final ten days after the mailing of the notice of the entry of the Order to the parties unless either party files a written demand with the Prothonotary for a hearing de novo before the Court. DRO: R. J. Shadday Mailed copies on 8-14-01 to: < BY THE COURT, Petitioner Respondent Jane Adams, Esquire Lindsay Baird, Esquire ~. A-~ Kevin AA'Iess J. '" ',t..'-' l;. ' ~jfii;&,\~-1J,"i:t!iN-",,'~';..~db,~I'-;.', 'i;; \A':f;M:!iillI~:r@RA,>\)'1l.d,<-;-U:,,~ '"'' '," ";,;.,.j"~'U!1.-i.;~,it"""---,,,,.d.ll!.' "'" ~L ~ ~lllfJli<~~~~lli&:i;.,j,,,,, -~_r."..A:::. II ',- - 0 CO C) C ~ " I -0 "'" nl fTi ~':;5 ...,. -.", <,- zf g~~:~ c-. , -.'e' () "'" " ~ -- z(:;' 5>;;2 c :',) c:..J r-i-l ,-- Z ~ -:i ~ -< <;:, :D -< i I ~ " , . --o_-.rM.~ Aug 07 01 03:19p FROM : JANE_ADAMS BAIRD LAW OFFICE 717-243-8110 FAX IoU. : 7172458538 Aug. ~7 2091 12.55AM P3 '-. '. IN THE-COURTpF~ PLEAS OFCUMBERLANl)COUN1Y. PENf'lSYL VANIA KRISTf I CLARK, Plaintiff : DR1I30671 ; PACSES #312103462 and #271l103055. ; vs. : ~. 01 - 762 Civil Term ,;~"IIDNoINDlVORCE' , STEVENB..CLARK, Defendant STIPm;ATION AND AGREEMENT. , , -/L '. AND NOW, this ~ day of ~ ' 200!, the parties, KRISTI 1. CLARK, Plaintiff, and STEVEN B. CLARK, Defendaljt, do hereby Agree and Stipulate as fullows: I. Plaintiff, Knst.i J: CI81:k. (heteiilafta' refened to as<'Plainfifi") CUIImtly resides at 401 GarlaitdIlrive; Carlisle, Pa 171)13;;", ! r ._~umber (717) 249-3053. 2. Plaintiff's dateofbittb,iii-.February >I; 1958 and her -w,;e,-ity number is: 185-38- 5974. 3. Defendant, Steven D. Clark, (bereinafter referred to as "Defenrnn currently resides at 25334 Beantree Court. Moreno Valley, CA. 92551. telephone mDDber (909) 374-0633. 4. Defendant's~.~;iS~19S6.aildbis~number is; 441- 48-1720. 5; Defendimt'..r;.;w,.,."-' n"-"-r-.rs;.$ /7 IZ=? qZ) -" -, , 6. Defendant.,-. 'y",miS~Foods;inc,.'212~~ Springs Road, Suite ',,~ - --1..:- n', .. ; " , '" ,_"'n .,; ""'~~ p.4 " . Aug 08 01 11: OOa BAIRD LAW OFFICE 717-243-8110 FR()'l : JANE_ADAMS FAl< /0,1). : 7172458539 A~9' B720Bl 11:S4PM P2 , 1 207. Moreno Valley, Califurnia, 92557, telephope no. (909) 784-n82. S. Plaintiff and Defendant are the parenlS of two minor children. namely. Joshua B. Clark, date of birth, 6-17-115, soeial security no. 160c66-7948 and ]o~ S. Clark, date of birth, 8-19-87. social security JlO. 202-70-4475. 6. Plaintiff filed a fur Spousal support and child support, under P ACSES #2711l 03055 lind an initial bearing was held 011 February 28, 2001. On or about April 30. 2001. a Petition fur Alimony Pendente Lite (P ACSES #312103462) was filed witb the CoUrt and served upon Defaldant. PurSUllDllolhese Petmons, 'the panij:S agree as follows: A. TheDefendant.~ ~ the lIIJIOIIJlt of.$1.360,~S~~onlb ,in child ~rt and $500.fJtfamonth m1lfunony1o 1he:l'laintl'lf;'W!th~on addressed m section DrbelQw. . , B. ~w.iJJ.bedediwled.fr(lm~nm.nt's:payc;hefk and be forwarded to Plaintifflhrougb PSECDU. C. This Agn:ement s1ial1'~ effective immediately. D. Upcmexecution,ofthiS 8g1ee..wrt; Plaintiff sball,befnlly teSJlOnsible for all lQa11 P"l'''ent:.due tv......ds1hewuple'BIsIl%Uit.odee.. tlaintiffsball retain po~session orlbe vehicle. _ E. Mec1iveSepteJDbeFc.l:,2OOt,DefeDdam'jj.tof8l ~.;1t payment sball be reduCed' bytiJe amount.ofthe 1IIOJltb!y pl&l...111~on the jointly titled lsuzu Rodeo. {S2S1.J4f.c l1ieam~ ofS2SI..J4;&llooatiBut.to-htdeducted from Defendant's cb:eddng.1l:CO~3Dd forwarded toUSAA. to satisfy the monthly payment~.tIJe~'sIsuzvlWdeo.. l)efen<lane~lotal support payment sbal1becredueed UIlliI such time-asthe Isuzu'Rodeo.is sold or the loan is paid in full, when ~total support payment to- Plaintiff shali again equal $1860.45. i F. oM ofStptembcr 1;2001, the amotm10f~ owed to plaintiff shall ~:$8038.m~Sl86OAj{thellllHWBtllf.JlBt'l!1Cl1t to be f01WBJded 10 Plaintiffby August 13, 2001) to equal $617756. G. O.tt..... ,1ialJ" pay at least $llllUlO per mOlllll',lowards any arrearages. 7. Unreimbutsed medical expenses are to be paid ~ by the Defendant. and MHl by the Plaintiff. . > i"';;.i~;, p.2 -,' ~' ~ " "'~, ~ ~ ':"'''!Iii~, , 8. Plaintiff, Kristi J. Clark, currently carries, and shall maintain medical coverage for the couple's minor children with the following medical plan: Blue Cross and Blue Shield, QBDI85385974 in Plan 022656000. 9. Within thirty (30) days of Defendant's request, Plaintiff will provide written proof of medical coverage for the couple's two children. Proof of coverage shall consist, at a minimum of: 1) the name of the health care coverage provider(s); 2) 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. 10. Settlement proceeds in the amount of$18,672.69 from the sale of the couple's home are have been held in escrow. Pursuant to prior agreement of the parties, $2,500.00 of this amount was disbursed to Kristi J. Clark. The remaining proceeds equal $16,172.69. Pursuant to this Stipulation and Agreement, the remaining settlement proceeds have been disbursed as follows: $4,596,17 disbursed to Steven B. Clark. $288.00 to Jane Adams to cover attorney's fees for time spent on settlement. $11,288.69 disbursed to Kristi J. Clark. II. Nothing in this agreement shall prevent the parties from requesting a modification ofthis agreement where there is a material change in the circumstances of the parties or the children, and this agreement shall not contractually obligate the Plaintiff or Defendant to pay an amount per month without regard to the circumstances of the parties or the children. ,,. Au~ 07 01 03:19p BAIRD LAW OFFICE 717-243-11110 FROM : JANE_ADAMS FAX NO. : 7172458538 Al,t9. 10.' 2!'J01 12:56AM P6 " IN WITNESS WHEREOF, the parties hereto have set their .ds and seals the date and year above wnllen. ~~r:J,~\- ,Date: COMMONWEAL'FH-OFPl\NNSYLVANlA ) ):5S COUNTY OF ) , OntWs,the ~~.of Av,U-fl- ,-2.oo1,<<fere~eundersignedofficer, personaHyappeated ". ~{Jd kilown tome, (9r~sfaewrily proven) to be 'the per&oII.wltose.nam8~s s~wlhc.witI1iuiBslmmeat;.lIBS:' "~ .",wltdged that helshe elteeuted the same for the purposes therein contained. IN WITNESS WHEREOF.I.........""" set ID1' hand and official-seal. , \. Myeommissi9D ! ~. l~OT~;~lSEfd. SEAL f lA,,!;; E.J\i).Ih:". i.!'O;~"J 1>"b'I'~ , r>'''rli~lt!\!::'!"" <'~ ",' ""'''''','1,' u~ l", ~dl.l'''iY Q'VrD, ~;mnr~rfB'r'a (~'tni-'1 My Commissic~ tc~i'iras Sap!, Ii; 2004 "--' . '. . .hi~~'-l!;;jw-!\ p.7 Au~ 07 01 03:20p FROM : JI'N'_ADAMS . , .' '~.I- t .J ~ ~'...,' BAIRD LAW OFFICE 717-243-B110 FAX NO, : 7172458538 ""19. 07 ~1- 12:,56AM P7 ~~ ~~k~~o . WITNESS Dale: COMMON~, ~SYLVANIA ) ):ss COUNTY /~/pe ) On1lris; the 6#1" dl!J'lf d-a qa.fL.-Ju ,200 I, before me, ~ undersilllled officer, . JIOI"SOIlaIIy "Pp",red ( ~r;;;)J. ~~1O=e.,'(or~oven) to be the-persorrwhowname is SUbscribed'to ~ ,wil~iDstrumenl. and "1"ow1ed8ed llIat he/she executed the same fur the pwposes therem cont.airtedC IN WITNESS WHFRPOF.l ' My commission expires: SEAL ''il ' ".-.......-:aL.a. - ,- _"'..,'",,'___ ",. 1 ," "",':~~,m;'" 6)' ' O"....IIdIiII.l21...... ~ " ttotay,,*-c.&..III_ ,J___~~~~~t 0' ';e.i; 'h!, p.B ~ti;:.:;";' ,;=z,;-"",.. -, IJii~' >~,,,-~., , < ~. --, ,-,.,~~;""~ ,~" :.H~, li!(>'i~,...~.."".<,_' 'Yo'.;' J ,,~ ,~ ~-, .d " " ~, >."" J~~ " '^'" -~'- ,,>,.F', . q 0 0 C -;, S ~ ..,J CL' G:; rn n i Z :0 r",.) Z " (j) ',~ ~' , ~:) ~:::t--:. ,",,') _;" -,"'1 ::.-~' c (;t:~ ~: C,J ~"J ~~; iTl ~' C~ -'!'-~ ~~ -'..:) ~ -< r...::' ~ ,. ...." Ie ,,- IJKfs1J1.~ 7&]), (U'l/tL jJf/&l.E(j 3'/"j/o!J <yf..,/ ORDER/NOTICE TO WITHHOlD INCOME FOR SUPPORT i)JC. 30&7 r M, 3;;..f S /'*7:; Slale Commonwealth of Pennsvlvania /7h'&S a. 7/(030$--:;- Co.lCity/Dist. of CUMBERLAND /~I " , Date of Order/Notice 09/20/01 JfL. c)-/J-OY Cou rtICase N um ber (See Addendum for case summary) ~"1' o Original Order/Notice @ Amended Order/Notice o Terminate Order/Notice ) RE: CLARK, STEVEN B. ) Employee/Obligor's Name (Last, First, MI) ) 441-48-1720 ) Employee/Obligor's Social Security Number ) 2901100703 ) Employee/Obligor's Case Identifier ) (See Addendum for plaintiff names assoaated with cases on attachment) ) Custodial Parent's Name (Last, First, MI) ) EmployerlWithholder's Federal EIN Number PHILLIPS FOODS INC EmployerlWithholder's Name STE 207 EmployerlWithholder's Address 21250 BOX SPRINGS RD MORENO VALLEY CA 92557-8712 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 1,609.31permonth in current support $ 100.00 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in medical support $ 0.00 per month for genetic test costs $ per month in other (specify) for a total of $ 1, 709 . 31 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 394.46 per weekly pay period. $ 788.91 per biweekly pay period (every two weeks). $ 854.66 per semimonthly pay period (twice a month). $ 1.709.31 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10l working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on pg. 2). If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDUl Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: ~. ~ I(t?t,f" AI Jol_ II &;5, 4.. Date of Order: SEP 2 1 2001 Service Type M ~ : q.JI-OI - OMj),No.:0970-0154 Expiration Date: 12/31/00 JtJtJb6 Form EN-028 Worker 10 $IATT ~1j~-iilu'.jI;jj ~-<~:iiiii~'~' 0-;- "._~~,~,,~',~' >,,,, ~ "" " -" "~"r""'. ,,',~ ,'" ,"""",,1-','1"" ",,,,,E"'U@;"f!u!l_;;U:,,.,,o:..qi:~.~~ ,~ a..il&lfll!li!ilii",ili\'l>~;.",.'" <--"'''.'~''1- \jJN~1I7)"SNN3d l\lNnn""j nA "", ',"CI'''",", ...... '-.. , , ~ "}~' ;0.:],,::, i' VI 1\.J ~(":I ~.!; .::J..J IVO ;'7e d]S /0 Atita.C/\\'"j", .,,'; , ',',' I ' "-, 1,_.:](1 ~=/.:J!~L.'C)-;Y]:i~~:: ,'&I'''~''''~~~'\~',_~",>< '~'1'~o_~ "'''''_1,"_'''', , ,,~ ' '" >"~ ..~ ._o:...Jw.iW~ "~~ ~ .-!~ ~ ~, F.'?" ," I. ,,' -,'" ", ell!i )'1 ;;1 (1 ~,i " 1; \'j ,,~" ~, ~', ~._>o''''''!~3: _~ ".~",=, _'" ,_,",_ ~_~_,~,~ ~"_""" ." ."'-,~ "'U ,~ >"^ - ",',' 1 "i, '. ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If checked you are required to provide a copy of this form to your employee. 1, Priority: Withholding under this OrderINotice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below, 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding, You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3. * Repultil,g tI 1<= PaydcloofDale o('/,f;U,I,oldil 15. 'loti Illlolst lepo!! tIle paydcilt/da-te of vv;t1II,oldi"5 vvl lell -"<=1 Idil,g tll<= I-'aylllclll. TIle payJab'date of vvitLlrolJ;1I5 is tile Jate Oil vvL;cl, ill 1I01ol I It vvClS vvillllleld f1oll1 lire ellll--Ivyce's vv~5<=;)' You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4. * Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S ID: 44J.48J.7200 EMPLOYEE'S/OBLlGOR'S NAME: CLARK, STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you hav~ any questions about lump sum payments, contact the person or authority below. 7, Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9, * Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (1 S U.s.c. 91673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment The Federal limit applies to the aggregate disposable weekly earnings (ADWE), ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. 10. "NOTE: If you or your agent are served with a copy of this order in the state that Issued the order, you are to follow the law of the state that issued this order with respect to these items. Requesting Agency: DOMESTIC RELATIONS SECTION 13 N HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact by telephone at (717) 240-6225 or by FAX at (7171 240-6248 or by Internet @ Page 2 of 2 Form EN-028 Worker ID $IATT Service Type M OMBNo.:0970-0154 Expiration Date: 12/31/00 - ". . ,. . L~ -,"" ~oo jlliiiUif"l ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. 271103 o 55;{9./ d20f PACSES Case Number Plaintiff Name KRISTI J. CLARK Docket Attachment Amount nilS1993 $ 1,360.45 Child(ren)'s Name(s): &g~~~;8~~.'..."..'..'..'...""" DOB " ",06/1.7! ~5, ..,.',.',ii6ii!illj@1 "''''.., ........,... ..','..,.".::..:............'.",':' ,,:., . .................. ....,.,',....,....'......'.'