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Home My WebLink About01-1399 FX ",__, -.0-' ~,<" _ _ " __ __, '<' ,'. ]' "..",~, , ~ ;"'0'. ,- :,;, ',--,~'~: -"J!I~ii JONNIE A. LEAPHART, Plaintiff v IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR. Defendant 01-1399 CIVIL TERM IN RE: PETITION FOR BIFURCATION ORDER OF COURT AND NOW, this 8th day of February, 2006, upon consideration of Plaintiff's Petition for Bifurcation, and following a hearing held on this date, the record is declared closed, and the matter is taken under advisement, By the Court, Karl E. Rominger, Esquire 155 S. Hanover Street Carlisle, PA 17013-3455 For the Plaintiff )~q.iffr; G-t~ ~ :;Is Herschel Lock, Esquire 3107 N, Front Street Harrisburg, PA 17110-1343 For the Defendant :mae lli.~'w'~~~mi_l'k:'il.~ ,~" ~~~~~'~_.d;';:.;.~d'i(l' 0,,;' ~~'l ~ ;"<...,"1."" i&.- , ~, a: =' f"::::: lL!~j h%~~ (?t:> gff r;-l1J .......-,..- F':: u. o '~H''''''K "''''.'>-l ,..- ..- , ,-- ~- ~: ~ /~ ',~~~ ,~]; cn I co I..U lJ.. '-<> = = "" -1 >~-~~ "hl-;?~ n".1..1 ~Q () "." "'.'.'.' "","",^"'~., ;-'" "' -"," """~",," ,~,,," ~"- 1tt "~,'~ '0'"""'- ~- _ ., ,,~O' ,'''" ~,,l, , "'" ~, "-.. ~, .. .. JONNIE A, LEAPHART, Plaintiff v, THOMAS NILES GOLLICK, SR. Defendant .,=- ,,- ", . ~ ~. , ~,<<, ,..", ,,'."~""~ "---'v '; "'^''''i~~:; IN TIIE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA CIVIL ACTION - LAW NO, OI-1399 CIVIL TERM IN RE: PLAINTIFF'S PETITION FOR BIFURCATION BEFORE OLER, J. ORDER OF COURT AND NOW, this 20th day of February, 2006, upon consideration of Plaintiffs Petition for Bifurcation, and following a hearing held on February 8, 2006, the petition is denied, Karl E, Rorninger, Esq, 155 South Hanover Street Carlisle, PA I7013 Attorney for Plaintiff Herschel Lock, Esq, 3107 North Front Street Harrisburg, PA I7110-131O Attorney for Defendant BY THE COURT, /?4. . }~'y~-Ll~ ~ ~ J14S :rrr:H ~ ""'''-- ~,.' , ;J"'iIi...d~"'::"""'J).' ---,,' 'h ~~ ,', ':~h!r'{:Jd '-, ":i~'~\lnJ 011:7 ;"1,.1 ...' -'.... ;'U 77 "J 10"0,' L(. Cl-;:l JUul, A' 'Ii' ,">, "'-'1 I ' , I ~1' I' >-J""'J'I>", ',::I"'~rl ~'!"'l ,_,.-J... I\..._,j ,.,.....;"'jU ..J. ~DH,::()~CEJl!:1 :IO _,~ ~ .',4,~"~"'''"_' ,_ ~~~_ _~,~, -. .. ~_< ~ ". ti ~t4) " .. . l - ""' ~'" -, .- ^ "",'.i, "-" '"""">'''"",,,,-,,"' "~"""""'-."'>"'''''--';;d"-~~'',,' ,,_,+, "'jj .. JONNIE A. LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v, CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR. Defendant NO, 01-1399 CIVIL TERM IN RE: PLAINTIFF'S PETITION FOR BIFURCATION BEFORE OLER, J. OPINION and ORDER OF COURT OLER, J" February 20, 2006, This divorce action was commenced by the filing of a cornplaint, with a count for equitable distribution, in 200 I, 1 For disposition at this time is a petition for bifurcation filed by Plaintiff,2 A hearing on the petition was held on February 8, 2006, For the reasons stated in this opinion, the petition will be denied, STATEMENT OF FACTS The parties were married, according to Plaintiffs complaint, on February 19, I998,3 Her complaint, filed on March 12, 200I, was based upon an alleged separation of two years and irretrievable breakdown of the marriage4 A count for equitable distribution was included in the complaint,5 but according to Plaintiffs counsel the only item to be distributed is "some debt.,,6 I Complaint under Section 3001(c) or 3301(d) of the Divorce Code, filed March 12, 2001 (hereinafter Complaint -->, 2 Plaintiff's Petition for Bifurcation, filed October 6, 2005, 3 Complaint ~ 4, 4 Complaint ~ 6, 5 Complaint, Count 2, ~~ 1-3, 6 N,T. _, Hearing, February 8, 2006, - , '~ 'n < ~-, ~ -. "'"--~, ."...' -- - - -- ~,~ "~.,~, "~,~~~"~"""c",,,' ',,' "---' "tJs;i1f':i .. Plaintiff did not, by her counsel's admission, vigorously pursue a resolution of the action,? Much of her effort has been directed toward securing the exclusion of Defendant from rnedical insurance coverage provided by her employer at no cost to her, 8 An order was entered by agreement of counsel on October I3, 2003, whereby Plaintiff agreed to file a praecipe for appointment of a divorce master and to confirm the continued existence of the aforesaid medical coverage of Defendant.9 On January 30, 2004, Defendant filed a petition for contempt against Plaintiff, averring that she had "neither filed a Praecipe for Appointment of Master nor, , ,confirmed for Defendant that he [was J still covered by her health insurance, , , ,,,10 As of May 19, 2004, Plaintiff had still not filed a praecipe for appointment of a rnaster and, pursuant to an agreement of the parties, she was adjudicated in contempt of the court's October 13, 2003, order.ll The divorce master was appointed by the court on May 24, 2004,12 but a hearing has not yet been held in the case,13 and it is apparent to the court that neither party has aggressively pursued a disposition of the case,I4 The petition for bifurcation sub judice was filed by Plaintiff on October 6, 2005,15 It alleges that "Petitioner's employer is renegotiating its health insurance and Petitioner may be forced to exp[ e Jnd large sums of money to obtain health care coverage, and those sums of money will increase substantially if Respondent 7 NT , Hearing, February 8, 2006, 8 See, e,g., Plaintiff s Petition for Special Relief and Bifurcation, filed May 14, 2003, 9 Order of Court, October 13, 2003, 10 Petition for Contempt, '\f 4, filed January 30, 2004, II Order of Court, May 19,2004, 12 Order Appointing Master, May 24, 2004, 13 N,T, , Hearing, February 8, 2006, 14 N,T, , Hearing, February 8, 2006, 15 Plaintiffs Petition for Bifurcation, filed October 6,2005, 2 . .~. u ""',"'. ~,-" "",'> ._"" s -, ""'t~ remains on her health insurance,"16 that "PIaintiff wishes to remarry,,,I? and that "[b]ifurcation will not prejudice the rights of either party,,,18 Defendant filed an answer in opposition to the petition on October 3 I, 2005,19 At a hearing held by the court on Plaintiff's petition, the evidence tended to show that (a) Plaintiff has medical problems in the form of dry eyes and neck and back problems, (b) Plaintiff mayor may not have cancer, (c) medical insurance coverage is provided free of charge through Plaintiff's employer to Plaintiff and Defendant, (d) at some point in the future this insurance coverage may not continue to be free, (e) Plaintiff would Iike to remarry, (f) Defendant suffers from diabetes for which he takes Glucovance and Actos, (g) Defendant also suffers from a condition for which he takes Wellbutrin, and (h) the loss of insurance coverage provided by Plaintiff's employer would be a financial hardship for Defendant,zo DISCUSSION Under Section 3323(c,l) of the Domestic Relations Code, "the court rnay enter a decree of divorce or annulment prior to the final determination and disposition of [ econornic claims] if , , , the movmg party has demonstrated, , , compelling circumstances exist for the entry of the decree of divorce or annulment, , , and sufficient economic protections have been provided for the other party during the pendency of the disposition of [econornic claims ].,,2l "[B]ifurcation should not be made pro-forma," Frank & Gale, Pennsylvania Family Practice Manual 96,06, at 192 (1990), 16 Plaintiffs Petition for Bifurcation, '\f 5, filed October 6, 2005 (emphasis added), 17 Plaintiffs Petition for Bifurcation, '\f 7, filed October 6, 2005, 18 Plaintiffs Petition for Bifurcation, '\f 8, filed October 6, 2005, 19 Defendant's Answer to Plaintiffs Petition for Bifurcation with New Matter, filed October 31, 2005, 20 NT _ _--' Hearing, February 8, 2006, 21 Act of December 19, 1990, P,L. 1240, ~2, as amended, 23 Pa, C,S, ~3323(c.l) (emphasis added), 3 ... = -..~-.,-'- ~ ~"',-'"'~'~ ---,-~ ""._"_'~____O"'.'<"'_~"~'_'_'.,_ " ''"'-'"'+u~ ~ Rather, such a determination should be made only after the disadvantages and the advantages have been carefully explored and analyzed, Each case must be reviewed on its own facts and only following the court's deterrnination that the consequences of bifurcating the case will be of greater benefit than not bifurcating, should it grant the petition, Walk v, Walk, 3I8 Pa, Super, 311, 3I7-I8, 464 A.2d 1359,1362 (1983), In the present case, where the economic issue between the parties involves only a division of debt, where Plaintiff could have long since secured a resolution of the case through the master's process and thus "gotten on with her life," where a bifurcation would cause a financial hardship to Defendant through the loss of insurance coverage, where any loss to Plaintiff through provision of continued coverage is entirely hypothetical at this time, and where Plaintiffs medical condition in terms of cancer is also hypothetical and Defendant's medical condition in the forrn of diabetes is not hypothetical, the court is unable to conclude (a) that sufficient economic, protections will be provided to Defendant should bifurcation be ordered, (b) that the consequences of bifurcating the case will be of greater benefit than not bifurcating, or (c) that "compelling circumstances" exist for entry of a divorce decree at this time, For these reasons, the following order will be entered: ORDER OF COURT AND NOW, this 20th day of February, 2006, upon consideration of Plaintiffs Petition for Bifurcation, and following a hearing held on February 8, 2006, the petition is denied. ... BY THE COURT, s/ J, Weslev Oler, Jr, J, Wesley Oler, Jr" J, 4 "'^""--"~= ^">,~'., "'"".""'" - -~"'^'''' ,"",'0 "'-""_"~A"',""-;,,,"."" _. _,~_ ~ Karl E, Rominger, Esq, 155 South Hanover Street Carlisle, PA I7013 Attorney for Plaintiff Herschel Lock, Esq, 3107 North Front Street Harrisburg, PA l7IIO-131O Attorney for Defendant 5 iijilt,~,", 'd~, c' '- '~ '~~""""-'~ ~~" ,_"",,~ oe, ~,,~ ,. , ,':, - ',. ,", '" "".:.;1,:0-' ":~" <- ~_~EOOl~ 1-; ttjQl ,,,-~..,-~ ',~.