...,'..,....' tJ ifch~cl<~d,you are required to enr~11 the child(ren) identified above in ~ny health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroli the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee'slobligor's employment. Addendum Service Type M OMBNo.:0970.01S4 Expilation Date: 12131/00 312103462~f~Z;Le~f PACSES Case Number Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 01-762 CIVIL $ 348.86 Child(ren)'s Name(s): DOB .,........'....,'.........,..,.. ........' . '...,....... ..,............ ....,.,.. ...., .... ...., '.. ........... ........ ." ,...... ,.,.........,.. bli~i,;cked, you ;re required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB If checked, you are required to enroll the child(ren) above in any health insurance coverage available the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. Form EN-028 Worker ID $IATT ,1:: .1_ ,.... -}>", . '~ ORDER/NOTICE TO WllHHOLD INCOME FOR SUPPORT :])eC, 3,),>f S r''1.p'3 State Commonwealth of Pennsvlvania ;J1Je.,*> 0l7N03>C'rr o Original Order/Notice Co.fCity/Dist. of CUMBERLAND iYC- ;J.r~q J:j!!$,'CJ/ - ;:it,;;l. t!./VlL 0 Amended Order/Notice Date of Order/Notice 09/26/01 fl/leflf'S 3/;J./tJ3~;) @ Terminate Order/Notice Court/Case Number (See Addendum for case summary) b;c "3 tt" 71 ) RE: CLARK, STEVEN B. ) Employee/Obligor's Name (Last, First, MI) ) ) ) ) ) ) ) 441-48-1720 Employee/Obligor's Social Security Number 2901100703 Employee/Obligor's Case Identifier (See Addendum for plaintiff names ilSSodated with cases on attachment) Custodial Parent's Name (Last, First, MI) EmployerlWithholder's Federal EIN Number PHILLIPS FOODS INC EmployerlWithholder's Name STE 207 EmployerlWithholder's Address 21250 BOX SPRINGS RD MORENO VALLEY CA 92557-8712 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 0.00 per month in current support $ 0.00 per month in past-due support Arrears 12 weeks or greater? Oyes <Xl no $ 0.00 per month in medical support $ 0.00 per month for genetic test costs $ per month in other (specify) for a total of $ 0 .00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 0.00 per weekly pay period. $ 0.00 per biweekly pay period (every two weeks). $ 0.00 per semimonthly pay period (twice a month). $ 0.00 per monthly pay period. REMITTANCE INFORMA TlON: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on pg. 2). If remitting by EFT/ED!, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADO/TlON, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: Date of Order: gp 2 "[ 2001 /(EV/~~ ~MBNO"0970'OlS4 "- - vpiration Date: 12131/00 /9. Ai JVO(.,E Form EN-028 Worker ID $IATT Service Type M " ~. ..,,-' '<~~,!i_ ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If checked you are required to provide a copy of this form to your employee. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State iaw against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3. * ,RePOltilfg tllG r-ayJcrte/Ddtt of 'vVitl.I,Uldil,g. '/OU lIltlS! I.=I-'Olt tile paydatc!datc of vvitltltvldil.g nheh 3~IIJihg tIle, paylll{'llt. Tile p.ayJahddate v{ _vitl,l,oIJ;lIg is tile Jate on nl.id. ilJlIVUllt vvd5 yy;t1.I,eld (10111 tile L111t-'lvyee's yy.!agC3. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4,' Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See 119 below) 5, Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S ID: 4414817200 EMPLOYEE'S/OBUGOR'S NAME: CLARK, STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6, Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7, Liability: If you fail to withhold income as the OrderINotice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania Stale law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8, Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding, Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governS. 9,' Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S,C, 91673 (b)1; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income ieft after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. 10. 'NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. Requesting Agency: DOMESTIC RELATIONS SECTION 13 N HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by teiephone at (717) 240-6225 or by FAX at (717) 240-6248 or by Internet @ Page 2 of 2 Form EN-028 Worker 10 $IATT Service Type M OMB No,; Q970-0154 Expiration Date: 12/31/00 ;~ I ~ _ ',~." "''''''''-=~~': ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 27110305(oZ(~f Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 32881993 $ 0.00 Child(ren)'s Name(s): JOSHUA B. CLARK 116liouMilS!."ilililllllk, DOB ::'}"}':i(":'("'(}':';""(}('::}:(,":('/'i;"};'~~,~,[,~~~~ dl;~~~~~:J:;~~~;:;:~~i;:~;~~~;~;;;~:~~il~i;:~;"":"",(ii'" identified above in any health insurance coverage available through the employee's/obligor's employment PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment Addendum Service Type M OMB No.: 097(}'01~4 Expiration Date: 12131/00 31210346~ifO~!1( PACSES Case Number Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 01~CIVIL $ 0.00 Child(ren)'s Name(s): DOB d'li~~:~~:~~;~~~;:;:~~;;:~";~:~~~li;~:~~:I~(;:~;"."',',",," , identified above in any health insurance coverage available through the employee's/obligor's employment PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment Form EN-028 Worker 10 $IATT [~ ~.@l~,~!'bJt'lil",#&lI~~iII'&<lliOffi..'8<t;k'~fillW-_\"""j"'>>":""iciki'~'4M&>;U"~ol!i"~"""""'"'"''''''"....W'""''~~'''''." - ,~ ~ - ~ ^' ~? "'""~'"__~ _, ,~ J, , . '.r,.^,~",,~i ^" " ~.. , ~ ",.., ",,-~ C-) 0 0 C -n ;,:.... (n ""() \-"1 rn " '"(J ~ ~~ r...,) ", ~- ...--.! Cf~ !"-; -~ , ~ "-.:1 -- ~U ~...'. , '::<:- f~" ~_--i'~ ,-') '-,) 0 ri'! y~ C~ "', ::::=:t r~; .<-.., Cl ~ ::< .-J .,.."..... I:,j " !; r I: I' t' Ii Ii f\ ~ ~ '" _ > ~ " J -"", , " '1'-'=.1,,,:; In the Court of Common Pleas of CUMBERLAND County, Peunsylvania DOMESTIC RELATIONS SECTION KRISTI J. CLARK ) Docket Number 01-762 CIVIL Plaintiff ) vs. ) PACSES Case Number 312103462/030671 STEVEN B. CLARK ) Defendant ) Other State ID Number Order AND NOW to wit, this OCTOBER 10, 2001 it is hereby Ordered that: THE ORDER OF AUGUST 13, 2001 IS AMENDED IN THAT PLAINTIFF IS TO MAINTAIN MEDICAL INSURANCE FOR HERSELF. BY THE COURT: DRO: RJ Shadday xc; pl;tlntiff defeIrlant Jane Adams, Esquire Lindsay Baird. Esquire ~. A 4- Ke~ Hess JUDGE Service Type M Form OE-520 Worker ID 21005 iiilf -~ I!U" I' ~~\'1l!.~~.i;;f.I!j"!c'"tili"I!it~<i:f$6iA'>01iliOOiF':d"",o.illi;Ii;;I:0.;j-~~llr\llil ""'...."'''".~1i':JlIjttl!~~~~'IliWJlII" t [ I I , , i I I r i I i I I 1" (') c:> 0 C -" s: 0 '.:;j -Ow, n m" ..... ,,,:::;-1'1 Z:r:' .1;:::::: , z~ ~g9 ge..z: N 96 r::o <: -0 -"j,; ~o ::JI; 1'-)11 ;- ?5 >8 ~ 15m ~ U1 s;! :J:l U1 -< , ~'F';~ . ,"-,'," '~'1! o~ ,.,,~=~_ - ~ ': -'.~ ~, '.. ~.I _" _.. '_."_ ,0, ~J ,," _,H" ',,~. _I " . , -' "~ , "', '>-- ,~ , - -',""--<"^" ,-- - , " 1 __~ ~'" - '. ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsvlvania Co.lCity/Dist. of CUMBERLAND Date of Order/Notice 10/15/01 Court/Case Number (See Addendum for case summary) 3) 21 03%.2 OI-lLod.- CI\J II 1).3J(Pil @Original Order/Notice o Amended Order/Notice o Terminate Order/Notice ) RE: CLARK, STEVEN B. c2 7 I I 0 ~05 S l Employee/Obligor's Name (Last, First, Mil ) 441-48-1720 _::::S;:;\ 9; 5 cr,::> ) Employee/Obligor's Social Security Number ) 2901100703 .3) AI I ::7. lJ'X' ) Employee/Obligor's Case Identifier ) (See Addendum for plaintiH names assoaated with cases on attachmenV ) Custodial Parent's Name (Last, First, Ml) ) EmployerlWithholder's Federal EIN Number HENRY'S SEAFOOD INC EmployerlWithholder's Name PO BOX 164 EmployerlWithholder's Address WRIGHTSVILLE PA 17368-0164 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA nON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 1,609.31 per month in current support $ 173.00 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in medical support $ 0.00 per month for genetic test costs $ per month in other (specify) for a total of $ 1,782.31 per month to be forwarded to payee below. , You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 411.30 per weekly pay period. $ 822.60 per biweekly pay period (every two weeks). $ 891.16 per semimonthly pay period (twice a month). $ 1.782.31 per monthly pay period. REMITTANCE INFORMA nON: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydateldate of withholding. You are entitled to deduct a fee to defray the cost of Withholding. Refer to the laws governing the work state of your employee for the the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on pg. 2). If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCOU Send check to: Pennsylvania SCOU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: Date of Order: OCT 1 6 2001 ~. A. 4.. ./ SelVice Type M OMB No.: 0970.0154 Expiration Date: 12/31/00 Form EN-028 Worker ID $IATT "' .-. """,,,-' ~', <"0 - -~""- , ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS D If checked you are required to provide a copy of this form to your employee. 1, Priority: Withholding under this Order/Notice has priority over any other iegal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding, You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Rt....ultillg tl.<;;; l^a)date-/DQtt uf'vVitl.l.uldillg. You II lUst Ie..polt t1.<;;; pa)'dak/Jatt of vvitl.l.uldihg nIl..,.. ;,d.dillg lL<;;; pa)'llIc"l. TLe pa)'datefJatt uf vvitl.l.oIJ;..g is tllG datt Oil nl.id. ahloullt vvd;, nitlllleld NUlll tile elll/:,Iu)'<;;;<;;;';, vvag6;,. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.' Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support OrderlNotices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S ID: 2324908340 EMPLOYEE'S/OBLlGOWS NAME: CLARK, STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7, Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs, 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.' Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S,c. 91673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxesi and Medicare taxes. 10. 'NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. Requesting Agency: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.o.. BaX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (71 7) 240-6225 or by FAX at (717\ 240-6248 or by Internet @ Page 2 of 2 Form EN-028 Worker ID $IATT Service Type M OMBNo.:0970-0154 Expiration Date: 12/31/00 " , ~, ,,' l,; , ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 271103055 Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 32881993 $ 1,433.45 Chi/d(ren)'s Name(s): DaB ~g~:ilr~;ia~~ )'..',ir:i...,\\..'..'.....:.'.,'..,~~~.i~~~~ PACSES Case Number 312103462 Plaintiff Name KRIST I J. CLARK Docket Attachment Amount 01=7"62CIVIL $ 348.86 Child(ren)'s Name(s): DaB 'bl~~~:~~:d,;~~~r:;~~~i;~~;~~~r~II;~~~~il~;;~~;....,.}ii.'.' identified above in any health insurance coverage available through the employee's/obligor's employment. bl;~~~~~~~:;~~~;e..;:~~i;:X;~..:~r~il..;~::~iIJ(;:~;....'.,..',' identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DaB Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DaB o If checked, you are required to emollthe chi/d(ren) identified above in any health insurance coverage avai/able through the employee's/obligor's employment. o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Chi/d(ren)'s Name(s): DaB Docket Attachment Amount $ 0.00 Chi/d(ren)'s Name(s): DaB 'd:i~~~~~~~:;~~~;~;~~~i;:~;~.;~;~il;~~~~il~;;:~;..,..i\\..,.... identified above in any health insurance coverage available through the employee's/obligor's employment. o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee'slobligor's employment. Addendum Form EN-028 Worker ID $IATT Service Type M OMB No.: 0970.0154 Expiration Date: 12/31/00 " ~ ~iij'!L~,,,wilg~;-~-;:'~lilW<h>l;';~'~;.W'~Jdg,'",,';<f!t--"1',',%A;~~11',{;;olf.WW);j-l;""".Ml~~',,,,",JiiI';" ~'" I '~i\i$!I!iii'.