~; "',T" ~ " ",,<,,~ ~',~, .".-" ~i I",' iJ I' c,',' " " <i! ;:' !i: 11 I, -I !.! ~ - "I, _' ~"_ ~ -< ,. - ~.... .... , " '~.- . '~;,' 'li'~.;JkI:' , JONNIE A, LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL V AN1A : CIVIL ACTION - LAW v, THOMAS NILES GOLLICK, SR" Defendant : NO, 01-1399 CIVIL TERM : IN DIVORCE ORDER OF COURT AND NOW, this ~ay of ----1\11 ? 1 ' 2003, a Rule to Show Cause is issued on the Respondent to show cause why the special relief requested by the Petitioner in her Petition 'sCJVlt's;.. for Special Relief should not be granted, Rule returnable within 2.'D days of'J..~ ~~~ otthis Order. Distribution: Karl E, Rominger, Esquire Herschel Lock, Esquire ~~ 5. /(,,03 ~ !lli~~~IiiWlj~!!-'liII.;lm\,;~~imlil~~'1;Jf.di.i'_~fAi,;.-wi~~BlijlliL ii - Ullliii'~' '"_".0,," 1_'.llti:.\jiSjJ~'~ \;,l~.lvi";:^SNN:Jd /-1. "J:':'?[/IJn8 ':1'1,( - ~ "-, t\ ~ , . ! ~~D -"-llij."'J!!ij~~~' i:lfU i "'" - ~ <,:<l JONNIE A. LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW v, THOMAS NILES GOLLICK, SR., Defendant : NO, 01-1399 CIVIL TERM : IN DIVORCE PETITION FOR SPECIAL RELIEF AND BIFURCATION AND NOW, comes Jonnie A. Leaphart, by and through her privately retained counsel, Karl E. Rominger, Esquire and seeks special relief under the Divorce Code and avers as follows: I, Your Petitioner inadvertently became married to Respondent when she executed Affidavits of a common law marriage in order to place the Respondent on her health insurance, 2, On March 12,2001, your Petitioner initiated an action in divorce, 3, The parties have not lived together for a period of approximately four (4) years, 4, There are no assets of great value which need to be divided amongst the parties, but there are outstanding issues as to debts, which a Master mayor may not have to assign, 5, The Pennsylvania Department of Transportation is renegotiating its' health insurance contracts, and your Petitioner may be forced to expend large sums of money to obtain health care coverage and those sums of money will increase substantially if Respondent remains on her health insurance, 6, There is no reason why Respondent need remain on Petitioner's health insurance, and has had the benefit ofthe same for many years without providing anything back to Petitioner, 7, Petitioner thus seeks either a bifurcation of the divorce so that the property issues for equitable distribution and the like may be handled later, while enabling her to provide proof of a M~'V ~ j '- '" -> L'. ~;~~h ," divorce to the health insurer. 8, In the alternative, an Order of Court granting Petitioner the right to remove her husband from the health insurance may be acceptable for the insurer. WHEREFORE, Petitioner respectfully requests that this Honorable Court grant her Petition for Special Relief and bifurcate her divorce so that she may avoid the additional cost of health care, and allow the parties to handle the equitable distribution issues subsequently, Respectfully submitted, ROMINGER & BAYLEY / ~'. Karl E, Rominger, Esquire 155 South Hanover Street Carlisle, PA 17013 (717) 241-6070 Supreme Court ill # 81924 Attorney for Plaintiff Date: May 14, 2003 ~" " ~. ~ ,.J=~ l' ~ " , '"' - ".~~ ""~"""''IiIJ[:~'';:r'':'~ll.ji~ll!\j''", VERIFICATION I verifY that I am the petitioner and that the statements made in the foregoing Petition are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa, C, s, 9 4904, relating to unsworn falsification to authorities, Date: -5 ;/'111_3 / . " "~ '>i _ j ;" ,~ .',L, ~':_~'~'_' -:&"I1'$).:0 JONNIE A. LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL V AN1A : CIVIL ACTION - LAW v, THOMAS NILES GOLLICK, SR., Defendant : NO, 01-1399 CIVIL TERM : IN DIVORCE CERTIFICATE OF SERVICE I, Karl E, Rominger, Esquire, attorney for Plaintiff do hereby certify that I this day served a copy of the Petition for Special Relief and Bifurcation upon the following by depositing same in the United States Mail, first class postage prepaid, at Carlisle, Peunsylvania, addressed as follows: Herschel Lock, Esquire 3107 N, Front Street Harrisburg,PA 171109-1310 l ~ Karl E, Rominger, Esquire Attorney for Plaintiff Dated: May I4, 2003 .u~~~lfj'~#"'-i'Hb'""""i'I~,,'Wilf~!l!:lI.liig,"'i.#~-,",;';;.;p,IJji;:2<@,"'~~1y<~,'"i<.i:r.;&;;li<l\\'1?:i:t~~,.-! "" ,,",,-". -:afi.~ir1r;.' ~"KJit'-~ (') , , c::' ~~; :;..) -n " '"," ,..,c ITi .' ,- - C ",,- .t:-. CJ~ " ) ~ , ,;-.:" .- b )> ~;~ r:,) ,-,} ~ " ~- "'J :2 (,.) ::.< ~ '~ - , ~, l!!l~ ' 1i ~""":.j" JONNIE A, LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs, NO, 01-1399 THOMAS NILES GOLLICK, JR" Defendant CIVIL ACTION - LAW DEFENDANT'S ANSWER TO PLAINTIFF'S PETITION FOR SPECIAL RELIEF AND NOW, comes Defendant THOMAS NILES GOLLICK, JR" by his attorney, Herschel Lock, Esquire, and files his Answer to Plaintiff's Petition for Special Relief as follows, to wit: 1, Denied and, by way of further answer, it is averred that Plaintiff, an adult individual claiming no intellectual incapacity or disability, knowingly and purposefully took actions necessary to create a common law marriage between her and Defendant, 2, Admitted and, by way of further answer, it is averred that Plaintiff's Divorce Complaint requested that a divorce be granted her under Section 330l(c) or 330l(d) of the Divorce Code, but, despite that and the passage of over two years since her separation from Defendant, she has failed to have her case scheduled before the Divorce Master, 3, Admitted and, by way of further answer, it is averred that even though Plaintiff requested in her Divorce Complaint that a divorce be granted under either Section 330l(c) or 330l(d) of the Divorce Code and more than 2 years have passed since she and Defendant separated she has failed to have her case scheduled before the Divorce Master, 4, Admitted in part and denied in part, By way of further c_ . " .. , , ~ ~~~~ answer, while it is admitted that the parties are not people of substantial economic means, it is denied that they have no marital assets of value nor debts of significant amount to be equitably divided by the Divorce Master, 5, After reasonable investigation Respondent is without knowledge as to the truth of the averments of Paragraph 5 as they relate to future events arising from contract negotiations between the Commonwealth of Pennsylvania and its employees' union and proof thereof is hereby demanded, By way of further answer though, it is averred that Defendant is presently covered by the health insurance plan provided Plaintiff through her employment with the Commonwealth and at no cost to Plaintiff, It is further averred that upon divorce Defendant will not be able to avail himself to such coverage without paying a significant sum therefore which would cause him great financial hardship, 6, Denied and, by way of further answer, it is averred that Defendant's present coverage under Plaintiff's health insurance plan greatly benefits him but, in no fashion, harms Plaintiff, 7, While it is admitted that Plaintiff seeks to bifurcate her divorce action, it is denied that doing so would presently benefit her in any fashion since Defendant's health insurance coverage costs her nothing and the economic count of her Divorce Complaint would still have to be dealt with after bifurcation. S, While it is admitted that Plaintiff wishes Defendant to be removed from her health insurance, it is denied that there exists any factual, legal or equitable basis for doing so, - , ~ I ~ I " ~~..f,i;r.G!' ~ NEW MATTER 9, The averments of Paragraphs 1 through 8 hereof are incorporated herein by reference thereto, 10, Plaintiff filed her Divorce Complaint against Defendant over two years ago, 11, Since that time, Plaintiff has failed to move the matter towards conclusion by scheduling it for a Divorce Master's hearing, 12, Defendant believes and avers that Plaintiff's present request to bifurcate the divorce count of her Complaint from its count for equitable distribution would not obviate the need for a Divorce Master's hearing and is merely a vindicative attempt by her to harm Defendant by denying him the present "no cost" health insurance coverage he presently enjoys as a result of his marriage to Defendant, 13, Defendant believes and avers that if Plaintiff's request for bifurcation s granted it would cause him great economic harm without presently benefiting Plaintiff, WHEREFORE, Defendant prays your Honorable Court to deny Plaintiff her prayed for relief, DATED: 6/3(03 Respectfully Submitted: ~J,2c>l;( HERSCHEL LOCK, ESQUIRE Attorney for Defendant 3107 North Front Street Harrisburg, PA 17110 (717) 238-6661 -,~ 0"" """ .