&;ij~IL~' ~,,,,~_.... ~!! II , " 'I il ii '! i I I I :1 rl ,i I, 'I I I I 0 0 0 c " <'" 0 -Om .... (""") ,.. L:P rn -I !;1_:IJ ___Xi r- 2t;;" "om SQ~i -.l :;::to 06 ~o -0 ..=i )>0 T~ :::: 0 20 2m )>C - 0 ~ ., ~ N .r:- -< ~ ,i f\l~ "I .. ~ KRIST! J. CLARK, Plaintiff v. STEVEN Boo CLARK, Defendant - , - ~"' ,- ~~ ~ '''1- -", ~rL~ ." ; IN TIIE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : DOCKET NO. 328 S 1993 ; P ACSES Case Number 271103055/21208 : 01-762 CIVIL (APL) PRAECIPE FOR ENTRY OF APPEARANCE To: Prothonotary Kindly enter my appearance on behalf of Steven B. Clark, Defendant, in the above matter. Dated: November 28,2001 ~ lli';;..~'C_ ., -llJr!ilIliltt1!IiiJIl!~iii\<U"'~ 'rttilOO~~~j1llii~1J~U'#~ito'Mlo.diMilil'~^"''Y'- 1iJll p-'-~, , 'Iii.UI-1T < "~I '-I Ii ~I " II 'I II I' [1 [I , , II 11 " :1 II " 1 I I , I Ii ,I Ii ~ il I I !i ;1 I I (') 0 c s: "CO"'" -orD ,S n1fi"; ..c ..,.~ ~."" N z.' (f) '"]:' co ,~ "< -', , (,') .c , !<,O -0 " :".'\'.; )> , (') ZO ,;-;-" -=c' t:'? 7:::;;T", )>c::: ,~ d Z 01 ::0 :.t (,J;) '-< ~ "~-"'-~"""UI"'.""-'.1llIa<l~~""~I~='~. "h~"""",,,,,_...~~~~.~ ~, .~_.~ '""~ .~'l!!llli~~'-~Y~;i!)~1i '...) 4"'oj' '- Eri\pI6y~r?Wi,hltolder'sFederal EIN Number Hitm/('s..SllAFOOD INC E~~1i!Vi'~ill\lf61~ers'Name pQLB0Jt.164 En)~lo\,!!ilWilhholder's Address wRIGHTSVILLE PA 17368-0164 , ORDERlNOTI{:EJO W"IIHHO,L,D INCOME FOR S,UPPORT , , })Kf, 30..'(.$ ft(rj3 , S~teito~manwealthof penqsylvania ~ /~7fr~3{}5~. ' C?/C1ty!lDist. of CUMBER~ , . '-lJI(. &//# '{ 1JKI~f/l&~ {!f {/I(.. DNe of Order/Notice 12/17/01 ,,/lk.r.fr ..s,IJI03 t/&} CaurtlCas,e Number (See Addendum for case sunimary) Pt<.. ' ~&, 71 ) RE: C4AR~.STEVEN B. ) Employt!!~Obligor's'Nam'e '(last, FirSt, MI) ) 441-4ie.172iO ) Emplo~"IObll~6r's ~ocial Security Number ) 2901io0703 ) EmployeWOhligo.r's Case Identifier ) (See AriiJfilriimr.tor plaintiff names assodated with, ""ses QR at(achmenO ) Custodial Parent's Name (last, First, MI) ) o Original Order/Notice @ Amended Order/Notice o Terminate Order/Notice See Addendum ,for dependent names and birth 'elates ~ociated with cases on attachment. O/~.DER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBER~ County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not isslJed by your State. $ 1,860.45 per month in current support $ 173.00 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in medical support $ 0.00 permonth for genetic test costs $ per month in other (specify) for a total of $ 2,033.45 per month to be forwarded to payee. below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the foliowing to determine how much to withhold: $ 469.26 per weekly pay period. ' $ 938.52 per biweekly pay period (every two weeks). $, 1.016.73 per semimonthly pay period (twice a month). $, 2.033. 45 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later thaI) the first pay period occur~i!lg, ten(10) working days after the date of this Order/Notice. Send payment within seven (7) working days of thepaydateldate of withholding. You are entitled to deduct a fee to defray the cost of witnholding. Refer to the laws governing the work state of your employee for the the allowable amount. The total withheldqrnount, and your fee, cannot exceed 55% of the employee's! obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See ,#9 on pg. 2). If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDUl Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA seou Send check to: Pennsylvania seou, P.O. Box 69112, Harrisburg, Pa 17106.9112 , IN ADDITION, PA YMENTS MUST INCLUDHHE DEFENDANT'S NAME AND THE PACSES MfMI1ER lD(shown above as th~EmployeefQbligor'sCaseldentifier) OR SOCIAL SfCURI'fY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: Date of Order: DEe 1 8 ?n01 I("E;WA./~' ~ AL JU 06>0 Form EN-028 Worker 10 $IATT SelVice Type M MlULED 1~/f-DI OMBNo.:0970-0154 EKpiration Date: 12/31/00 ~ J"l:itd"I~,(', ilj'1.~.J~hLh~>" ,,_-'- " .-, ,'-_:..-'-':-~"' ' '!:-,-.>, , -', 0'-) "_""""-'" ,.: __";,,:,'-,~,, ,",;:'!i;ji!!,IJiilii.'~,l;<tUf.cll~!liiffirk~'!~~UlUk,~,b_Eht;i'4-:'.c~.""e1~,,",il-'''''h!,",,,-=-~;J,<I'ilJ!iI'A~!~~h1Jifuil~\\i!i~~"~ <;:; 1'1 -,--1 ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If checked you are required to provide a copy of this form to your employee. 1. Priority: Wit~holding under this Order/Notice has priority over any otherlegal process underState law against the same, inCome, Federal tax levies, in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting, agency listed below. 2, Combining Payments: You can combine withheld amounts from more than one employee/obligor's income ina sing,l~pa~l1\ent to each agenCy reqiJe~ting withholding. You must, however, separately identify the portion of the single paymentthat is attrib'l,lahJe ,I<:> each employee/obligor. 3.' ,Rer<>,ting,d,e Pa,d~lt>Da~ ufWitl,holdi"g. Yvu hlu't.epOltd,epa,date!date of ..itl,l,oldiloe "I,~n 'e',dillgd"S,;~it;~llt. Tli~' '. pa"ydatJaate of ;vitl',llUldII:l&,_i! t1.c;'..i8tc 01. l(vl,i,~I, an.OUl.l ..AS ~vitl,l,c;IJ hulll t11~ elllplo}'~~'! nagtl;S. You must complywIt.h:_:;th~',I;a,w~_,ohhe state olthe, eroployee's/oblig(),'s principal place of employment with respect to the time periods within which you must implem~rit the withholding order and forward the support payments, 4.' Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/oblig()r and you are unable to honor all support Order/Notices due to Federal or State withholding limitS, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5, Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S 10: 232~9083~O EMPLOYEE'S/OBLlGOR'S NAME: CLARK. STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of"the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging anemployee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which heor she is employed governs. 9.' Withholding limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.s.c. ~ 1673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE), ADWE is the net income left after making mandatory deductions such as: State, Federal, focaf taxes; Social Security taxes; and Medicare taxes. 10. ONOTE: If you or your agent are served with a copy of Ihis order in the state that issued the order, you are to follow the law of the state that iSsued this order with respect to these items. Requesting Agency: DOMESTIC RELATIONS SECTION 13 N.HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you Or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (71 71 240-6225 or by FAX at (7171 240-6248 Or by Internet @ Page 2 of 2 Form EN-028 Worker ID $IATT Service Type M OM8No.:0970.0154 Expi...lion Dale; 12/31/00 ~'"""",="-~~~./",l;,,r~"-''''''"~''''''=". ~ -<:"'........._<-~- .,. .. - .~ ""'..-wLlI....... '" o....d= -~ ~ ''''~liIl.flIIH~~~'''",,~-'''''FW.f!!i' ADDENDUM Summary of Cases on Attachment . '. _ . , ' J,~: _:: ;'.1 Defendant/Obligor: 271103055~~/~~ CLARK, STEVEN B. PACSES Case Number Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 328 S 1.993 $ 1,433.45 Child(ren)'s Name(s): DaB ;.jiiw~:,.',r&~:~ffi~~~~ :::::::::::::::::::::::;:::;:~::::::r:::;::::::~:::::~t:::;:::::::::~:::~:::r:t::: ::.::.:::::'.}:;:::: :;:':;'::'/::;~:.:~ ::::?)\:/.::.:::::::::::::::::::":::::;::;::,:',::::::::'::::'::':: :::::.:':: :::':.:::'..:::':":" o If checked, you are required to enroll the chil~:Hren) identified above in any health insurance coverage available through the employee's1obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DaB :-,.;.:...:.:.,,:"..:.::;:::::::::;::'::::::::~:::.):::~::::~:,...:::...:...:.,...:...:................, .....,.. .........,.............. .,.... ........... ......:...,., : ,.::. ::.: ". :, ,.:.: ,.:: .: ,.: ., ,.: .... . .Dli~h~~k~d,.y~~ .~~~.r~q~i;~dt;~~r;ilth~ .~hildir~~).. identified abOve in any h.ealth insurance coverage available through the employee's1obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DaB :.:.:.:.:.:.:...;.:.;.:.;.:.: . .............. .... ......................................... ..............................'.......................................... ............................ ... ............ [jif~h~~k~d;y;~~;~;~q~ir~d;;~~~;il;h~~hiid(;~~)....... .. . identified above in any health insurance coverage available through the employee's1obligor's employment SelVice Type M 312103462!3af; 7 I PACSES Case Number Plai"tiff Name KRISTI J. CLARK Docket Attachment Amount 01~CI~IL $ 600.00 Cliild(ren)'s Name(s): DaB :..di;~~~~~~~:~;~;;:;:~~;;:~;~~~;~;i~:~~;;~;~~i('.(...::....::.:... . identified above in any health insurance coverage available through the employee's1obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DaB ............... ........................ ................. . ................... ..................... ....... .. ......... .......... .....................................,...... Dif~h~~k~d, y;~~r~r~q~ir~d ;;~~r;ilth~ ~hild(r~~). identified above in any health insurance .coverage available through the employee's/obligor's employment. PACSES .Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DaB ................... ......................................-.........,..... .........................................,.............................................................. ................... .. ... . ..... ........................ .................................................. o If checked, you are required to enroll the child(ren) .identified above in any health insurance coverage available through the employee's/obligor's employment. Addendum Form EN-028 Worker 10 $IATT OMBNo.:0970-?154 Expiration Date: 12/31/00 ~ ...,,"'.,.--....>-"'--~. .;. ..-......~~- - . . - ~~~~b}~)Mljj_;;>."""b~W,;lli');;''i:i;J,k;'''!&;'li1ID,;~",,,o",,,-.''jV.''''~'";N.i'''''''''','i;;;;';;;',"'~ii~J.i!j~l,"",,''" ,",~""'.",",llii ~~" (') 0 0 C -o/!ii " 0 ---! iT, ~~ n j'-h~ i75~ N -TJr~n 0 :;;0 -<L (:),J.~ kG -u :'~'J ::(; ~o :Jil: ;::-:;..., :'';:0 5>0 w 6rn c z t:" ~ =< (J} -< f' 'li .,'! li ,-, [: ~:: ,i ":J'~iL_',,_' , "i"'""'t'--i~ . ~ .' , '-L_~~...i-;-' DR 30671 PACSES In 312103462 KRISTI J. CLARK, Plaintiff/Petitioner vs. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DOMESTIC RELATIONS SECTION : CIVIL ACTION - LAW STEVEN B.CLARK, Defendant/Respondent : NO. 01-762 CIVIL TERM ORDER OF COURT AND NOW, this 17th day of December, 2001, based upon the Court's determination that Petitioner's monthly net income/earning capacity is $N/A and Respondent's monthly net income/earning capacity is $NI A, it is hereby Ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit, $600.00 per month payable monthly as follows; $500.00 for alimony pendente lite and $100.00 on arrears. First payment due next modified wage attached payment. Arrears set at $1,885.87 as of December 17, 2001. The effective date of the order is November 1, 2001. This order is based upon the fact that a loan for plaintiff's vehicle has been paid in full and is no longer an obligation for the defendant. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all ofthe means as provided by 23 Pa.C.S.g3703. Further, if the Court finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and its discretion make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Said money to be turned over by the P A SCDU to: Kristi J Clark. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and mailed to: P A SCDU P.O. Box 69110 Harrisburg, P A 17106-911 0 Payments must include the defendant's PACSES Member Number or Social Security Number in order to be processed. Do not send cash by maiL ~ ' >! Li "<il.ii',: ............ .l. Unreimbursed medical expenses that exceed $250.00 annually are to be paid 86% by the respondent and 14% by petitioner. The petitioner is responsible to pay the first $250.00 annually in unreimbursed medical expenses. Petitioner to provide medical insurance coverage. Within thirty (30) days after the entry ofthis order, the Petitioner shall submit 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. This Order shall become final ten days after the mailing ofthe notice ofthe entry of the Order to the parties unless either party files a written demand with the Prothonotary for a hearing de novo before the Court. DRO: R l Shadday 1Y,I.