-1 ',- VERIFICATION I verify that the statements made in the foregoing Answer are true and co~rect. I understand that false statements made herein are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. DATED: 6i3/03 0,"- ~ Ji !9~~~~l1l::ffi!~~~~f&Wd;.;..0";l,"l\l:~~'iiiiip",-jj'~'"L1'j"liotic~~,",4:f.,,*~~~~1M.4:J:IIlM -~ ~ ~ , I i I I 'I :1 , II ,1 ;1 ii Ii II I' d " ii '[ II " I I I :! () 0 0 c W 'n s:: '- --i "'Ow c:: ;O::l;Q mrr- z Z:J. I ..,-:m ZC- ':.-,JC;J UiY cr, ~', 1- -<.,.,,-,. '~::~; C> t<C -0 ~~~~ ~~,. ='S: --,c 1'-) ;.0:-::: m )>c: ~"J ;:::; ;:- ~ --i :JJ -< <{) -< ~ " ..- ,,"' -, ";'"'~w,.'" '...r '. , '";;;,;~,,,~ JONNIE A. LEAPHART, PIaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v, CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR" Defendant NO, 01-1399 CIVIL TERM ORDER OF COURT AND NOW, this 28th day of July, 2003, upon consideration of Plaintiffs Petition for Special Relief and Bifurcation, and of Defendant's Answer to Plaintiffs Petition for Special Relief, a hearing is scheduled for Monday, October 13, 2003, at 9:30 a,m" in Courtroom No, I, Cumberland County Courthouse, Carlisle, PennsyIvania, BY THE COURT, ~arl E. Rominger, Esq, 155 South Hanover Street Carlisle, PA I7013 Attorney for Plaintiff .~ yHerschel Lock, Esq, 3107 North Front Street Harrisburg, PAl 7 II 0-13 10 Attorney for Defendant > ~I;J)) o .~ . A.. KS 01- 30-(f3 :rc 1~ ,,~ ~.."~L~""~~i~~~~~_r.:4fu."H~W~l;...~iVrr '~t-""" '. ~ ,-" ~ - ..... Vi~jI-!^l^SNN3d ! I~ 'r--ro.,'" .....~ 'l I~]'~ I\J.~\!I :\.,1,.." !,~I',:\:. ~.,-J.'fql.'^lnl', ,'-q, ,''4', v 8S =5 f,jV DC "mf SO ACJiiLCi\DiilCdd j:-Il :10 ,"'~ 'Q-n3'"'_l :J;JU~.1 ,,_!b -' ~~ Ii! ,<I Iii r:i ifl [' d 11 11 I I ! ,I Ii ti II 1 [i ,I II II ! II 'I r" .. J -~, , ,'" -1_, ,,_~" _ '. > "coo"" -" ., - "- ,.,," -,"'-""',__'''c,' .' ,,' .,', "-"f't JONNIE A. LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v, CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR, NO. 01-1399 CIVIL TERM ORDER OF COURT AND NOW, this 13th day of October, 2003, upon consideration of Plaintiff's Petition for Special Relief and Bifurcation, and purusant to an agreement reached in chambers between Plaintiff's counsel, Karl E, Rominger, Esquire, and Defendant's counsel, Herschel Lock, Esquire, it is ordered and directed as follows: 1, It is agreed upon between the parties that the instant petition be withdrawn without prejudice to either party and be allowed to be refiled as circumstances or events dictate; 2, Plaintiff/Petitioner agrees to file timely a praecipe for appointment of Master; 3, Plaintiff/Petitioner and Defendant/Respondent agree to cooperate with timely filing the income and expense and inventory and appraisement forms necessary to move forward with a Divorce Master's hearing; and 4. Petitioner/Plaintiff agrees to reaffirm' that Defendant/Respondent is still covered by her state-sponsored health insurance program and will continue iI~)~~~~~iitJ.;!,l_~~'W!l",-";@M!ill:fj\j~~iful$i!,;<m,'W/.1_!lg~",~~'~ li1liiiEO'~ """""w",,, ,,' ~~~ : ~ :j\ '\./11\" 1,\"1''''\1 ;';lj'JII'[ 1\;""'); N:Jj !r'(j'~' ';",~ "~;'l'L~1glNn8 ill :[J! HV i111JO 80 }.J1VJl~A(~~-L~;:'::'~O'-':'~_lH11 :10 v.~_, _I.!,-, ." ,~~ ~~~ --150 ' I' .lit ~ ' '''\ I Ii' i, I, I [' t C I, ]!\ j:' I~:; i i'i I I I' I: I I' i: I: - /,-A l , , . . , /" ~ I:~ ~__~ ;i" _~''', ",~, I - ':;iJ,j( to be so covered until further Order of Court or direction of the Master. vKarl E. Rominger, Esquire For the Plaintiff/Petitioner ~erschel Lock, Esquire For the Defendant/Respondent wcy By the Court, J ~~ RKs JO-/4 -CJ3 .t~ '~ ' .;~:~ ;,; iil~~~I"li:,_m!Wl"'';",lWl:\~~i'1J&<-~':i!'i~:t!~J&iId~iio\iW'f,.$liiI~''.'' ",.1 ~ ',~ 1~' ~"l', l~k~:~_~[jiliWljll' ~ ~,. ~~~ c~=,~~~~ . ,~, ~ ~ --, ~," , ~ """',, -' ,~ ~ ,<,.I~"""" \.~'-" [,: ! i i' . i , ;\ " " I !-- , I,; ! II il i ~1 11 II , I ,- -.', ,'~"'" - "",-"~[~" "'''~'.' "<~,, ~"'--'-"'';'" ',.",,",',--, ''"'"'<'+'..-'',,-.''' '" ','c.\-,>,' -". d , JONNIE A. LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v, CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR., Defendant NO, OI-I399 CIVIL TERM ORDER OF COURT AND NOW, this I2th day of October, 2005, upon consideration of Plaintiffs Petition for Bifurcation, a hearing is scheduled for Wednesday, February 8, 2005, at 9:30 a,m" in Courtroom No, 1, Cumberland County Courthouse, Carlisle, Pennsylvania, BY THE COURT, ~arl E, Rominger, Esq, I55 South Hanover Street Carlisle, PA I70l3 Attomey for Plaintiff ~rschel Lock, Esq, 3107 North Front Street Harrisburg, PA I7110-I3IO Attomey for Defendant '>l IA ,(}5 IO-\J :rc ~j~"'" ,', ~~...; :,;, ll&li:i'!lll'l"lillii'-,4 c'oi 2...,',,,' .,.,;.,'.,',1,',:.....,;", "' "IIlti'1~i~~~'lii"1' ..., ~~0;( , id~" \i!N\;i~\.lN;i\ii'~::k:l j j 'Ir,,"'-'-. ~. ,. "'-'",~rHn,", 1\.:.1\, it,),! '1;. ,.' : '''~:,'->iJ HJ 'l2 :8 !~~ S I1JO SOOZ 1\,1' "0' ""',1 "'\'-'d :JHL' .:10 I\u"h j\jl,)j ,".\.,,\.j' ...J '-''')I~ 'I.f!TII j :!v,"='C u" ,; ,"~ ' 'l* '"~. ~o Ii . " , .-", ~- >ir!:,,: . V RECEIVED OCT 102005 '\. P .... ... ; IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA JONNIE A LEAPHART, Plaintiff Civil Action - Law v, Docket No, 01-1399 CIVIL TERM THOMAS NILES GOLLICK SR, Defendant RULE TO SHOW CAUSE AND NOW, this _ day of , 2005, the Court hereby issues a Rule upon Respondent to Show Cause why a Bifurcated Decree in Divorce should not be granted, Said Rule is returnable within _ days of the date of this Order, By the Court, 1. Distribution: Hershel Loc~ Esquire Karl E, Rominger, Esquire ., ~ '~L... ... __ ~~> ~ -,l ';";"=0'_",;, .... .' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA JONNIE A LEAPHART, Plaintiff Civil Action - Law v, Docket No, 01-1399 CIVIL TERM THOMAS NILES GOLLICK SR., Defendant ORDER OF COURT AND NOW, this day of , 2005, upon consideration of Plaintiff's Petition for Bifurcation of the Divorce Proceedings, the within Bifurcated decree in Divorce is granted, 1. Distribution: Karl E, Rominger, Esquire Herschel Lock, Esquire ~~~ ~ .. - _.;1_ '"'_ ~ 'iif ,"'- ,:~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA JONNIE A LEAPHART, PIaintiff Civil Action - Law v, Docket No, 01-1399 CIVIL 1ERM THOMAS NILES GOLLICK SR., Defendant PLAINTIFF'S PETITION FOR BIFURCATION TO THE HONORABLE, THE JUDGES OF SAID COURT: AND NOW comes Plaintiff, JONNIE LEAPHART, by and through her attorney Karl E, Rominger, Esquire avers the following: L Plaintiff JONNIE LEAPHART is an adult individual who resides at P,O, Box 345 Mechanicsburg, Cumberland County, Pennsylvania 17055, 2, Defendant THOMAS GOLLICK SR. is an aduIt individual who resides at 1809 Willow Street, Carlisle, Cumberland County, Pennsylvania 17013, 3, On March 12, 2001, your Petitioner initiated an action for divorce, 4, The parties have not lived together for approximately (6) six years, ,~ " '- , - ~ -'.~" ",' ~,' ;~ U""', 5, The Petitioner's employer is renegotiating its health insurance and Petitioner may be forced to expand large sums of money to obtain health care coverage, and those sums of money will increase substantially if Respondent remains on her health insurance, 6, There is no reason why Respondent need remain on Petitioner's health insurance, and has had benefit of the same for many years, 7, Plaintiff wishes to remarry, 8, Bifurcation will not prejudice the rights of either party, :~ - ~>'" , _J' .- , d'<_ .' WHEREFORE, Petitioner respectfully requests that this Honorable Court issue a Rule upon Husband to show cause why a bifurcated Decree in Divorce should not be entered with the following provisions: (a) AIl economic issues or other marital claims shalI be preserved; (b) The Dead Man's Rule and the provisions of the Dead Man's Statute shalI be waived in the event of the death of either party hereto prior to final resolution of a1I economic issues of other marital cIaims; and (c) Until final resolution of all the economic issues or other marital claims, the parties hereto are hereby enjoined from alienating, assigning, concealing, conveying, dissipating, encumbering, pledging, secreting, transferring or otherwise disposing of any marital property, RespectfulIy Submitted, ROMINGER ,BAYLEY & WHARE ? Date: JO-~-D5 Karl E, Rominger, Esquire 155 South Hanover Street Carlisle, Pa 17013 (717) 241-6070 Supreme Court ill # 81924 Attorney for Plaintiff l.._ "., L " ""-,,,<,'.,,_,,1, _'" k. r' ~.., .. ~",-"""","'"",", ;","<'~ ,~..:,.}~" "' '~t,~ '~ ..' IN THE COURt OF COMMON PLEAS OF CuMBERLAND COUNTY, PENNSYLVANIA JONNIE A, LEAPHART, Plaintiff Civil Action - Law v, , Docket No, 01-1399 CIVIL TERM THOMASNILES GOLLlCKSE", Defendant vERIFICATION I verify that the statements made in this Petition for Bifurcation are true and correct. I understand that false statements herein are made subject to thepenaltiesofl8 Pa, C, S, g4904, relating to unsworn falsification to authorities, Date:~5 jg \ I' I \~CX} , r,e Leaphart, PI tiff '-~ ---0- .,j. ~ , ~q.- "-~. ~ ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA JONNlE A. LEAPHART, Plaintiff CiviI Action - Law v, Docket No, 01-1399 CIVIL TERM THOMAS NlLES GOLLICK SR, Defendant CERTIFICATE OF SERVICE I, Karl E. Rominger, Esquire, attorney for PIaintiff, do hereby certifY that I this day served a copy of the Plaintiff's Petition for Bifurcation upon the following by depositing same in the United States Mail, first class postage prepaid, at Carlisle, Pennsylvania, addressed as follows: Herschel Lock 3107 N, Front Street Harrisburg, PA 17110-1310 ? Dated: ItY itJ 1f .s KarI E, Rominger, Esquire Attorney for Plaintiff !~Ii~MI~f~ti!l"li'Jl1<'""'*.J;i'ii1!:t;~141"~'fi-'Ji,"""",\,,~tJI'"<;Jid'ii"o,{,~,'-'lii~l~iI!'~~~I!m..';i""''''''''''-~ "~'~""'!iliiiMiI'liI!iil]l-J;j "'*'.-""".....l~"h' " .- .~ ,'- ,~,,-,,'" --~~ ~,., """"""I:' 4~ ," (') "-, = 0 C~ = " ::;.::n- "-" &::r 0 :r! C'? m" ::7 -l r- ei; I -elm :;;-;CJ -< en ("" i r:= "_ .~o- ,-' -0 ::-C=i~ ~i3 ~: (YT ,.;-' ~-- ~.,;;'~~ ~ W Y ;;:..:: ,""' ::;! ::0 c.;n ,-< ~R " ",_. ,.' ,,'J' ,.,~ _' -- ~ , "<" _' ,"--" """,,< ""-,~_->.A' '''c' '."~ 0;.: JONNIE A. LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v, CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR., Defendant NO, OI-1399 CIVIL TERM AMENDED ORDER OF COURT AND NOW, this I7th day of October, 2005, the prior order of court in this matter dated October I2, 2005, is hereby amended to reflect the date of the hearing scheduled on Plaintiffs Petition for Bifurcation to be Wednesday, February 8, 2006, at 9:30 a,m" in Courtroom No, 1, Cumberland County Courthouse, Carlisle, Pennsylvania, BY THE COURT, J 1. ..,Karl E, Rominger, Esq, 155 South Hanover Street Carlisle, PA 17013 Attorney for Plaintiff ~rschel Lock, Esq, 3107 North Front Street Harrisburg, P A 17 II 0- 1310 Attorney for Defendant ~ :rc ~~ ",~, ,_ 0 '",~, ,~._~~ 'h '~U~il!l1iiiisliI!{Jiiil1li;i'!i~~_(il: <c - ~ < ",.. ~ - ,,~-,~, ,~.'~'- 0'" ,':; " (,:S 'C..- ;,c:d .c-' .;,<1 -" -~- ,'.' if i,Jr.;';,,:; J I. J ,1:]0 gUlz 1'Ll"'."("'''''' 1'-i'/.l....;,\il.}...:!(',I..;,) -'1'1 :;r~r ' :~'""-.:,-'':!_~:J -1 "',W!{}{I'J'/:I "- ,~ .. -~,- - , -- ., :Ie 1~'7J^ l jjJ~ ,. "'. ...:... '. "H 1..:;;:,,;....'- "" ,."' '" ~M ". ,",~ "",' --H",",,,"I';; "',"" "=,"/<~,,,,,',,,o'" _"'0 ~".d.--~,~,;:;,_,'],".',;,,,;,-,'i ,,"~'=',",," "," _ A" = ::-,~~! JONNIE A. LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v, : CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR., Defendant : NO, CIVIL TERM 01 - 1299 : IN DIVORCE NOTICE You have been sued in court, If you wish to defend against the claims set forth in the following pages, you must take prompt action, You are warned that if you fail to do so, the case may proceed without you and a decree 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, When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling, A list of marriage counselors is available in the Office of the Prothonotary at the Cumberland County Court House, High and Hanover Streets, Carlisle, IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER'S FEES OR EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM ANY OF THEM, YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 Phone: (717) 249-3166 ~'" -._' ",',Jh ,l]~ ,. '~;., ~/,,- ~ "'.~;"o ',0-"",,- ',;' ,,- '><"'''-..~,.' - - ,~,"-~, ,,' ",,'" JONNIE A. LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v, : CIVIL ACTION - LAW : I /3'1'1 : NO,b_ CIVIL TERM : IN DIVORCE THOMAS NILES GOLLICK, SR., Defendant COMPLAINT UNDER SECTION 3301(c)or 3301(d) OF THE DIVORCE CODE 1. Plaintiff is Jonnie A. Leaphart, who currently resides at p,O, Box 11, Mt. Holly Springs, Cumberland County, Pennsylvania, since 1999, 2, Defendant is Thomas Niles Gollock, Sr" who currently resides at 1809 Willow Road, Carlisle, Cumberland County, Pennsylvania, since 1990, 3, Plaintiff and Defendant have both been bona fide residents in the Commonwealth for at least six months immediately previous to filing of this Complaint, 4, Plaintiff and Defendant were married in a Common Law Marriage on February 19, 1998, 5, There have been no prior actions of divorce or for annulment between the parties hereto in this or any other jurisdiction, 6, The marriage is irretrievably broken, 7, 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, 8, Plaintiff requests the Court to enter a Decree in Divorce, ~, , -'.- "~~ - "', "- .-'>' _'_';._.c' ,,~" ~"^_ ,"?'.' '.-"C4:",'.,':~_,-;-' ^':""c.','"' ~,_",: -N ,'_ COUNT II: REOUEST FOR EOUlTABLE DISTRIBUTION OF MARITAL PROPERTY UNDER SECTION 3502 (d) OF THE DOMESTIC RELATIONS CODE 1, The prior paragraphs of this Complaint are incorporated by reference, 2, Plaintiff and Defendant have acquired property, both real and personal, during their marriage, 3, Plaintiff and Defendant have been unable to agree to an equitable distribution of said property, WHEREFORE, Plaintiff respectfully requests the Court to enter an Order equitably distributing the parties marital property pursuant to Section 3502 (d) of the Divorce Code, 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, 9 4904, relating to unsworn falsification to authorities, Date: ;;., l6~ ~O(J / r ~ ~ - By: .....- Karl E, Rominger, Esquire Attorney for Plaintiff 155 South Hanover Street Carlisle, P A 17013 (717) 241-6070 - - .' i^; '..' '':ili1lIlOO!ilGlI<I!J~' ,. JONNIE A, LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs. NO, 01-1399 THOMAS NILES GOLLICK, JR" Defendant CIVIL ACTION - LAW DEFENDANT'S ANSWER TO PLAINTIFF'S PETITION FOR BIFURCATION WITH NEW MATTER AND NOW, comes Defendant THOMAS NILES GOLLICK, JR" by his attorney, Herschel Lock, Esquire, and files his Answer to Plaintiff's Petition for Bifurcation follows, to wit: 1. Admitted, 2 , Admitted, 3 . Admitted, 4 , Admitted, 5. After reasonable investigation, Defendant is without knowledge as to the truth of the averments and proof thereof is hereby demanded, By way of further answer though, Defendant avers that he has been and continues to be covered by Plaintiff's health insurance plan provided through her employment with the Commonwealth of Pennsylvania at no cost to either him or her, 6, Denied and, by way of further answer, it is averred that being covered free of charge by Plaintiff's employment provided health insurance plan so long as he is married to Plaintiff is of a significant monetary benefit to Defendant while, at the same time, has no adverse monetary impact on Plaintiff, 7, After reasonable investigation, Defendant is without knowledge as to the truth of the averments and proof thereof is hereby demanded, ,-- " . -,,'~ ",> ,~,-- '~i~ 8, Denied and, by way of further answer, it is averred that after a divorce is granted Defendant will not be allowed to be covered at no cost by Plaintiff's health insurance plan provided through her employment with the Commonwealth of Pennsylvania, NEW MATTER 9, The answers and averments of Paragraphs 1 through 8 hereof are incorporated herein by reference thereto, 10, On or about May 14, 2003 Plaintiff filed a Petition for Special Relief and Bifurcation of the instance divorce action, 11, On or about June 5, 2003, Respondent filed his Answer to Petitioner's Petition for Special Relief and, in it, averred that a bifurcation of this divorce action would harm him inasmuch as it would cause him to no longer be able to be covered at no cost by Petitioner's health insurance plan provided through her employment with the Commonwealth of Pennsylvania, 12, Petitioner's aforesaid Bifurcation petition was denied. 13, Defendant believes and avers that Plaintiff's instant Petition for Bifurcation has already, in essence, been considered and rejected by your Honorable Court, WHEREFORE, Respondent prays your Honorable Court to deny Petitioner her prayed for relief. DATED: 10-28-05 ,;;p;J':r Submitted, HERSCHEL LOCK, ESQUIRE Attorney for Defendant 3107 North Front Street Harrisburg, PA 17110 (717) 238-6661 L i '0"- ~'"' '- "~" of.",-,^<' 'c,: .~ '''V VERIFICATION I verify that the statements made in the foregoing are true and correct, I understand that false statements made herein are subject to the penalties of 18 Pa, C,S, Section 4904 relating to unsworn falsification to authorities, DATED: 10-28-05 ii~IWi~'!~illi~WjW\;~...~H!>iilili~~'~.i.-**'lifr~it,;&~tl5l'ifl" ',.~,~, ,,-~ .--~"~ """"' I ~1;" ~,"~', ~",",-- "' ~l "~- "~ ..," ,~ , ~~ IJllj' ~"liiid_lll:!iJ ,~, ~" ~.. .....,_.. i:'; (') "., 0 = C = -n s:: ..,... 0 -I .....'Cr.! ffl:I! rftln' ("') -;;>' '''--~ -< r- '--~"-' -am zr-' W 0~, e36 r:c ~ ~, " ;:r!'Ti )>0 o:Il <?':O :x ZO ):>c Cf? Om ~ N ~ =< =,' ~ INCOME AND EXPENSE STATEMENT OF THOMAS NILES GOLLICK, JR. INCOME Employer: US Dept, of Defense Address: DDSP-DLA, New Cumberland, PA Type of Work: Warehouse Payroll Number: 187-44-8632 Pay Period (weekly, bi-weekly, etc,): Bi-week1y 0/- ~" IV--"""jg,cs 1399 Cc.