\lifS;\J,R.~IJi;,s_~n.. 12:J 8-01 to:' < BY THE COURT, Petitioner Respondent Jane Adams, Esquire Lindsay Baird, Esquire 7'~~ Kevin 'A. Hess 1. """-' -', j -'--~ 1 _ -"'1-.aOOW1if~~ ,- t~~lI>liJi:;:~~>a~r.ij"'~li...Ml.!clM).at~;~ '~1.... ''';'_B~ ' !ilu;;rt".;\lljj~n ._" ..~ I;; "~-I I: t"; :,,! !'! :-i ": (,; " ~:: ::1 " [:, ",I , ~ t: ~1 , Ii 1'1 ~ , I (") 0 .. .fE 0 "Ocu 0 " cpm r<1 ~:Jj <J ;:'il/:;};J 2:C- N en,.....3 ~~j8 ::<(2: 0 ~o ,-'" , ~o ""0 :"~6 :x (~;; ,$0 ~ ~ Orn :::- );! O"l ;:n --< ~, ' ~ ,-, , '~- , - , iitfri~ ORDER/NOTICE TO WITHHOlD INCOME FOR SUPPORT lJld 3~r;.,g /fCi3 State Commonwealth of Pennsvlvania /J.JI!.~E( d- 7//03055" Co.lCity/Oist. of CUMBERLAND D-e J;2/2bt Oate of Order/Notice 01/09/02 Jlfl CJI-1!P;;.(!(illL- Court/Ca5e Number (See Addendum for case summary) ;J~..3/,;z/ () ?it/&:? JVc .:JO& 7 ( ) RE: CLARK, STEVEN B. ) Employee/Obligor's Name (last, Firstl Mil ) 441-48-1720 ) Employee/Obligor's Social Security Number ) 2901100703 ) Employee/Obligor's Case Identifier ) (See Addendum for plaintiff names assodated with cases on attachment) ) Custodial Parent's Name (Lastl First, Mf) ) o Original Order/Notice @ Amended Order/Notice o Terminate Order/Notice EmployerlWithholder's Federal EIN Number HENRY'S SEAFOOD INC EmployerlWithholder's Name PO BOX 164 EmployerlWithholder's Address WRIGHTSVILLE PA 17368-0164 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA nON: Thi5 is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 1,507.56 per month in current support $ 173.00 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in medical support $ 0.00 per month for genetic test costs $ per month in other (specify) for a total of $ 1,680.56 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered 5upport payment cycle, use the following to determine how much to withhold: $ 3B7. 82 per weekly pay period. $ 775.64 per biweekly pay period (every two weeks). $ 840 28 per semimonthly pay period (twice a month). $ 1. 6BO. 56 per monthly pay period. REMITTANCE INFORMA nON: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's! obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on pg. 2). If remitting by EFT/EOI, please call Pennsylvania State Collections and Oisbursement Unit (SCOU) Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106.9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: Oate of Order: JAM 1 () 2002 ~. /<@//~A _ f!tEC;S ~4.. SelVice Type M ~BNO.:0970-01S4 / ....If) .lid- Expiration Date: 12/31/00 c7'UD&G Form EN-028 Worker 10 $IATT "." ~_"-c" IL:.1 ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If checked you are required to provide a copy of this form to your employee. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Rt:.poltil'8 tL~ PaydarelDare o('NitlflloIJ;l.g. '/01:. IlItlst "=polttlle j...a.ydare!Jare o( nitlflfoIJ;f15 nL~I, ;,elldil,511Ie Pa,1I11e11t. Till. pttyJctb::JdAtf:. of nitl:,I,vldillg ;;, tile dAte vI. nl,;....L alllotllll nas n;llflleld (lOin tll(. clllploycc/:!' nage~. You must comply with the law of the state of the employee's1obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S ID: 2324908340 EMPLOYEE'S/OBLlCOR'S NAME: CLARK. STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from empioyment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.' Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.c. ~1673 (b)1; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. 10. 'NOTE: If you or your agent are selVed with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with resped to these items. Requesting Agency: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contad WAGE ATTACHMENT UNIT by telephone at (71?) 240-6225 or by FAX at (71?) 240-1i248 or by Internet @ Page 2 of 2 Form EN-028 Worker 10 $IATT SelVice Type M OMB No,: 0970-0154 Expiration Date: 12/31/00 . '"',, , '.;,~, ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 271103055 I.2rJ-O'( Plaintiff Name (<> KRISTI J. CLARK Docket Attachment Amount 32s-s:L993 $ 1,062.56 Child(ren)'s Name(s): JOSHUA B. CLARK ddltlJi.im,Il/6mlt DOB ;:,.::;...;, "..,::..,;::;::: "...:/:;.;:.;:;::...:...::.,., .,:i.. ;..~:~u.i~~~.i Efii~~~~~;~;;~~~;;~';;~~i;:j;;~~;~;I'..;~~~~il~(;:~;' c.,.."... identified above in any health insurance coverage available through the employee's1obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ....",..............,..,....,.. ::,::':~:":,'/,'~:::.;;:~';~':;'::,':' ;:':: ::",:", ,', " PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB El'li~~~~~!~:;~~.~;~;~~~i;:~;~:~;~ll:~:~~:l~(;:~i.'.....,.,...,.. .,....,...... identified above in any health insurance coverage available through the employee's/obligor's employment. Addendum SelVice Type M OMB No.: 0970-0154 Expiration Date: 12/31/00 PACSES Case Number 312103462/304-71 Plaintiff Name KRI STI J. CLARK Docket Attachment Amount 01~CIVIL $ 618.00 Child(ren)'s Name(s): DOB "tS;;~~~~~:~,~~~;;~;:~~i;~~;~~~;~ii;~~;;~.~.;ld~;~~;"'>i..;...".. identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB .."...... ...... ,;";(";",::::"",,,, o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's1obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s}: DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's1obligor's employment. Form EN-028 Worker 10 $IATT ., ~-::.::~;-- ';Jl~iIlilllilii!i<<.m~~~&il!j~ii-Jii;l103,r4;1,r.i!.Jir~_ti~1~;;,lJi~4i;,:~T~tJ:~~l(fj'~''''''"'_il'MIl _~~.~=~,....~....J-r ~- o c ~W (J) r-., ~eS ~E; c 2: =< ,",' I I I '1 I! " ,I 'I I I I ., Ii II I 'I II I !I i-I I, II 'I i,1 " II II I ,I !I I, II I a N S- f"'" ;:;: n -/'j ::cJ ;;g 't? ;.r, -~: ~;-'! . ~, ....."7 ') i ~':::; C) ~r{ _.~ ?o -< -- , =..'~-,-..:." J:o' fMr~1l'Ii'1'" .. -f '~ DR 30671 PACSES 312103462 KRISTI J. CLARK PlilintifflPetitioner vs. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA DOMESTIC RELATIONS SECTION CIVIL ACTION - LAW STEVEN B. CLARK, Defendant/Respondent NO. 01-762 CIVIL TERM ORDER OF COURT AND NOW, this 9th day of January, 2002, based upon the Court's determination that Petitioner's monthly net income/earning capacity is $847.62 and Respondent's montWy net income/earning capacity is $3,562.91, it is hereby Ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit, $618.00 per month payable weekly as follows; $119.54 for alimony pendente lite and $23.07 on arrears. First payment due with next modified wage attachment payment. Arrears set at $1,543.80 as ofJanuary 9, 2002. The effective date of the order is November 14, 2001. Defendant is to directly pay plaintiff forty two percent (42%) of any and all net bonuses within five days upon receipt of the bonus. Defendant is to send verification of said bonus and payment to the Domestic Relations Office within the same five days. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.s 3703. Further, if the Court finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and its discretion make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Said money to be turned over by the P A SCDU to: Kristi 1. Clark. Payments must be made by check or money order. All checks and money orders must be made payable to P A SCDU and mailed to: P A SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the defendant's P ACSES Member Number or Social Security Number in order to be processed. Do not send cash by maiL l'd , ~ ~ . ,I '" ,- ..~ ~~-""" - ~i ""'''' .. ',,,,_...\ ." (\ Unreimbursed medical expenses that exceed $250.00 annually are to be paid 81% by the respondent and 19% by petitioner. The petitioner is responsible to pay the first $250.00 annually in unreimbursed medical expenses. Petitioner to provide medical insurance coverage. Within thirty (30) days after the entry ofthis order, the Petitioner shall submit written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at a minimum, of: 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage contract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms. This Order shall become final ten days after the mailing of the notice of the entry of the Order to the parties unless either party files a written demand with the Prothonotary for a hearing de novo before the Court. DRO: R. J. Shadday Mailed copies on 1-10-02 to: < BY THE COURT, Petitioner Respondent Jane Adams, Esquire Lindsay Baird, Esqnire 7' A- 4.. Kevin A. Hess 1. ~~~,~~jijj!lili,WtJ.tffiili,J;;;'l'.w;;!~~tml.}il1l~l:t!J;;Ji.Jlllj!ifut~~,fH:;,~.i:""'lf!Jl~i4iiiJ:fu~"ol"~'/i!i~""""'''~ ~, ~ , ~ ~~". 0 .",_ ~,_~~ l J..,.,,~~ ,~< w "L ~, "r.ilf"'<->.--'''Ni~~~ilII" .-, ='-'~- -~,"-'-- -~,""-'"-~,' o S;; < -0'.- n'l~~~ Z:I.: zr ~(~: -.;:; ~S c 2: --< -< -~. ~.,,? "~ ~~~~ nr I-~ o r.-....' C") ~l ,- J:;:'.. .~ :-n -~;~ij -0 , ) - ~.:f, ~~~~ -1 ::;;:; ~, -< '!? 0' ~~ , n" ,- ~ " ORDfR/NOT/.off TO WITHHOLD INCOME FOR SUPPORT Did, 3$i.'? s 11'13 . . . State Commonwealth of Pennsvlvania /Y]t! sE9 J2. '7/1 (! "3 0 ~ 0 Onglnal Order/NotIce Co.LCity/Oist. of CUMBERLAND 1;)/?" d-I d-D b" '~"""'."'.'''."!'F'.'''''';.'.'.'''.'.''.''''.';.''''.'.'(ff!f!i:....Q._ ~mended Order/Notice Oate of Order/Notice 04/26/ 02 _;:t~U?ii\8iW&'~:V;'<'i<U:I:Vi'terminate Order/Notice Court/Case Number (See Addendum for case summary) pJ9t!.<;f'> 3/;2/63'/0,d- 01( 5U., 7 1 ) RE, CLARK, STEVEN B. ) Employee/Obligor's Name (Last, First, Mil ) 44~-4S-1720 ) Employee/Obligors Social Security Number ) 290n00703 ) Employee/Obligor's Case Identifier ) (See Addendum for plaintiff names associated with cases on attachment) ) Custodial Parent's Name (Last, First, Mil ) EmployerlVVithholder's Federal EIN Number HENRY'S SEAFOOD INC EmployerMlithholder's Name PO BOX 164 EmployerNVithholder's Addres5 WRIGHTSVILLE PA 17368-0164 See Addendum for dependent names and birth dates aSiWciated with cases on attachment. ORDER INFORMA nON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERL.llliD County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's1obligor's income until further notice even if the Order/Notice is not issued by your State. $ 0.00 per month in current support $ 0.00 per month in past-due support Arrears 12 weeks or greater? Oyes <X> no $ 0.00 per month in medical support $ 0 . 00 per month for genetic test costs $ per month in other (specify) for a total of $ 0.00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 0 . 00 per weekly pay period. $ 0.00 per biweekly pay period (every two weeks). $ 0.00 per semimonthly pay period (twice a month). $ 0.00 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate!date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on pg. 2). If remitting by EFT/EDI, please call Pennsylvania State Collections and Oisbursement Unit (SCOU) Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER 10 (shown above as the EmployeelObligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: Oate of Order: 11AY 3 Z002 7' /<f11i1V Ie:), /..;-b<;. '-. ~4... SelVice Type M ~':'::",07'" ~ 11 ~D OMB No.: 0970-Q154 J'~,;,:'.r>f.~,,-~~ ':" '-!~Zk' ' E);plrationDate:12/31JOO ?- :J.o~ JU !::JtfC: Form EN-028 Worker 10 $IATT .~~ .~ .,",- -,"- ,-,. .-,,,::"" =< -" ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If checked you are required to provide a copy of this form to your employee. 1. Priority: Withholding underthis Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withhoiding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3. * Re!50ltiltg t11~ raydat~Date of\Nithholdi"g. YOtllllUst 1(!.!5oll tIle pAydAlefdate of nithl,oldil'5 vvl,el, selldil,g tile paYlllellt. TIre pa,dateldAte vi "itl,l,vldi!,g i, tI,e date on "I,ie!, a!noo!,t ,,", "itl,t,,,ld ~o!" t1,,, "!"plo,,,,', "ages. You must comply with the law of the state ofthe employee's/obligor'sprincipal place of employment with respect to the time periods within which you must rmplementthe withholding order and forward the support payments. 4.' Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor'sprincipal place of employment You must honor all Orders/Notices to the greatest extent possible: (See #9 below) S. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and retum a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S ID: 2324908;140 EMPLOYEE'S/OBLlGOR'S NAME: CLARK, STEVEN B. I;MPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW I;MPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsyivania State law governs unless the obligor is emplo~ed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligorfrom employment, refusing to employ, ortaking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law govems unless the obligor is employed in another State, in which case the law of the State in which he or she is employed goveJ11s. 9.' Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.5.C ~ 1673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. 10. 'NOTE: If you or your a,gent 'Ire selVed with a, copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. Requesting Agency: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISI F PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (71 7) 24D-6225 or by FAX at (717) 24D-6248 or by Internet @ Page 2 of 2 Form EN-028 Worker 10 $IATT SelVice Type M OMBNo,:097Q-0154 Expiration Date: 12/31100 l!!ililllilliil\l;Illi~J1r&illfb'dMli~"Li'''AoldJ\,j-ij;o*;e1itt<ill'''ilillffi"Wi;,;',''''r~;.il<'~\:.;""" ""i""-~}~"";odn"bill!b.;:.,,,,,r:~d-t,:a;ID<~.,.,l"Mi";/.< "'''''.'''''''''''-m1iIi~I.BjiWi1ilil$;!b'ilY.b.J<ill~JW~iliiiI.o~~lW~'~ ~, I, ., < ~ " ~ . .' n_ - . ~ ~--'~i'''''''''''- .... ':rf ~ ~ C c ~ "Z 0) r& ~~ '. , . ~_o n" ,-". , ""'"'-" KRISTI J. CLARK, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA vs :NO.01-762 CIVIL TERM STEVEN B. CLARK, Defendant :IN DIVORCE AFFIDAVIT OF CONSENT, ACCEPTANCE OF SERVICE AND WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF DIVORCE DECREE UNDER SECTION 3301(C) OF THE DIVORCE CODE 1. A complaint in divorce under Section 3301 (C) of the Divorce Code was filed on February 7, 2001. 2. 06fendant acknowledged receipt and accepted service of the Complaint on February 17,2001. ," 3. Tn~.marriage of the Plaintiff and Defendant is irretrievably broken and ninety days nave elapsedlrom the date of the filing of tne Complaint. 4. I consent to the entry of a final decree in divorce without notice. 5. 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. 6. 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. 7. I have been advised of the availability of marriage counseling and understand that I may request that the Court require counseling. I do not request that the Court require counseling. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. Date: \ \ - \ ~- 0), c1Jc efendant . , ~\J:~~;.wi~~H'~;;;e~~"':Skh"'1","'+~;!iI:~i.li!!~;Et~,*I";l""'JM&!&;;i~-\tlt:k:1W.",',,,,,;;;i!;""'",";!i',"ljlli"~'HH,cll~"~#~~~~~lrllililili!l ~w~h-~l.lll > ~ ,- ',I , ~. 0 0 IV ..." ;;:::. Z -< !~ 0 ::C-n < rnp :JJ N ~}i9 .~~ N Sig 120 .." :l:-H 3tg ::J:: <;)0 Zm )>~ - 8 .. .0 ~ :;! U1 , . , ~ " l'" , ->~ ",...""~,, "~,j-,,-,. (',,; tJf,"-I""" ~~,J\ KRISTI J. CLARK, Plaintiff v. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA :NO.01-762 CIVIL TERM STEVEN B. CLARK, Defendant :IN DIVORCE AFFIDAVIT OF CONSENT, ACCEPTANCE OF SERVICE AND WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF DIVORCE DECREE UNDER SECTION 3301(C) OF THE DIVORCE CODE 1. A complaint in divorce under Section 3301 (C) of the Divorce Code was filed on February 7, 2001. 2. Defendant acknowledged receipt and accepted selVice of the Complaint on February 17,2001. 3. The marriage of the Plaintiff and Defendant is irretrievably broken and ninety days have elapsed from the date of the filing of the Complaint. 4. I consent to the entry of a final decree in divorce without notice. 5. 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. 6. 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 . 7. I have been advised of the availability of marriage counseling and understand that I may request that the Court require counseling. I do not request that the Court require counseling. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. Date: /) /If'~L ( I ~6~ Steven B. Clark, Defendant &1w' (:~'f;.fI_'"';'.'"'~ltJlAAlij~,al"<1r>~mThf'.J~~~I;jt;,-"M~i'0'!li",,-,<-j$1j'-,lCl"i'.~.;j'"),,jli!ikEt:-!S';llM'~l<~I'''~'''''''''' N f{, ~ '"-~ -~ "_~_~,, "J..___. -~ ,~ ~>:lill--~~ , - -~"- ~ 0 0 N ..0 % ..., t~ C> :I"T1 ..;: t:t'1~ :n N O~ enS:;; N :D ~e () -0 :J;l:::fi ~g ::It 0(') 15m Z C> ~ =< (J'l '< r~'- """_ " ~~ Ii I;' ~ f: I , I [.: ~. ~A ". " '~ '" ",,'" ,- "_ -d'-' "'", "" "J PROPERTY SETTLEMENT AGREEMENT THIS IS AN AGREEMENT made this .Ml!dday of November, 2002, by and between Steven B. Clark, of 101 West Main Street, Apartment 6, Mt. Joy, Lancaster County, Pennsylvania, (hereinafter referred to as Husband) and Kristi 1. Clark, of 53 Brian Drive, Carlisle, Cumberland County, Pennsylvania, (hereinafter referred to as Wife). WHEREAS, Husband and Wife were married on April 15, 1982, in Cleveland County; Oklahoma, and WHEREAS, various differences have arisen between Husband and Wife, whereby they have been living separate and apart since February 8, 1999; and WHEREAS, the parties have agreed to maintain separate and permanent domiciles and to live apart from each other; and WHEREAS, the parties desire to enter into an amicable settlement to provide for all of the property rights of the parties and to dispose of the rights and obligations of each to the other in respect to support, maintenance, alimony, counsel fees, equitable distribution, and all other rights and obligations under the Divorce Code of 1980, as amended, and it is the intention and agreement of the parties that this Agreement be a full, complete and final settlement of all of those rights and obligations under said Divorce Code; and NOW, THEREFORE, for and in exchange of mutual considerations, and intending to be bound by the provisions hereof, the parties agree that their recitals form a part of this Agreement and waive any right to counseling under the Divorce Code of 1980, as amended, and right to counsel fees, costs, alimony, support, maintenance, and any other rights under the said Divorce Code not provided for herein and agree as follows: "- 1. SEPARATION. The parties agree that it shall be lawful for each party, at all times hereafter, to live separate and apart from the other, at such place or places as he or she may, from time-to-time, choose or deem fit. Each party shall be free from interference, authority or contact by the other, as fully as if he or she were single and unmarried, except as may be necessary to carry out the provisions of this Agreement and as may be necessary to exchange information that pertains to the parties' minor child. Neither party shall molest the other or attempt to endeavor to molest the other, nor compel the other to cohabit with the other, or in any way harass or malign the other, nor in any way interfere with the peaceful existence, separate and apart, from the other. 1 . ;,~ - '-~', , J ' " ", lL!-' , '-'~,,~_ f 2. REAL ESTATE. Husband and Wife jointly owned the marital residence located at 1873 Holly Pike, Carlisle, Pennsylvania. The marital residence was sold, the mortgage obligation removed and the proceeds divided between the parties as mutually agreed. 3. AUTOMOBILES. Husband and Wife shall have as his or her sole and exclusive property, title to and possession of any vehicle in that party's name as of the signing of this Agreement. Each party shall indemnify and hold the other harmless from and liability on any loan encumbering the vehicle, cost of repairs, maintenance, registration, insurance and/or inspection of the vehicle which each is has as his or her sole and exclusive property. 4. PERSONAL PROPERTY. The parties have divided or have agreed to a division of their personal property which includes bank accounts, certificates of deposit, life insurance policies, jewelry, clothing, furniture and other personal items. After the aforesaid division of the personal property is complete, any and all property in the possession of Husband shall be his sole and separate property. Any and all property in the possession of Wife shall be her sole and separate property. Each party forever renounces whatever claims he/she may have with respect to the property which the other is taking. Each party understands that he/she has no right or claim to any property acquired by the other after the signing of this Agreement. 5. PENSIONIRETIREMENT PLANS. Wife hereby releases any and all claims or demands she may have on Husband's pension or retirement plans. Husband hereby releases any and all claims or demands he may have on Wife's pension or retirement plans. 6. DEBTS. The parties represent and warrant to each other that neither has incurred any other debts nor made any other contracts for which the other or his/her estate may be liable, from date of separation forward. Neither party shall contract nor incur any debt or liability for which the other or his/her property or estate might be responsible and agrees to indemnify the other from any claims made against the other because of debts/obligations not incurred by the other. 7. ALIMONY, ALIMONY PENDENTE LITE. Alimony paid by Husband to Wife is addressed in a January 9, 2002, Order of Court, docketed at No. 01-762 Civil Term, DR No. 30671, PACSES No. 312103462. Husband shall pay the current amount until June of 2006. 8. EFFECTIVE DATE. The effective date of this Agreement shall be the date of execution by the parties if they had each executed the Agreement on the same date. Otherwise, the execution date of this Agreement shall be defined as the date of execution by the party last executing this Agreement. 9. DIVORCE. A Complaint in Divorce, claiming that the marriage is irretrievably broken under the no-fault mutual consent provision of Section 3301@ of the Pennsylvania Divorce Code, was filed on February 7, 2001 in the Court of Common Pleas for Cumberland County at 2 -",,= . ';.-,';,1.;,' ""Nl"' ,..,1 ,~' '''''''-''"'~i l Docket No. 01-762 Civil Term. Both parties agree to execute any and all affidavits or other documents necessary for the parties to obtain an absolute divorce pursuant to Sections 330 ll1J of the Divorce Code including waiver of all rights to request Court ordered counseling. 10. INCORPORATION INTO DECREE. Should a decree, judgment or order of separation or divorce be obtained by either of the parties in this or any other state, country, or jurisdiction, each of the parties hereby consents and agrees that this Agreement and all of its covenants shall not be affected in any way by any such separation or divorce; and that nothing in any such decree, judgment, order or further modification and revision thereof shall alter, amend or vary any term of this Agreement, whether or not either or both of the parties shall remarry, it being understood by and between the parties hereto that this Agreement shall survive and shall not be merged into any decree, judgment, or order of divorce or separation. It is specifically agreed, however, that a copy of this Agreement or the substance of the provisions thereof, may be incorporated by reference into any divorce, judgment or its decree. This incorporation, however, shall not be regarded as a merger, it being the specific intent of the parties to permit this Agreement to survive any judgment and to be forever binding and conclusive upon the parties. 