~L L l~L Itemized Payroll Deductions: Gross Pay per Pay Period: $1,152,90 Federal Withholding Social Security Local Wage Tax State Income Tax Retirement Savings Bonds Credit Union Life Insurance Health Insurance Other (specify) Union TSP Savings Medicare FEGLI FEGLI optional QASDI Debt Routine Net Pay per Pay Period 138,73 18,44 35,40 8,35 11.00 104.40 16,71 4,52 12,60 71.48 18,18 $713,13 Other Income: Interest Week (Fill Dividends Pension Annuity Social Security Rents Royalties Expense Account Gifts Unemployment Camp. Workmen's Comp, Total TOTAL INCOME ""'-' ~- " ~" '~, Month Year in Appropriate Column) $ $ $713,13 Home Mortgage/rent Maintenance Utilities Electric Gas oil Telephone Water Sewer other Employment Public transportation Lunch Taxes Real Estate Personal property Income Insurance Homeowners Automobile Life , ~~. EXPENSES Weekly Monthly Yearly (Fill in Appropriate Column) $590,00 100,00 35,00 50,00 26,00 100,00 63.00 36,00 ""'-',";;.',";. ,'~ -~-Pl" ,',. '" Accident Weekly Monthly Yearly (Fill in Appropriate Column) Health Other Automobile Payments 450,00 Fuel 130,00 Repairs Medical Doctor 10,00 Dentist 20,00 Orthodontist Hospital Medicine 30,00 Special needs (glasses, braces, orthopedic devices) Education Private school Parochial school College Religious .," '''"'^ JI"" (J~;,r Personal Clothing Food Barber/hairdresser Credit payments Credit card Charge account Memberships Loans Credit Union Miscellaneous Household help Child care papers/books/magazines Entertainment Pay TV Vacation Gifts Legal fees Charitable contributions Other child support Alimony payments Other TOTAL EXPENSES ~ " ",-',-, '.' -l~ Weekly Monthly Yearly (Fill in Appropriate Column) --, -, "'" "' ~' , '~'~':& PROPERTY OWNED Ownership* Description Value H N iI Checking account Commerce Bank $60,00 X Savings accounts Commerce Bank $10,00 X Credit Union Stocks/bonds Real estate 1809 Willow Rd, $78,000 X Carlisle, PA Other IRA - Charles $30,000 X Schwab TOTAL $108,070 * H ~ Husband, W ~ Wife, J ~ Joint ""H".'" .,.- -",,' ~' j "Ili':',:j, LIABILITIES OF PARTIES ( X ) Plaintiff ( ) Defendant marks on the list below those items applicable to the case at bar and itemizes the liabilities on the following pages, Secured X 1, Mortgages 2, Judgments 3, Liens 4, Other secured liabilities Unsecured 5, Credit card balances 6, Purchases X 7 , Loan payments 8, Notes payable 9, Other unsecured liabilities Continqent or Deferred 10, Contracts or Agreements 11, Promissory Notes 12, Lawsuits 13, Options 14, Taxes 15, Other contingent or deferred liabilities , '< ~ ,~'," ; j~iJJ'!. '~'lff~- ASSETS OF PARTIES ( X ) Plaintiff ( ) Defendant marks on the list below those items applicable to the case at bar and itemizes the assets on the following pages, If an item has been appraised, a copy of the appraisal report is attached, X 1, Real property X 2, Motor vehicles 3, Stocks, bonds, securities, and options 4, Certificates of deposit X 5, Checking accounts, cash X 6, Savings accounts, money market and savings certificates 7, Contents of safe deposit boxes 8, Trusts 9, Life insurance policies (indicate face value, cash surrender value and current beneficiaries) 10, Annuities 11. Gifts 12, Inheritances 13, Patents, copyrights, inventions, royalties 14, Personal property outside the home 15, Businesses (list all owners, including percentage of ownership, and officer/director positions held by a party with company) 16, Employment termination benefits - severance pay, worker's compensation claim/award 17, Profit sharing plans 18, Pension plans (indicate employee contribution and date plan vests) X 19. Retirement plans, individual retirement accounts X 20, Disability payments 21, Litigation claims (matured and unmatured) _I~ , ._._'~ ~. ~, . ~'~~ 22, Military/V,A, benefits 23, Education benefits X 24, Debts due, including loans, mortgages held 25, Household furnishings and personalty (include as a total category and attached itemized list of distribution of such assets is in dispute 26, Other ~~" ,;;.'^ ~ - 1,- - ~ " - , . ,- ><,-, O\<(~""~ MARITAL PROPERTY: (X) Plaintiff ( ) Defendant lists all marital property in which either or both spouses have a legal or equitable interest individually or with any other person as to the date this action was commenced, ITEM NO, I DESCRIPTION: 1809 Willow Rd, Carlisle VALUE: $75,000 DATE OF VALUATION: 1997 NON-MARITAL PORTION: All except for any increaser in value durinq time of marriaqe & prior to separation AMOUNT/NATURE OF ANY LIEN: 3 mortqaqes (see liabilities) ITEM NO, 5/6 DESCRIPTION: Commerce Bank - checkinq/savinqs VALUE: Minimal DATE OF VALUATION: Time of separation NON-MARITAL PORTION: None AMOUNT/NATURE OF ANY LIEN: None ITEM NO, 19 DESCRIPTION: Husband's retirement-Calabrese & Sons _VALUE: Unk, DATE OF VALUATION: NON-MARITAL PORTION: All except for anY increase in value durinq marriaqe & prior to separation AMOUNT/NATURE OF ANY LIEN: None ITEM NO, 20 DESCRIPTION: Wife's Workers Comp Settlement VALUE: $25-30.000 DATE OF VALUATION: When received durinq marriaqe & prior to separation NON-MARITAL PORTION: -0- AMOUNT /NATURE OF ANY LIEN: None TOTAL VALUE OF PROPERTY IN HUSBAND'S POSSESSION: ~l _ ~ "'-' I ' ~ -~ ' - ;.. -- ~~" W,<, . '.." , ~H~ NON-MARITAL PROPERTY: (X) Plaintiff ( ) Defendant lists all property in which a spouse has a legal or equitable interest which is claimed to be excluded from marital property, ITEM NO, 2 DESCRIPTION: 1985 Ford Blazer VALUE: $600 DATE OF VALUATION: 11/03 REASON FOR EXCLUSION: Owned prior to marriaqe AMOUNT/NATURE OF ANY LIEN: -0- ITEM NO, DESCRIPTION: VALUE: DATE OF VALUATION: REASON FOR EXCLUSION: AMOUNT/NATURE OF ANY LIEN: ITEM NO, DESCRIPTION: VALUE: DATE OF VALUATION: REASON FOR EXCLUSION: AMOUNT /NATURE OF ANY LIEN: ITEM NO, DESCRIPTION: VALUE: DATE OF VALUATION: REASON FOR EXCLUSION: AMOUNT/NATURE OF ANY LIEN: .J ~ ' - ,~"~ .", , b ~' ~...~, PROPERTY TRANSFERRED: (X) Plaintiff ( ) Defendant lists all property in which either or both spouses had a legal or equitable interest individually or with any other person and which has been transferred within the preceding three years, ITEM NO, 2 DESCRIPTION: 1987 Chevrolet NAME OF OWNER: Husband DATE OF TRANSFER: ll/03 CONSIDERATION: $800 PERSON TO WHOM TRANSFERRED: Trade in ITEM NO, DESCRIPTION: NAME OF OWNER: DATE OF TRANSFER: CONSIDERATION: PERSON TO WHOM TRANSFERRED: ITEM NO, DESCRIPTION: NAME OF OWNER: DATE OF TRANSFER: CONSIDERATION: PERSON TO WHOM TRANSFERRED: ITEM NO, DESCRIPTION: NAME OF OWNER: DATE OF TRANSFER: CONSIDERATION: PERSON TO WHOM TRANSFERRED: _"F"""""~'=W -,~~ , ~, ,~ , ~ """"~"-';!;b" LIABILITIES: (X) Plaintiff ( ) Defendant lists all liabilities of either or both spouses alone or with any person as of the date of separation, ITEM NO, 1 DESCRIPTION: Mortqaqe - Bank of America AMOUNT OF DEBT PRESENTLY: $44.187,34 AMOUNT OF DEBT AT SEPARATION: DATE DEBT INCURRED, INITIAL AMOUNT OF INDEBTEDNESS AND PURPOSES OF DEBT: $54.000 - 1991 AMOUNT PAID BY DEBTOR SINCE DATE OF SEPARATION: $590 per Month ITEM NO, 1 DESCRIPTION: Mortqaqe - Conseco (Greentree) AMOUNT OF DEBT PRESENTLY: $15.500 AMOUNT OF DEBT AT SEPARATION: $17.500 DATE DEBT INCURRED, INITIAL AMOUNT OF INDEBTEDNESS AND PURPOSES OF DEBT: $18.100 - 1997 AMOUNT PAID BY DEBTOR SINCE DATE OF SEPARATION: $226 per Month ITEM NO, 7 DESCRIPTION: Household Realty Corp, AMOUNT OF DEBT PRESENTLY: $15.000 approx, AMOUNT OF DEBT AT SEPARATION: $10.000 approx, DATE DEBT INCURRED, INITIAL AMOUNT OF INDEBTEDNESS AND PURPOSES OF DEBT: $10.000 borrowed to payoff wife's credit cards, Loan in wife's name but secured by Husband's home, Wife filed for bankruptcy and debt was. in essence. transferred solely to Husband, AMOUNT PAID BY DEBTOR SINCE DATE OF SEPARATION: -0- , ,- ".-, -I' '= " -,;. n'--'~jf I understand that the statements made herein are subject to the penalties of 18 Pa, C,S, Sec, 4904 related to unsworn falsification to authorities, ~ ~001Y. I verify that I have reviewed this form with my client to the best of my knowledge the answers herein are true and correct, and 4JJ Jell HERSCHEL LOCK, ESQUIRE Attorney for Defendant "~ -., ,':" '~'-". '1;(' JONNIE A, LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs, NO, 01-1399 THOMAS NILES GOLLICK, JR" Defendant CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, Herschel Lock, Esquire, do hereby certify that on this 2nd day of June 2004, I served a copy of the Income and Expense Statement and Inventory and Appraisement by depositing same in the United States Post Office, certified mail, return receipt requested, at Harrisburg, Pennsylvania, as follows: Karl V. Rominger, Esq, 155 S. Hanover Street Carlisle, PA 17013 DATED: t/1,)01 , , ~~tll BY: HERSCHEL LOCK, ESQUIRE Attorney for Defendant 3107 North Front Street Harrisburg, PA 17110 (717) 238-6661 -(,t ~p ll1!_~!!'i~~a~I:iiB"JI"'I;IHij;;W,,;j~-&1WIl!i~J1ii;j~:kl;f.~";'-,M:bll,,(,j,",Mi""iElIi!'i:d~,~~~.!j*~;.;;;\t!!~~~'~ ~ ~~ ~,_ .n, ~- ',' ~~"Hr."""",<L~-' "-.~I~" II :1 ,I I :1 il " " :1 I ....., 0 0 = ~. "2 -n -I -r:r ,'-' <.