11. MUTUAL RELEASE. Husband and Wife do hereby mutually remise, release, quit claim or forever discharge the other and the estate of such other, for all time to come, and for all purposes whatsoever, from any and all rights, title and interest, or claims in or against the estate of such other, of whatever nature and wherever situate, which he or she now has or at anytime hereafter may have against such other, the estate of such other or any part thereof, whether arising out of any former acts, contracts, engagements or liabilities of such other or by way of dower or curtesy of claims in the nature of dower or curtesy, or widow's or widower's rights, family exemption or similar allowance or under the intestate laws; or the right to take against the spouse's will; or the right to treat a lifetime conveyance by the other as testamentary or all or other rights of the surviving spouse to participate in a deceased spouse's estate, whether arising under the laws of Pennsylvania, any state, commonwealth or territory of the United States, or any other country or any right which either party may now have or at anytime hereafter have for past, present or future support or maintenance, alimony, alimony pendente lite, counsel fees, costs or expenses, whether arising as a result ofthe marital relation or otherwise, except and only except all rights and agreements and obligations of whatsoever nature arising or which may arise under this Agreement or for the breach of any provision thereof. It is the intention of Husband and Wife to give to each other by the execution of this Agreement a full, complete and general release with respect to any and all property of any kind or nature, real, personal or mixed, which the other now owns or may hereafter acquire, except and only except all rights and agreements and obligations of whatsoever nature arising or which may arise under this Agreement or for the breach of any provision thereof. 12. COUNSEL FEES. Each party individually covenants and agrees that he or she will individually assume the full and sole responsibility for legal expenses for his or her attorney and 3 " - h, .,-,; - - , ',-,-'- ", ""- "-"ii court costs in connection with any divorce action which may be brought by either party and shall make no claim against the other for such costs or fees, except for $518.00 which Husband agrees to pay on behalf of Wife to Wife's attorney. 13. ADDITIONAL INSTRUMENTS. Each of the parties shall, from time-to-time, at the request of the other, execute, acknowledge and deliver to the other party any and all further instruments or documents that may be reasonable required to give full force and effect to the provisions of this Agreement. 14. MODIFICATION OR WAIVER. A modification or waiver of any of the provisions of this Agreement shall be effective only if made in writing and executed with the same formality as this Agreement. The failure of either party to insist upon the strict performance of any of the provisions of this Agreement shall not be construed as a waiver of any subsequent default of the same or similar nature. 15. ENTIRE AGREEMENT. This Agreement contains the entire understanding of the parties and there are no representations, warranties, covenants or undertakings other than those expressly set forth herein. 16. SEPARATE PARAGRAPHS. It is specifically understood and agreed by and between the parties thereto that each paragraph hereof shall be deemed to be a separate and independent agreement. 17. BREACH. If either party breaches any provision of this Agreement, the other party shall have the right, at his or her election, to sue for damages for such breach or seek such other remedies or relief as may be available to him or her and the party breaching this Agreement shall be responsible for payment of legal fees and costs incurred by the other in enforcing the rights under this Agreement, or in seeking such other remedies or relief as may be available to him or her. 18. CONTROLLING LAW. This Agreement shall be construed under the laws of the Commonwealth of Pennsylvania. 19. INVALIDITY OF PROVISIONS. If any term, condition, clause or provision of this Agreement shall be determined or declared to be void or invalid in law or otherwise, then only that term, condition, clause or provision shall be stricken from this Agreement, and, in all other respects, this Agreement shall be valid and continue in full force, effect and operation. 20. BINDING NATURE. Except as otherwise set forth herein, this Agreement shall be binding and shall inure to the benefit of the parties hereto and their respective heirs, executors, administrators, successors and assigns. 4 ,,' L J.~"' - ,~-'. ",-..:a~1:1I!;: ....." . ......~ 'f', '.' \. IN WI1NESS WHEREOF, the parties have hereunto set their hands and seals the day and year first above written. WI1NESS ~V)~ Steven B. Clark '" _jti7t"1 O-"'"'~"''''''''''''ilNim''!4h''~.:I!i!!l&~~~!#lWN.1;i!i:",-':-;;:~.i:w~~:,"i:;d.!.i,.,.@\'''ilih<>M~IJliJlllilIl' ~ .. ,. '. ~~ =~"~,_ =~ """_ "eo_,. < ,'~'''", - _"N.~ ~_ ___I ,_, .,''"~ 1lII1liI~~,jm-"~""",-,",,I.._p' , ...,e, ~, ~,' _. __~w_ '-","- ~ "1!Ili!l:i~'" .,1' II ~ i I II II il I' () 0 () C fv .." s:: Z -l ""OUJ t:Jr:n C) m::2J ~- 4-_.-..., ,. gsc. N ~-c.f'-T1 -" ''-l _~nO ~ ;:$4 0.1- r"J ~~~ ~'- V ~O ::A ;1~ :IJ ~;!() )>0 Om c: z => i :::< 01:"" -< , ~- -~ ...., 'c" KRISTI J. CLARK, Plaintiff v. STEVEN B. CLARK, Defendant "~',_. ;.. '~-4 -,:,... , "-t".' "t, : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA :NO.01-762 CIVIL TERM :IN DIVORCE PRAECIPE TO TRANSMIT RECORD TO THE PROTHONOTARY: Transmit the record, together with the following information, to the Court for entry of a divorce decree: 1. Ground for Divorce: Irretrievable breakdown under Section 3301 (C) of the Divorce Code. 2. Date and manner of service of the Complaint: February 17, 2001, Certified Mail 3. Date of execution of the Affidavit of Consent required by Section 3301 (C) of the Divorce Code: By Plaintiff: November 18, 2002; by Defendant: November 19, 2002. 4. Related claims pending: None. 5. Date Plaintiff's Waiver of Notice in ~3301 (C) Divorce was filed with the Prothonotary: II-'?'.? . (J.;< Date Defendant's Waiver of Notice in ~3301 (C) Divorce was filed with the Prothonotary: II ,).;;. 'CJ.2.. ~ii ,-,-I ..', ';"':"'~:~!it-~~i1o"I01~;;ikmffiM.J;,,;~,~,Ml~~tUillilllj -~'., ~ ,<, "^ "' ,- ~ .J...lIIlil"> =~"W" ~,,~ "Ii:i. ':tt: " ~: " l: , ! I, g 0 9, N s:: ~ :::::1 "OlD rii~ ~m <: ::IJ N -nh~l ~.~ N :d9 ~O ,<0 -p x""1'j ~8 :x 00 2m >c - 8 .. ~ 0 ~ ,&:" . " ,,- -- _I ,"' c.'~' ^, ~'.^ ' II &,~i: . ~ ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsvlvania Co./City/Oist of CUMBERLAND Oate of Order/Notice 11/29/04 Tribunal/Case Number (See Addendum for case summary) o Original Order/Notice @ Amended Order/Notice o Terminate Order/Notice Employer/Withholder's Federal EIN Number RE: CLARK, STEVEN B. Employee/Obligor's Name (Last, first, Mil 441-48-1720 Employee/Obligor's Social Security Number 2901100703 Employee/Obligor's Case Identifier (See Addendum for plaintiH names associated with cases on attachment> Custodial Parent's Name (Last, First, MI) RITTER FOOD SERVICE PO BOX 720 MOUNT JOY PA 17552-0720 ]Xl 3~~ $ /193 j>1'/(!.(}E.S ,;L7/1{)3D6~ D;d, ,,2a)1- 7IP")- (! (/ PAeSf.. S, .31 il./03 y&, :J- See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. 8y law, you are required to deduct these amounts from the above-named employee's!obligor's income until further notice even if the Order/Notice is not issued by your State. $ 1,057.00permonth in current support $ 136.50 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in medical support $ 0 . 00 per month for genetic test costs $ per month in other (specify) for a total of $ 1,193.50 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 275.42 per weekly pay period. $ 550.85 per biweekly pay period (every two weeks). $ 596.75 per semimonthly pay period (twice a month). $ 1.193.50 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydatefdate of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount The total withheld amount, and your fee, cannot exceed S5% of the employee's! obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #10 on pg. 2). If remitting by EFT/EOI, please call Pennsylvania State Collections and Disbursement Unit (SCOU) Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAil. MAILED ~ BY THE COURT: . / NOV 3 0 200% ~ . .19. /-14. Oate of Order: ' ~ Kev~.~ SelVice Type M OMB No,; 0970-0154 Form EN-028 Worker 10 $IATT '.-l .~ ~~ ~ ;'.. ,',,- '" "',.-~,,' ~~'.; > ~~ "'; 't ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o dlf.checked youhare required to provide a copy of this form to your employee. If your employee works in a state that is Itterent from testate that issued this order, a copy must be provided to your employee even if the box is not checked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and lndian-owned businesses located on a reservation that choose to withhold in accordance with this notice. 2. Priority: Withholding under this OrderlNotice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 3. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employeeJobligor. 4. * R't'0Itilog t1,~ Pa,date'Date afWitl,1 ,oldi,'g. Ya" Inu;1lepall the pa,d.le.'d.le af "ilhholdilog "I,en selodil,g the pa,n,ent. TI,e pa.ydate!o&lL of vvit:\.l.old;llg ;5 'lLe date 011 vv\.;cL alllOullt vvaS vv;lLLeld flOlll 1:l.e elllplOye~'5 vvages. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 5. * Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unabie to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #10 below) 6. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this OrderlNotice to the Agency identified below. WITHHOLDER'S ID: 8593100023 EMPLOYEE'S/OBLlGOR'S NAME: ~MPLOYEE'S CASE IDENTIFIER: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: CLARK, STEVEN B. 2901100703 DATE OF SEPARATION: 7. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 8. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld irom the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law govems unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 10. * Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.s.c. ~1673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxeSi Social Security taxes; and Medicare taxes. 11. Additional Info: *NOTE: Ii you or your agent are selVed with a copy oi this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. Submitted By: DOMESTIC RELATIONS SECTION 13 ~. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 Form EN-028 Worker 10 $IATT SelVice Type M OMB No.: 097Q.01 54 . , " ,.,-. -~"" ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 271103055 Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 328 S 1993 $ 575.50 Child(ren)'s Name(s): DOB J()RDA!'1.S.,. c;LM.K ... ........... . ...............y...............9H/1U~? b;i~~~~t~~:;~~;;~;~~~i~d;~ enroll the childi;:~;............................... identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Pialntiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB D If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment Addendum SelVice Type M OMBNo.:0970-0154 PACSES Case Number 312103462 Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 01-762 CIVIL $ 618.00 Child(ren)'s Name(s): DOB dli~~:~~:~:~~~..;;:;~~i;~~;~:~;~il.i~~..~.~.;l~(~~;....\....... ..... . ...... identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's1obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment Form EN-028 Worker 10 $IATT , I " . - ,,,.hob-.;,.-,.",",,.,,,.."~-~"~;t'[&..~'!t,%;~h;:"~;fJ'jl:>E;?,a~,~liNIl;l;ktJ~w''''lliM~'lbl "," '<" .-,', '. "';~~~OO~~__~~, ~'~~"'lIln ~';r C: ,~- ~t t1-~ t~,i ~ - i 1j:LIlllI~-V~-b^-~j''' ~ ~, -(](;L.\ r11f'l Z':-;;~ ZC__< (t),:." ~<F"::I I2l_, :p::r:J ~t) "PC: ~ '-diL ,..., 0:;> c? .;::- ~ ~ <-" c::> ".111m. :1 " o ..n -4 ::r::n rtlr: :g'9 ()() -:!-'i'. 1-:0 Qc?, c{ ~ ~ ~i I ., I I 01 I, I' II [I " II i' II 'I I, " Ii ;1 II II ""'0 :s '-? Ul -I ~ STEVEN B. Employee/Obligor's Name (Last, First, Mil 441-48-1720 Employee/Obligor's Sodal Security Number 2901100703 Employee/Obligor's Case Identjfier (See Addendum for plaintiff names associat@l/ with cases on attachment) Gbstodial Parent's Name (Last, First, MI) ...- I . ~. ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania Co.lCity/Oist. of CUMBERLAND Oate of Order/Notice 02/03/05 Case Number (See Addendum for case summary) RE: CLARK, EmployerlWithholder's Federal EIN Number RITTER FOOD SERVICE PO BOX 720 MOUNT JOY PA 17552-0720 Dk) .3J)1' It /973 fJl1{!r;f'; ;2 7/ /()30 ')5'" \..0'.'..1. .'''-c. ..."._. .,.,. ""l) ,~:,.,+.... : {Jt tilL- ~~,::.:\~_~,~,.,,,_,"_pr.;:q;tr "",,~ ,0'+6.[ ~ d I ;;U 0 ~_y (, J- ,~ ~~."-~ ""., ..--- i. ~T' !~_t': o Original Order/Notice o Amended Order/Notice @ Terminate Order/Notice See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's!obligor's income until further notice even if the Order/Notice is not issued by your State. $ 0.00 per month in current support $ 0.00 per month in past-due support Arrears 12 weeks or greater? Qyes <X) no $ 0.00 per month in current and past-due medical support $ 0 . 00 per month for genetic test costs $ per month in other (specify) for a total of $ 0 . 00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 0.00 per weekly pay period. $ 0.00 per biweekly pay period (every two weeks). $ 0.00 per semimonthly pay period (twice a month). $ 0.00 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's! obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). If remitting by EFT/EOI, please call Pennsylvania State Collections and Oisbursement Unit (SCOU) Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. Oate of Order: FES - 4 2005 BY THE COURT: I<EU"J% SelVice Type M OMB No,; 0970-0154 19, ,,( VV ))&E Form EN-028 Worker 10 $IATT "'" '"' "'"'MJ!i~il\!:i:'~ t. ~, ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If!;hecked you are required to provide a copy of this form to your employee. lfyo~remployee works in a state that is ditterenffrom the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3. * Repv,l;"5 tll(. F' ayJatelDdh:: vfWaldlold;"g. \\.,u Illubll1::::tJOlllln:::: tJayJateldah:::: vf vy;t1lllvld;"5 VVllel1 :J~IIJ;llg llle tJaYlllelrl. TI,~ paydate!daL~ vf v'valll'lvIJ;Jlg;;, LI,~ date VII vvl,;d, alllvullt neb vvitl,I,~IJ hV1I1 tile ellltJlvyee's vva5t::::J. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.' Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honorall support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) S. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the Information requested and return a copy of this Order/Notice to the Agency identified below. THE EMPLOYEE/OBLIGOR NO LONGERWORKS FOR: 8593100023 EMPLOYEE'S/OBLlGOR'S NAME: .. C':LARK. STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed govems. 8. Anli-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, In which case the law of the State in which he or she is employed governs. 9.' Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.5.c. 91673 (b)l; or 2) the amounts allowed by the State ofthe employee's/obligor's principal place of employment. The Federallimil applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amoun15 allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amoun15 allowed under the law of the state that issued the order. 10. Additional Info: 'NOTE: If you or your agent are selVed with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11.Submitted By: If you or your employee/obligor have any questions, DOMESTIC RELATIONS SECTION contact WAGE ATTACHMENT UNIT 13 N. HANOVER ST by telephone at (717) 240-6225 or P.O. BOX 320 by FAX at (7171 240-6248 or CARLISLE PA 17013 by internet www.childsupport.state.pa.us Page 2 of 2 Form EN-028 Worker 10 $IATT SelVice Type M OMB No.: 0970-0154 ~~~q;"1l'''';~lt&b*,;i,,''''*'~itfl~o!.i'''~'''Eh,'9'' >,.,!>-_,'":,,,^-__,,".,;...~r: ""'-'E.b",:<H_""",,41~~il\!>~~il>lif.."'1!liillltilil!\fIIooI~iIiMlIi1l.il. S:b':~t-::::t~r-l-~~}t~~,~i -rf I Y ;11 ~ '"~"- ., "--'-~' ~~ '" . ~>>~, "'"'.''0 "_0 ,~" ~_ __~_ . o ~i?~ -;-1 (,L' rf1i'\ \ ',-"", ~2(_:_ (J'" ~t) S? Cd) Z,{:-'-j J;~ J ....> '2\ cf' ...,., rn dO I -l ~'<.j-- il " ,i i' " Ii il II II II II I I' ,I 'I I, il :1 I :1 " Sf. --1 ::r~ -l', n11~ _Of1' ...nt? cjt(~. ~~7j ,t",~ I n ~~ 20 :J.:;. -0 ::l~ r-;? N dO . . .,...-~ ,. --.. '-'-~-., -~ '. "'"i;-lilII':"~ ~ ;-' ~ "" State Commonwealth of pennsylvania Co.lCity/Oist. of CUMBERLAND Oate of Order/Notice 08/05/05 Case Number (See Addendum for case summary) ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT ;)'l\\O~'::lS .3~'iS :') ,C\C\::, @Original Order/Notice o Amended Order/Notice o Terminate Order/Notice EmployerANithholder's Federal EIN Number RE: CLARK, STEVEN B. Employee/Obligor's Name (Last, First, M/) TWIN TAILS SEAFOOD CORPORATION 8236 NW 30TH TER DORAL FL 33122-1914 -31~\03\ta:J. O\-ll.c2. eVIL 441-48-1720 Employee/Obligor's Social Security Number 2901100703 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, MI) See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 1,057.00 per month in current support $ 173.00 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in current and past-due medical support $ 0 . 00 per month for genetic test costs $ per month in other (specify) for a total of $ 1,230.00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 283.85 per weekly pay period. $ 567.69 per biweekly pay period (every two weeks). $ 615.00 per semimonthly pay period (twice a month). $ 1. 230.00 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). . If remitting by EFT/EOI, please call Pennsylvania State Collections and Oisbursement Unit (SCOU) Employer Customer SelVice at 1-877,676-9580 for instructions. Make Remittance Payable to: PA SCOU Send check to: Pennsylvania SCOU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEfENDANT'S NAME AND THE PACSES MEMBER 10 (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. Oate of Order: AUG 0 8 2005 Z:~T'A 4. XM\ [\, Qy.i) \JtuJ~' Form EN-028 Worker 10 $'ATT SelVice Type M OMB No,; 0970-0154 - ^ ~~ ",,,"- , -~ ~-~- "~ - -....'" ~ , ~ '"~ia ~. . .. ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If.~hecked you are required. to prpvi(le a copy of this form to your employee. If yo~r employee works in a state that is dltterent from the state that Issued this order, a copy must be provided to your employee even if the box is not checked. t. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3,* Rcpv.l;1I5 1I.~ PdyddlelDak: of'v\'itLLvld;"5' YOu 'IIU::.llepc.lIl ~.e Pd.yddhddat~ of vv;lllllold;hg vvl,~" $elld;lIg 1:I1~ pay...e'lll. Tl.~ p.1yJdLcfdak: of yvalllll.lld;115 ;::1 UI~ Jate 011 vvl.;d. CllllVUlIl VVd.!l YV;UII,dd ~V'll ll,~ cllqJlvY~~'::I yvoigt::l. You must comply with the law of the state of the employee's1obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4. * Employee/Obligor with Multiple Support Holdings: if there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's1obligor's principal place of employment You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. THE EMPLOYEE/OBLIGOR NO lONGER WORKS FOR: 6509551780 EMPlOYEE'S/OBlIGOR'S NAME: CLARK , STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed govems. B. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.* Withholding limits: You rnay not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.s.e. !i 1673 (b)t ; or 2) the amounts allowed by the State of the employee's1obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. 1 Q. Additional Info: * NOTE: If you or your agent are selVed with a copy ofthis order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Submitted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER 5T P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (711) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 Form EN-028 Worker 10 $IATT SelVice Type M OMB No:, 0970-0154 d~~'= - . ~ ..-- .... f , ~ ~~, L.il.~' 'jtt~.:-., -- ~. ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 271103055 Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 328 S 1993 $ 612.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available the employee's/obligor's employment. rACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB o If checked, you are required to enroll the child(renf identified above in any health insurance coverage available through the employee's1obligor's employment. SelVice Type M OMB No,: 0970-0154 PACSES Case Number 312103462 Plaintiff Name KRIST I J. CLARK Docket Attachment Amount 01-762 CIVIL $ 618.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child{ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ;::,::.::,.:',.','.',::::'.-:'::-C::',",::,-:,':'-":}:\::"'.:':"'':::';':;'',';::::::::'':':'':':;''::,::,:'''':,.'.,:',.,::","':::, df~I1~~k~d,~~~~;~;~~~i;;,d;~ enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. Addendum Form EN-028 Worker 10 $IATT ~~,~~,,"~l'r'fu!!f$~)~"'l:'J,i;I'ii;M!liIH~1!~!'fdi\'1e,1i;'5.""'f,",-;,,;t<-"""-~'f""':;"'''''';l~...",'''~Jir~;:[l1dID''''-;aJ"",-^W>~~,~ 0~ ~ I. ~ - 1- ~. ..- ~ ~" ~-,' "~~ I,: "'"", ,1; r - " " Ii' 0 r--> 0 = C, = ." c.n -S::" "'" -t -orT! I" ?2 !j-~: c: (;, ~hi Zl' (j) !- N 96 -<~ . ~c """""--i-j )> ,-', -0 ?5-:-1 -l..,1 :x '-0 ~c 6m Pc: W -~ z J.O ~ +"'" \,0 '< =" .~- ~, -~~= ""'"''',li<''ac''''' C" .,. '(' ~iJitr,', - ,- ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsvlvania CoJCity/Oist. of CUMBERLAND Oate of Order/Notice 08/19/05 Case Number (See Addendum for case summary) o Original Order/Notice @ Amended Order/Notice o Terminate Order/Notice TWIN TAILS SEAFOOD CORPORATION 8236 NW 30TH TER DORAL FL 33122-1914 ));j, PlMEE C; ~,t/. ,;JpO)- 7{p~ (1rJ//L ;D/}(!!;1s ..3/.2ID3 Y'tQd- RE: CLARK, STEVEN B. Employee/Obligor's Name (Last, First, MI) 441-48-1720 Employee/Obligor's Social Security Number 2901100703 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, Ml) 3JJ S /193 dL'7I/D3tJSr EmployerlWithholder's Federal EIN Number See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 518.00 per month in current support $ 173.00 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in current and past-due medical support $ 0.00 per month for genetic test costs $ per month in other (specify) for a total of $ 691.00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 159.46 per weekly pay period. $ 318.92 per biweekly pay period (every two weeks). $ 345.50 per semimonthly pay period (twice a month). $ 691.00 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's! obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). If remitting by EFT/EDI, please call Pennsylvania State Collections and Oisbursement Unit (SeDU) Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCOU Send check to: Pennsylvania SCOU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAil. MAIL~n ~THECO~_. AI- ~ Oate of Order: A/II:!" t'l 'IAft..- /"' ~ KfEV/Aj"'A.HG'S "Jl.JDIIG Form EN-028 Worker 10 $IATT SelVice Type M OMB No,: 0970-0154 ---.-" ~ .. .--. , -~~" '"~ ~~~-': - -- ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o I(~hecked you are required. to provi(Je a copy of this form to your. employee. Ifyo~remployee works in a state that is dltterent from the state that Issued thiS order, a copy must be provided to your employee even If the box is not checked. 1. Priority: Withhoiding under this Order/Notice has priority over any other legal process under Slate law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency iisted below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3. * RepurL;lIg tilt; F' ayddte/Date vf 'v"v'al,l,oIJ;JJ5. Yuu Jdusl 1t::I-'Vlt L1le ....aydateldatt vf vv;U,I,vldihg VVIIt.1 :>d Id;1I5 tilt:: paylllt::lIt. TIle ....ayddte/Jalt:: of vvalrllvld;1I5;$ tile Jdlt; VII vv!,;d, alllOUllL Ha:> vval,l,eld flVl1I Lilt:: elll....luyt::e'!J vva5t::::l. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4. * Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 beiow) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: 6509551780 EMPLOYEE'S/OBLlGOR'S NAME: CLARK , STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania Slate law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9. * Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.s.c. 91673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory dedLlctions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the slate that issued the order. 