- :;I:-n te' , ~ fl."?: " - -om - I ~')'1 ~~~ N Q,__l c' ~~1 " -,:) C?c> ::r: (J '~Irn :J::" ~; ':=:-t :-::"1 0 -~D -( '-< $;.- ~ "~-. .~ ," ~, i , " , i j ,- .~j,~*,) Mar 10 05 09:3Sp Romin~er Ba~1e~ L Whare 7172416878 p.1 ~~~~g~~ LAW OFFICES law@romingerlaw.com www.romingerlaw.com 155 SOUTH HANOVER STREET CARLISLE, PENNSYLVANIA 17013 KARL E, ROMINGER, ESQ, MARK F. BAYLEY, ESQ, MICHAEL j, WHARE, E5Q, JAMES I. NELSON, ESQ, TEL: 717,241.6070 FAX: 717,241.6878 March 10, 2005 E, Robert Elicker, 11 Divorce Master 9 North Hanover Street Carlisle, P A 17013 Via Fax Only: 240-7890 RE: LEAPHART v. GOLLICK DOCKET NO,: 01-1399 CIVIL ACTION Dear Mr, Elicker: This letter will confirm that the pre-hearing conference in the above captioned ca~e scheduled for March 14.2005. at 9:00 a,m, has been moved to March ]4.2005, at 2:00 p,m, by agreement of the parties, ]f you have any questions, do not hesitate to contact me, Sincerely, / ,-'dRominge~, Esquire KER/ljj ec, Herschel Lock, Esquire Via Fax Only: 238-5288 J onnie Leaphart ADVOCACY ADVICE ANSWERS [~ ~ ~ ~ (ii ::r' g. ~ U'l ~. ~ ~ "1.~ ..... .; ~. 0' S < " " a on " .!';. W~ ;::I: ~, -It' " . s on " ~ a 0 ~ " ..., on s ~ ~ ('> ~, " po ~, (JQ < " 8.. g. ..., ~, Jg n::c: a@ ~cr (ii E:l r6 0; R>~ " r.n ::to o ..., n P " o on S .g ~ "" tv o '0 o ;::> o o e [ ~ ~if '0 on o cr [ , "" - o '=' p ~ ~ Ul n n ~ ::r' 0 &' sJ on p " > (JQ (1 Ii > ttI" o Ii ~ @ ~ .... 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'0 Ul <= Ul <= -..l '= '= '= <= Ul <= <= <= '= '= <= <= .,_','C_" ",,",,"._' lil , , , '-.1__, , '~ " "-' VERIFICATION I verify that I am the petitioner and that the statements made in the foregoing Petition are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa, C, s, 9 4904, relating to unsworn falsification to authorities, Dat~?~j;f f' () '-;!'" \ . -L \"') !\ - \. \/\'\/'~ J .{i ! (-'t~t-lL f J./\JJ./t~ /' Jonnie Leaphart i , '"" '~,- . ..' "" -" .., ~" '"' ,;l' ~ .g~~~ml~'~jl,B,q:~""'lio"-'''I"jg'.~~il!i~J-i;",",,,fllIJ,r'';;iiiill,--0.1~l.i'''M_0;~lt.~ir.iilllti " ~ '-,'-' -'"" ,,~ -,~.~ :>- <'oJ f:: 0" ..;l' .0: Z b ("') u..!~ 0"- :r- CL-o (1- '.L :r.:: ~r 0 OJ QC w(l- :-y: -_JuJ ti:~:c , \- "-'J -:,.... U... ,_T ~3, .-..::;::t 0 ,:;:::;:::1 L) ,.--..J _.~ e' iilili\l;~'~ . u ~~_ ~- Hr'--~'" ""~""'" ." _ ,1- ,,' ~- "';J~"~_ . ....~{-;; JONNIE A, LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v, : CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR., Defendant : NO, 01 - 1399 CIVIL TERM : IN DIVORCE ORDER APPOINTING MASTER AND NOW, this t2 $!~ day of 'ftr.a;-- ,2004, < f: 6dd~uire, is appointed Master with respect to the following claims: Distribution of property and counsel fees, By the Court: Distribution: karl E, Rominger, Esquire ~rshelLock, Esquire -.l b'O~ D.?"1v ilf~~IIi:iiiiUi"'M!I;$'-ill<;;;o-$,~ilM~i~~~I,it,'liiiIiM-'<,~4*),",i>iiiW~~1lo/,~it:'~jjM'-' "_~I~ .~~ ".,--~, ,-, " 1 \t!N'\flilASNN:Jri IU~nQ:) :Ji,cr;\i'i~;v~no ".""'-"1l.1 , 2 :F; Wd ~Z ).VU iDOl JJNlQ;~9HlOl:Id 3H1. :10 :rvd:!(}{J3ll::/ , ,~ ~l~ . L. ,'" 1*'j':1 - -., " ii1 "" -' .- . 1- " ",.,,~ -.,' ,. .~",'~ ,'~ ""Ui':- JONNIE A. LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v, : CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR" Defendant : NO, 01 - 1399 CIVIL TERM : IN DIVORCE MOTION FOR APPOINTMENT OF MASTER Jonnie A, Leaphart Plaintiff, moves the Court to appoint a Master with respect to the following claims: (x) Divorce (x) Distribution of Property ( ) Annulment ( ) Support ( ) Alimony (x) Counsel Fees ( ) Alimony Pendente Lite ( ) Costs and Expenses and in support of the Motion states: 1, Discovery is complete as to the claim(s) for which the appointment of a Master is requested, 2, The defendant has appeared in the action by his attorney, Hershel Lock, Esquire, 3, The statutory ground for divorce is a irretrievable breakdown of the marriage, 4, The action is contested with respect to the following claims: Distribution of property and counsel fees, 5, The action does not involve complex issues of law or fact. 6, The hearing is expected to take I day, 7, Additional information, if any, relevant to the Motion: N/A Date: May 24, 2004 Respectfully submitted, ROMINGER, BAYLEY & WHARE 2- Karl E, Rominger, Esquire 155 South Hanover Street Carlisle, PA 17013 (717) 241-6070 Supreme Court ID # 81924 Attorney for Plaintiff iii~iIilDlllllilI~~:'"-- ~' '._~'li~~~w~' "'-'-'~f _.." " ~. ,.." ,. ~ .<."- \". '.-dJoI ~< ., , (") '" = ~ C ~ ~ -o([} ::a: s:!-n t!1 rn ".. ...~;Ll -< rn- r- Z,. N :sm ~~r .;::- 86 ~c; -0 ::C=i-j .:L""C) ::>!: Or) ~'r, 2m ~~.... c: ~ 0 ~ ---I :> ;J:j W -<. ., ~ " -:I--,,~ ',' "d;;-""'h","~Ai,,~<,'--'i, '~''''_ "__"'v', "~"1'\',J~~", -,,'-',;; "" 11HJIIIaS I~ GeWell Sr. -~~_v'17l1l 1809 Willow Road Carlisle, PA 17013 . Home Phone (717) 249,4869 JanUllIY 07, 2000 Ms, Jonnie A, Leaphart Post Office Box 11 Mt. Holly Springs, PA 17065 Dear Ms: Jonnie A. Leaphart , As you have canceled my health insurance, you are responsible for all medical debts incurred after the date of cancellation which was October 28th, 1999, This is clearly defined in the health insurance policy your employer holds, This action also has left me no choice but to bill yon for outstanding debts that you left when you chose to discontinue this relationship, The total of these debts is estimated at $11,001.80, Below these debts are individually listed, Greenl-ree Mortgage Company 2 payments @ $226,00 each Greentree Mortgage Company (half balance of loan) Sale of 1983 Oldsmobile Cutlass Brougham Supreme Storage costs from 10/1/1998 - 02/28/2000 (1011198-12/31/98 $97.50 no sales tax added) (01/1/99-12131/99 $413,90 sales tax added) (1/1/00- 02/28/00$68,90 sales tax added) Deposit for key to storage unit Estimated doctor's bills incurred due to health insurance cancellation $452,00 $8750,00 $500,00 $579,80 $20,00 $700,00 $11,001.80 You are to remove my property as security on your Household finance loan from which the proceeds you benefited from, In the event I must take legal action to collect these monies from you, I will have no choice but to also include all monies loaned to you over the period we cohabited together and have whatever attorney and court costs incurred reimbursed to me, Ms, Leaphart, yon have thirty (30) consecutive days (includes weekends) to make arrangements to repay these monies; remove my property from your Household Finance loan ; and to have your belongings removed from storage, ~ Jl~J. PLAINTIFPS EXHIBIT I J-ir~1..t ~ Thomas N, Gollick Sr, PEBTF f " f. \ " EMPLOYEE ENROLLMENTICHANGE FORM "-, = DEN:rM;J'LA!It,Q:1>,Jl9:t-!, ,~;;,,~; ~~~';i~,:,j~J,E;:}Y~~ ,~Pf!I",-~,,~~N1'AL'9.Ef19E (if[,~iif'il !,ius,pij9,!!!,;reJ"EL,ed) I: ' - ..!- ~ ~ " " ''''"'''~ "" " !li;:":-:, ,; ~ "__'''~,,-~''_, ~.,.,J: ',MEIlIC C" - . - ~".,,",, " ~.~~"., =GHMO ',' .< .~, ':;,~{~~ u .. . SOCIAL SECUl'llTt It GROUP #- EMPLOYEE It POSl110NIt HEALTH CAFl.E CENTER OFt DOCTOR NA 17.5-48-5040 940000 .. .-.'-; Dr.. R:)b~rt D~.Ji:: ~ HEALTH CARE PROVIDER NAME HEALTH CARE CEmER OR DOCTOR # heal-t 1:1 A-ner it:.a. " - NAME (FIRST, MI,I.AST) DATE OF BIRTH (MM,OD.YYl SEX (M.F) MARITAL STATUS C C-t':'U:'"i.('..;.:;.-l~':.T"'; J0:l:;.i~: ~:~ l...~.a?~r::!'l:. :':;-4- 57 F o SINGLE E3 MARRIED o WIOOWED o DIve STREET ADDRESS HOME TELEPHONE # WORK TELEPHONE # DATE OF MARRIAGE {MM.C: 1-809 ;"illo;; ~d Cil.7l ~:.49-4-86~ Gin 705-1142 '2-l7-9B u .. CITY STATE ZiP CODE COUNTY COUNTY CODE DATE OF DIVORCE (MM.iJC (1 THRU 99) c.:l.&:' li51~~ PA 17,)13 C:1.i~U::ir i..--:.TJ.{i - 21 EMPLOYEE DATA DE?ARTMEl'-.'T I COMMONWEALTH DATA Doe PREMIUM C = Pl..AN CODE ij2.5 EFFECTIVE DATE (M,D,Y) ~-17-96 DOES YOUR SPOUSE HAVE OTHER COMMONWEALTH COl/EBAGIi'l~e;NO IF YES, SPOUSES SOCIACSECURITY # NOTE: ENROlLMENT IN MORE THA!'j...,..~,."L~~"Dl?I)NiSi'?R~..pnon!Om:EF..:ao NOT LIST youFI SPOUSE IF ENROLLED IN PEBTF A' ACTIVE oR REfiRED EMPLOYEE,- , SOCIAL SECURITY 1/ NAME (FIRST, MI, LAST) DATE OF BIRTH ADD OR HEALTH CARE CENTER OR DOCTOR NAME OR # AND;' IM,O,Y) REMOVE DEPENOENT ADORESS, IF DIffERENT THAN THE EMPLC , -~- SPOUSE -:-Q:ADD IB7-44-d63Z Th''')fO,~S N G011:c~ $r 2-7~. 56 o REMOVE Good Hope FPC o SON o DAUGHTER o OTHER (Explain Relationship) DADO o REMOVE o SON D DAUGHTER o OTHER {Explain Relaticnsl1lpj DADO o REMOVE o SON o DAUGHTER o OTl-lEA (Explain Relationship) DADO o REMOVE ; DEPENDENT DATA z - ".',"." , '~)' '1ii1l:;oicp,L " " , .. ',;-'":,-:.~~'~~1:.,.,.,.' ''-,~/,':'' 'L#~j.;:. .' , -".-',,,,.-.....,-,, "<""".._c _"L~ , "'~ '~,-- ~J"~ , .. """ -,- ~'>;<; ',i. " INSlJRED NAME IDENTlACATION # - .- EMPLOYER GROUP ~ DEfENDANT'S GROUP It ~EXH1BIT - INSURANCE CQMPANY/AOMINISTRATOf! 11' ' '1:-. /l~ iP LIST OTHER COVERAGE FOR ENROLLEES UST THE"NAMES OF ALL ENROLI..EES COVERED UNDER THIS POLIC'i I~DENTAL'" .' ',>.' ,'~ .;,s.... ~.~...- ~--=>-' .