10. Mditionallnfo: *NOTE: if you or your agent are selVed with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Submitted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (71 7) 240-6225 or by FAX at (717) 240-62411 or by internet www.childsupport.state.pa.us Page 2 of 2 Form EN-028 Worker 10 $IATT SelVice Type M OMB No,: 0970-0154 "-="~- " P,-, ~" , -" Wl!!i 'ill1L~'; --- AODENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 271103055 Plaintiff Name !CRISTI J. CLARK Docket Attachment Amount 32881993 $ 73.00 Ch i1d(ren)'s Name(s): DOS PACSES Case Number 312103462 Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 01~CIVIL $ 618.00 Child(ren)'s Name(s): DaB you are required to enroll the child(ren) in any health insurance coverage available the employee's/obligor's employment. If you are required to enroll the child(ren) above in any health insurance coverage available the employee's/obligor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DaB Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB If checked, you are required to enroll the child(ren) above \n any health insurance coverage available employee's/obligor's employment. If you are required to enroll the child(ren) above in any health insurance coverage available employee's/obligor's employment. PACSES Case Number plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DaB Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) above in any health insurance coverage available employee's/obligor's employment. If you are required to enroll the child(ren) above in any health insurance coverage available the employee's/obligor's employment. Addendum Form E N-028 Worker 10 $IATT SelVice Type M OMB No,: 0970-0154 _~".."" "-'''="'1iiii&'j,#-"",iJ~~~;W,j""",IIJi~llifW';~",l(W,';:l.~",i&,!lidh\1Wi,,',i.Mi,'''~ffi,"'""tn~"<.i:l~JMhi;i:!;;Jil1iri,~"""""""'" It_I' ."'-'"1 . d "<, ~ , ,^" 0'. ~ ,~~",,'-~ ,', ',--' ~ >,,',= ('6. ~ ".I, ,~, -, ,^. '"'.. ,'" ~~~~~.dl:i " -~,._o ' ,'-,~~.- .< ' () s; ;gfl} ~-~,;.,. f5-~;.-,' t:~,~ Jfi~ ~- 3; -< _. ~ i;;g "'" c.r, ""~ C:'. ,,; '" '" """t:1 ::Jl:: 'i? =;:t Fi1:n -0111 :1]0 01 ::;:19 ?} -ri ~.?:O om 'j;! ::0 -< S> .!:- co -.-, "., -~ , , f 1.. "'" - r-' ',~, -',; d,~!SJ-', ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania Co./City/Oist. of CUMBERLAND Date of Order/Notice 08/24/05 Case Number (See Addendum for case summary) o Original Order/Notice @ Amended Order/Notice o Terminate Order/Notice TWIN TAILS SEAFOOD CORPORATION 8236 NW 30TH TER DORAL FL 33122-1914 1>K1, ~dg S 1'773 I'IJeJ;.L ('" ;;.. 7 f / D~ D'i"':l .JJd: ;)()O/ -7(.,").- ell fllest.s 3/;l/03lfCs,r RE: CLARK, STEVEN B. Employee/Obligor's Name (Last, First, MI) 441-48-1720 Employee/Obligor's Social Security Number 2901100703 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, MI) Ernployer/VVithholder's Federal EIN Number See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 1,057.00 per month in current support $ 173.00 per month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in current and past-due medical support $ 0 . 00 per month for genetic test costs $ per month in other (specify) for a total of $ 1,230 . 00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 283.85 per weekly pay period. $ 567.69 per biweekly pay period (every two weeks). $ 615.00 per semimonthly pay period (twice a month). $ 1.230.00 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate!date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's! obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). If remitting by EFT/EOI, please call Pennsylvania State Collections and Oisbursement Unit (SCOU) Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCOlJ Send check to: Pennsylvania SeOlJ, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. ::e::::D=:5~U5 ~~~~!;;f'H'COU7' A' k6WM;::J ,}.f&<;.J, ~ SelVice Type M OM6 No,: 0970-01 S4 ''JlJ~ Form EN-028 Worker 10 $IATT -,1. " "\ , -~' -) -", ~ .. jjl"i!;JMfuL'#lil',iKib ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o I(checked you are required. to provide a copy of this form to your~mployee. If your employee works In a state that is different from the state that Issued this order, a copy must be provided to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3. *. RctJOlt;1I5 tIle r aydale/Date OfV\I;L1 d ,old;"g. You 11IU51lctJOlllll'C: t-JClydalc/Jale vf vv;tLl,old;"5 vvl.e" ~clldiHg lilt:: ....ayI 11ellt. Tile payJdlc:/Jate vf vv;U.I,uIJ;I,g;:. tilt' date 011 VVII;LII cUIIOuIIl vvas vv;lIJI,eIJ hU1I1 tile 611/Jlvy6:::';) nCl5es. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4. * Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Plea.se provide the information requested and return a copy of this Order/Notice to the Agency identified below. THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: 6509551780 EMPLOYEE'S/OBlIGOR'S NAME: CLARK , STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State In which he or she is employed governs. 8. Anli-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9. * Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.c 91673 (b)1; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. 10. Additional Info: *NOTE: If you or your agent are selVed with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Subm itted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupportstate.pa.us Page 2 of 2 Form EN-028 Worker 10 $IATT Service Type M OMB No.: 0970.0154 -. : '\.. ~ ~ - '" - ".' ,,"'''-'- - ~ ,,~o ~"~llll<ro!$~{;." ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 271103055 Plaintiff Name :KRISTI J. CLARK Docket Attachment Amount 32iiSl993 $ 612.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available the employee's/obUgor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB If checked, you are required to enroll the child(ren) above in any health insurance coverage available the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB If you are required to enroll the child(ren) above in any health insurance coverage available employee's/obligor's employment. SelVice Type M OMB No.: 0970-0154 PACSES Case Number 312103462 Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 01-762 CIVIL $ 618.00 Child(ren)'s Name(s): DOB If checked, you are required to enroll the chlld(ren) above in any health insurance coverage available the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment Addendum Form E N-028 Worker 10 $IATT ~~lt'j~~"F.O"~""~1.!F~.*"!!iii!;,"~_.1:1,!""'b:"''i'''~ f;~W';:*'~''?_';;,f!tIi0;.;;>!i{,;)P,''~loofu~~~~l .' J ,'""""",, ~- 0S- ~ - ,~ ,~- "'-~~ o s~ ~i";'; :;::~ r u)_> -<"~ -. .~ij~' *:'(--=;' ~" S:;~ ;:--j ..<: - 00 ~ .I , . i: 'I' 1.1 , "'" = = c.n :> c: GJ N en o -n :r-n mr=; -om :0 c:r r) 1- :3y -1.--.0 C:,;?h om --, 55 --< ""U ~ S' Cl -' -~, " . ~L ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT -.3 /.2/03'1&2 01 - 7&), (!/IIIL ~ j , L .... State Commonwealth of Pennsylvania CoJCity/Oist of CUMBERLAND Oate of Order/Notice 10/02/06 Case Number (See Addendum for caSe summary) el7/ / 03055 3:;(<:6 s 93 o Original Order/Notice o Amended Order/Notice o Terminate Order/Notice TWIN TAILS SEAFOOD. CORPORATION 8325 NW 30TH TER DORAL FL 33122-1916 RE: CLARK, STEVEN B. Employee/Obligor's Name (Last, First, MI) 441-48-1720 Employee/Obligor's Social Security Number 2901100703 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, Ml) EmployerANithholder's Federal EIN Number See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 0.00 per month in current support $ 618. ooper month in past-due support Arrears 12 weeks or greater? @yes 0 no $ 0.00 per month in current and past-due medical support $ 0.00 per month for genetic test costs $ per month in other (specify) for a total of $ 618.00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in.compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 142.62 per weekly pay period. $ 285.23 per biweekly pay period (every two weeks). $ 309.00 per semimonthly pay period (twice a month). $ 618. ooper monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydateidate of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). If required by Pennsylvania law (23 PA C.S. ~ 4374(b)) to remit by electronic payment method, please call Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O~ Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. Oate of Order: aCT 0 32066 'nH'OO~ -L ~ ~ Form EN-028 Rev. 1 OM'N,.,0970-o154 Worker 10 $IATT SelVice Type M [ ,-'"'.- " __d" ..,.~, :;q-ie # ... ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If ,-hecked you are required to provide a copy of this form to your ~mployee. If yo~r employee ;yorks in a state that is ditterent from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obiigor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each em ployee/ob I igor. 3.* RetJoltillg lLe: rayJa~lDalc: vf,^-';1I11Ivld;1I5' YOu IIlldlle:I-'Vll tIle: t-'<lydatddale: of vv;1I11IoIJ;1I5 VVllell ;:Ie:lld;llg lLe: I-'.1YIlIe:lIl. TIle: p.1yddltl'dale v[ vvjU,I,vIJ;"g ;;:1 tile dale: VII vvl,;\.-I, .1l11VUlIl vva;:l Hal,I,e:IJ NOlll L11e: e:llIplOye:e:'$ vVd5e:;:I. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4. * Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principai place of employment You must honor all Orders/Notices to the greatest extent possibie. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: 6509551780 EMPLOYEE'S/OBlIGOR'S NAME: CLARK , STEVEN B. EMPLOYEE'S CASE IDENTIFIER: 2901100703 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from iump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State iaw. Pennsylvania State law govems unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State iaw governs unless the obligor is employed in another State, in which case the law ofthe State in which he or she is employed governs. 9. * Withholding limits: You may not withhold more than the lesser of: 1) the amounts ailowed by the Federal Consumer Credit Protection Act (15 U.s.c 91673 (b)l; or 2) the amounts allowed by the State of the empioyee's/obligor's principal place of employment The Federai limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts ailowed under the law of the state that issued the order. 10. Additional Info: *NOTE: If you or your agent are selVed with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Submitted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17.Q13 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 Form EN-028 Rev. 1 Worker 10 $IATT Service Type M OMBNo,;097G-0154 . .. _ ~ ., h ~. , ~ -~ ',' "~ ,-" J1>fkt-., ~J;idi' ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLARK, STEVEN B. PACSES Case Number 312103462 Plaintiff Name KRISTI J. CLARK Docket Attachment Amount 01-762 CIVIL $ 618.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB If you are required to enroll the child(ren) above in any health insurance coverage available the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB If you are required to enroll the child(ren) above in any health insurance coverage available through the employee's1obligor's employment. Addendum SelVice Type M OMBNo.;097(}'()1S4 PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Ch i1d(ren)'s Name(s): DOB If checked, you are required to enroll the child(ren) above in any health insurance coverage available the employee's/obligor's employment PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB If checked, you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment. Form EN-028 Rev. 1 Worker 10 $IATT . ;";;;';'-;" ,;,~ "$"t_jjj~.,Jl;it{~~~O''1~!ii!ljjjjlm,;j,j,'J'_;;''"\i>j(~'''''',1!'.u.iI,'M!ij;;;id.RI!3>!~}~~iiIIlillM!r~i.l~lIif ~ ~c ,'" ~/l ~'--".-... -- 0 ....., = 0 C = .." d{P~ cr> a :r" n ---- --I n1,= ... J -om 0) :u6 ;:S w C) .. -j :;;? ~'I ~:: ,,'- ?~ :IJ ~~-~:' ~ '-0 'Zm W 0 /"' s;! ==J -<. - ::0 w -< ":" . :1 ~ ~ 'I I. il il II II "I I, II 'I II " il I