--- Thomas N Gollick, Sr Health Insurance and Prescription Comparing Federal Health America Option vs. PEBTF FEDERAL HEALTH AMERICA (comparable will be hif!h option) $89.82 per pay x 26 weeks (Premium paid by employee) = $ 2335.32 Office visit $10.00 (based on 6x's a year) Specialist office visit $25.00 = $60.00 PRESCRIPTIONS $8.00 Generic $25 Name brand $40 Non-formulary Medications currently prescribed and refilled once a month: Actos generic $8.00x12 months =$96.00 Welbutrin (different dosages prescribed to equal 450 mg) $25.00x2=$50.00xI2 months=$600.00 Glucovance generic $8.00 x12 months =$96.00 TOTAL = $3187.32 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX PEBTF Insurance Health America No premium paid at this time Office visits $15.00 (6x's a year) =0 =$90.00 Prescriptions: (no chart available to Thomas to give generic price, name brand price, non-formulary price.) ACTOS- $18.00 a month x 12 months =$216.00 Welbutrin- $12 each prescription x 2 =$24 xI2=$288.00 Glucovance-$10.00 x12 months=$120.00 TOTAL = $714.00 ~ DEFENDANT'S ~ EX~IT ~ ...) ep..P il!J 't 6'- . . .. JONNIE A. LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR., Defendant NO. 01-1399 CIVIL TERM PETITION FOR CONTEMPT AND NOW, comes Defendant THOMAS NILES GOLLICK, SR., by his attorney, Herschel Lock, Esquire, and files his petition for Contempt as follows, to wit: 1. petitioner herein is Defendant in the above referenced divorce action. 2. On or about October 13, 2003, a hearing was scheduled before your Honorable Court to consider Plaintiff's petition to have Defendant removed from her health insurance. 3. At the date and time of the scheduled hearing, Plaintiff in essence withdrew her petition aforesaid and, by agreement of the parties, an Order of Court was entered which, inter alia, obligated Defendant to both file a Praecipe for Appointment of Master and to confirm that Defendant was still covered by her employment sponsored health insurance. (See Exhibit "A" attached hereto) 4. Since then Plaintiff has neither filed a Praecipe for Appointment of Master nor has she confirmed for Defendant that he is still covered by her health insurance despite Defendant's request that she do so. 5. Defendant believes and avers that Plaintiff's failure to act as above noted is in violation of your Honorable Court's Order - " - -'~~ ;"~~~\'.-, ". aforesaid and, therefore, places her in contempt thereof. 6. Plaintiff believes and avers that Defendant's failure to act in accordance with your Honorable Court's Order of aforesaid is injurious to him. WHEREFORE Defendant requests that your Honorable Court to consider as follows: a) finding Plaintiff in Contempt of the October 13, 2003, Order; b) direct that Plaintiff immediately follow the dictates of said Order; c) direct Plaintiff provide Defendant with health insurance cards; d) pay Defendant's legal fees in bringing this Petition; and e) enter any other order deemed appropriate. DATED: 1-28-04 Respectfully Submitted: ~~ oI.l{ HERSCHEL LOCK, ESQUIRE Attorney for Defendant 3107 North Front Street Harrisburg, PA 17110 (717) 238-6661 ......' L, " JONNIE A. LEAPHART, Plaintiff IN THE COURT OF CO~~ON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR. NO. 01-1399 CIVIL TERM ORDER OF COURT AND NOW, this 13th day of October, 2003, upon consideration of Plaintiff's Petition for Special Relief and Bifurcation, and purusant to an agreement reached in chambers between Plaintiff's counsel, Karl E. Rominger, Esquire, and Defendant's counsel, Herschel Lock, Esquire, it is ordered and directed as follows: 1. It is agreed upon between the parties chat the instant petition be withdrawn without prejudice to either party and be allowed to be refiled as circumstances or events dictate; 2. Plaintiff/Petitioner agrees to file timely a praecipe for appointment of Master; 3. Plaintiff/Petitioner and Defendant/Respondent agree to cooperate with timely filing the income and expense and inventory and appraisement forms necessary to move forward with a Divorce Master's hearing; and 4. Petitioner/Plaintiff agrees to reaffirm that Defendant/Respondent is still covered by her state-sponsored health insurance program and will continue EXHIBIT "An -.ii:l1ll'~~;," ". -~ "" 1;;~;m&AA'#"",:,,! " to be so covered until further Order of Court or direction of the Master. Karl E. Rominger, Esquire For the Plaintiff/Petitioner Herschel Lock, Esquire For the Defendant/Respondent wcy By the Court, 11/ o/:! ~ -- 0 ~ - ~, I , ""r::;,. 1 .0.,' 1 p,... '1" t....~ L V Ii - S ~ -.i - '-'J.,." - - ., J. - , < . ~ ""-.~~/ " . VERIFICATION I verify that the statements made in the foregoing Petition are true and correct. I understand that false statements made herein are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. 1-28-04 14.J~:f DATED: C".- .~-:;> '\ .~.;. ~ id~!ll~~FJ.!i'-n.'fkli,*"M dM#AOO!Ifu';';'<Miit*RJ"Jl),1W:,:;"!tj-,-d<t-51;k,';~,TiHt"',,,,-4!->iI',r.\l\;'-~_"'~~i#..--,;..,--,.MM.._ilIIt~ ~liil'~""~~':....L . lr ~-...,"'--, "" ~m"_ " ." _Lj_""^"'''"'''= ~~" () ...,. ~ = r- ~ L ~ <- ~a '''OeD rnrTl :00- --;;- '.fl :z: ~&~ w ~~ 0 -0 ?.;.C... ::Jl: g~ %.C) - c ~ 35 ~ .r:- w '< . November 26, 2003 Karl V. Rominger, Esq. 155 S. Hanover Street Carlisle, PA 17013 RE: Leaphart v. Go1lick divorce Dear Karl: Approximately five weeks have past since our in-chambers conference with Judge 01er. At that time, as a result of our understanding an Order of Court was entered which obligates your client to file in a timely fashion a praecipe for appointment of a. Divorce Master. To date, that has not been done and I ask you to let me know status of it. The Court's Order reaffirms Ms. Leaphart's responsibility to keep her husband under the Commonwealth sponsored health insurance program she has available to her. Towards that end, I ask you for confirmation that he is covered under it and to send me copies of the cards he needs indicating his coverage. If there is any problem with my client's health insurance coverage or providing him cards, I ask you to let me know immediately. Thanking you for your prompt attention into these matters, I - am Sincerely, Herschel Lock HL/cf cc: Thomas Gollick DEFENDANT'S b EXHIBIT i d 6/ ('1/04 ?f'C.9 -.....=" , ,.-~ , ~" "~_. .,"I1lilil'l!Ni$B!::' December 12, 2003 Karl V. Rominger, Esq. 155 S. Hanover Street Carlisle, PA 17013 RE: Leaphart v. Gollick divorce Dear Karl: I wrote several weeks ago concerning the above matter to inquire the status of your client complying with the Court's Order by filing for a Master's hearing. To date, I have not heard back from you and I ask you to let me know as soon as possible if Ms. Leaphart will do so. Additionally, the Couvt's Order reaffirmed that Ms. Leaphart keep her husband insured on the health insurance program available to her through her employment with the Commonwealth of Pennsylvania and I asked you to provide me copies of the cards indicating such coverage. I have not yet received them. I prefer dealing with these matters informally instead of through the court and hope Ms. Leaphart's cooperation will enable that to occur. Sincerely, Herschel Lock HL/cf cc: Thomas Gollick Karl V. Rominger, Esq. 155 S. Hanover Street Carlisle, PA 17013 .~ ~,1!iiJ,~- i January 29, 2004 RE: Leaphart v. Gollick divorce Dear Karl: Enclosed herein please find a courtesy copy of the Petition and Order I am filing in the above noted matter. HL/cf Enclosure be: Thomas Gallick Sincerely, Herschel Lock RECEIVED --- ~&~ FE8 4 2003 "- . LAW OFFICES law@romingerlaw.com www.romingerlaw.com 1S5 SOUTH HANOVER STREET CARLISLE. PENNSYLVANIA 17013 KARL E. ROMINGER, ESQ. MARK F. BAYLEY, ESQ. TEL: 717,241.6070 FAX: 717.241.6878 February 3, 2003 Herschel Lock 3107 N. Front St. Harrisburg, P A 17110-1310 RE: LEAPHART v. COLLICK DOCKET NO. 01-1399 Dear Attorney Lock: Enclosed please find a copy of a Motion for an Order Appointing a Master for the dispute between our clients. I note that there is a duty on both of us to work out a schedule of marital and non-martial assets. Pkase contact my office to schedule a time and date for you and 1 to conference and resolve how the schedule should be filled out. If! do not hear back from you in the next ten (10) days, ! will assume that your client is not planning on cooperating with preparing this matter for the Master, and I will prepare it unilaterally. Thank you for your time and attention. Sincerely.. ., - , , : ../~ .'" C ,4</ . ',' . !~I -.' ~..71 / '~-7'~t.L r< t:':I&~'---- . __r /, C,C- p ',' ".../ . ,.... r ,-' '- ,'- Karl E. Rominger, Esquire KER:ljj Enclosure cc. Jonnie Leaphart ADVOCACY DEFENDANT'S ~ EXHIBIT :!l 5'"' ~/1"7(()1.1 . /r--R ADVICE ANSWERS ~_....... -~~ .~ ~I JONNIE A. LEAPHART, Plaintiff v. THOMAS NILES GOLLICK, SR., Defendant '''; ".~;-~ .- .1 " '- ,- ~~Ll'W~~~_""I~~';; : : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYL VANIA : CIVIL ACTION - LAW : NO, 01 - 1399 CIVIL TERM : IN DIVORCE ORDER APPOINTING MASTER AND NOW, this day of , Karl E. Rominger; Esquire, is appointed Master with respect to the following claims: By the Court: 1. ..,,; ~~&iP},::: JONNIE A. LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v, : CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR., Defendant : NO. 01 - 1399 CIVIL TERM : IN DIVORCE MOTION FOR APPOINTMENT OF MASTER Jonnie A. Leaphart Plaintiff, moves the Court to appoint a Master with respect to the following claims: ( x ) Divorce ( x) Distribution of Property ( ) Annulment ( ) Support ( ) Alimony ( ) Counsel Fees ( ) Alimony Pendente Lite ( ) Costs and E"penses and in support of the Motion states: I. Discovery is complete as to the claim(s) for which the appointment ofa Master is requested. 2. The defendant has appeared in the action by his attorney, Hershel Lock, Esquire. 3. The statutory ground for divorce is a irretrievable breakdown of the marriage. 4. An agreement has been reached with respect to the following claims: (a) The action is contested with respect to the following claims: 5. The action involves/does not involve complex issues oflaw or fact. 6. The hearing is expected to take 1 day, 7. Additional information, if any, relevant to the Motion: N/ A Date: Karl E. Rominger, Esquire Attorney for Plaintiff ~~ . ~.~ <~. ~".-"-".,~ ~. 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[ > s c = :I ... c ..., C '" :r ... - :I ~. ... ~. ~ ~ - :I >- ~ s ~. ... c '" = ";l :I = ... ~ c ..., ... '" :r '" '" c '" 0- ... 0- '" c i;l '" .., '" ~ er '" = "0 "0 c ~ C ..., ... :r '" '" - ~ s' ::: > ::tI - --3 > t"" C l"'l Ci:l --3 1Jl .' ""~!, ~ 'I , JONNIE A. LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW v THOMAS NILES GOLLICK, SR. Defendant 01-1399 CIVIL TERM ORDER OF COURT AND NOW, this 19th day of May, 2004, upon consideration and agreement of the parties, Plaintiff is adjudicated as being in contempt of the Court's October 13th, 2003, Order entered herein and the sentence of the Court is that the Plaintiff serve 48 hours of incarceration in the Cumberland County Prison. However, commitment of sentence is deferred, and conditions of purge are as follows: 1. Plaintiff will file with the Prothonotary within 3 days of the date hereof, her precipe for appointment of Divorce Master. 2. Defendant shall file with the Prothonotary within 15 days of the date hereof, his Income and Expense and his Inventory and Appraisement forms. 3. Plaintiff shall, within 15 days of the Defendant's filings of the aforesaid statements by Defendant, file her Income and Expense and Inventory and Expense statements with the Prothonotary. 4. Within 15 days of the date hereof, Plaintiff shall pay legal fees in the amount of $350.00 to Defendant's counsel. 5. Within 30 days of the date hereof, Plaintiff shall provide Defendant with written reaffirmation of his continued coverage by her health insurance coverage provided by her employer. ~""'..," ~~~jfJj~~~- ~~~~.M6fti~~!i\>~*,,'=~ cll&..,;:-,~;..J.;.,...,;i' t,/,' '" ~ I' _.'i/vtljf'!Jn". "u..t\/r v....... I ,..",-,.,-I'~f'"l I ~} [:, _.';, i <'.:"',1',1,::;0 ;. ::':-;,--11,",,,,, ,,;c..!i'?i!V l C :! I nv .,. _. 6/ ;'!if..! ~[JOZ A,Qil(ii\fnJ'l ~",-", I\,j"-; n" ':)""1: V,j'd :11.{' C'J'::1;:10-(1::'7',": J. :f0 .J..... '4 '!!L., < < I.",..' ,,==?"!C_... "~ "._. .,..''''"','..... /.'. ,,,. h"~, ~_~,. ~. ;Oil I' " "0..".' ...... .".. ......"....'.".! ~ , ~ - ,~, j' , , \ vKarl E. Rominger, Esquire For the Plaintiff/Respondent vMerschel Lock, Esquire For the Defendant/Petitioner :mae " '-;", ~_~, .1 By the Court, .: ",;."~,.,.' -';":v -'''-',,,,--,,.-,~,-;-, ~7~ " ~\~~ ., ~ .--- -, ,- - _:.L~. - - "-'_ - .,~ '-ne "'Y_~. ;_ , JONNIE A. LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v. CIVIL ACTION - LAW THOMAS NILES GaLLICK, SR., Defendant NO. 01-1399 CIVIL TERM ORDER OF COURT AND NOW, this 1st day of March, 2004, upon consideration of Defendant's Petition for Contempt, and of Plaintiff's Answer to Rule To Show Cause, a hearing is scheduled for Wednesday, May 19,2004, at 9:30 a.m., in Courtroom No. I, Cumberland County Courthouse, Carlisle, Pennsylvania. BY THE COURT, i. Karl E. Rominger, Esq. 155 South Hanover Street Carlisle, PA 17013 Attorney for Plaintiff Herschel Lock, Esq. 3107 North Front Street Harrisburg, PA 17IIO-131O Attorney for Defendant ~~ ()3-();) .D'f ~, :rc l,S .:;:")"".; ~.,,.,, to SD~~~~~*_~~~,~~_~m~~~i1'~"'" is" t<P !EI'_ ~. ". ~~ ft~'O _" .l .".~ 'c.. ~ '"" \Ii i\jhj'rll <~II,i 3H~,..1 l "1 i\",_ ~I ~"""...: t\: ~1!'!IJ'! 1"1'< ~'.-tf~ ~"'!"""!'tn'" / ... d ,I,,, <.,' '_ J_ '.; '.' '~~J:1t:~Y~1 Il.,) Z I :C Hd 2-l:IVW ~aaz I, "'11''" 'C" I' '"'I'd 3'" .- ,\:j iI ,~il\A.k J\..It:1< Hl.=;v 381:!30-{J31!:J ,. - " . - '01, ." c\_ 1 ;:;@- . , '.. D Fr 22004 JONNIE A. LEAPHART, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR., Defendant NO. 01-1399 CIVIL TERM AND NOW, this " tt. ORDER fct..~ . day of ,3'~"uu~y, 2004, upon review of the within Petition IT IS HEREBY ORDERED AND DECREED that Plaintiff show cause, if any she has, why the relief requested herein by Defendant should not be granted. Rule returnable within Ie days of service. BY THE COURT: J. i~~~m."'~~'iill1a.mA1';i!ilii!~~:IJm"ilD<Il~(l?_;,;ii,iMkffi!,;;;gi~~>,,~~l'1lli ~ 1- -'''''~i'Wf.iiEl;W[I~~ ~Hi ~ " RLED-{)j:FiCE OF T\..IE PR01HO~;01AP.Y 203~ FEB 10 Ai1 9: 2i ,."c' '. ,''', (....., 'i..iT\1 CU0Njt;:i~~jt,li..; ~j.,",h.J 'Ill I ....r'l' I~ 11"'\' II' U,t t,} t"'Cl\I\~0) LVh,''ilr\ ....,,( I' If\- "')t ~ f- 0;) ~ ~ 5i"\~ fJ t' '1, 't\- ~r fJ ~ .~ 2,"""tJ, - . i ! .. , i ! I. \~ " . JONNIE A. LEAPHART, Plaintiff v. THOMAS NILES GOLLICK, SR., Defendant - -- . --.'" : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW : NO. 01 - 1399 CIVIL TERM : IN DIVORCE ORDER OF COURT AND NOW, this _ day of , 2004, going upon the review of the Petition of Defendant for Contempt, and Plaintiff's Answer thereto, Defendant's Petition for Contempt is denied. Distribution: Karl E. Rominger, Esquire Herschel Lock, Esquire By the Court: J. .'"' ,~-, -,.;:, o -..'~"') ..:)i'!C ":::1:l' """..., . .,"~ ~ '- ~ - '-' ,'-'- ,- :'-~l1_,~ JONNIEA. LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR" Defendant : NO. 01 - 1399 CIVIL TERM : IN DIVORCE PLAINTIFF'S ANSWER TO RULE TO SHOW CAUSE 1. Admitted. 2. Admitted. 3. Admitted, 4. Admitted in part and denied in part. By way of further answer, Defendant has continued to use the health insurance, and has in fact used the health insurance in approximately the last thirty (30) to forty-five (45) days, Therefore, Defendant knows he is still covered by her health insurance. Further, Local Rule requires that the Praecipe for an Appointment for Master include ajoint statement of matters and property, this has not been completed by either party and therefore, both are equally to blame. Further, it appears that the only outstanding property issues are actually debt issues which are being raised by Defendant. 5. Is a conclusion oflaw and requires no answer. By way of further answer, Plaintiff has substantially complied with the Order of Court, Defendant knows he has insurance, and Defendant and Plaintiffs counsel must submit the joint statement before a Praecipe is possible. 6. Denied and strict proof ofthe same is demanded. , l < ~. ,. _J ' j --''-'-'~~-''~.;,' WHEREFORE, Plaintiff respectfully requests that this Honorable Court dismiss Defendant's Petition or in the alternative enter an Order directing Plaintiif's counsel and defense counsel to meet and complete the joint statement required for a Praecipe to List for the Master to be filed. Respectfully submitted, ROMINGER, BAYLEY & WHARE . ad E. Rominger, Esquire 155 South Hanover Street Carlisle, P A 17013 (717) 241-6070 Supreme Court ID # 81924 Attorney for Plaintiff Date: February 20, 2004 _j_ -0-. -"~_b';:_d< '-~ j -ill -:.;,} JONNIE A. LEAPHART, Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION - LAW THOMAS NILES GOLLICK, SR., Defendant : NO, 01 - 1399 CIVIL TERM : IN DIVORCE CERTIFICATE OF SERVICE I, Karl E. Rominger, Esquire, attorney for Plaintiff, do hereby certify that I this day served a copy of the Plaintiff's Answer to Rule to Show Cause upon the following by depositing same in the United States Mail, first class postage prepaid, at Carlisle, Pennsylvania, addressed as follows: Herschel Lock 3107 N. Front Street Harrisburg, P A 1711 0-1310 --". I E. Rominger, Esquire Attorney for Plaintiff Dated: February 20, 2004 i1~~~M:1~lil!ifi;:~l'i~"'"",_\mlI>~}11!@".~~ihi1Mm,:~~,*,$f.:I!i,-[~" !!It,. ~,~ =. ~ ~"~., ~.W H_' f,lIIHI ,""'.,,- ui.lll!llr -,-. .- -' ~ Q ....., 0 = ..::.:) "T1 "" ~ ..,., --I "~CO, ~- ..1 f~:D C;) , f"- <:Jrn '" '1J9 " c::> >)0 l~: -1--- -0 ~:D ,-,'.:;,i ~.,L- ~-;!.O ~::S~~ -'.. 5rn (..:> Z S' _4 Cl :n -< (.jl -< ~ t COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF AGRICULTURE BUREAU OF ADMINISTRATIVE SERVICES September 2,2003 SUBJECT: Declaration of Spouse Health Coverage and Coordination of Benefits TO: All Employees FROM: Cindy A. Eckert-Horst ~~ Human Resource Director In accordance with the benefit changes recently announced by the Pennsylvania Employees Benefit Trust Fund (PEBTF), active employees as of July 31, 2003, who have eligible dependents on their group health coverage must comDlete the PEBTF Declaration of Spouse Health c;overage Form and the Coordination of Benefits Form, These forms are used to confirm spouse health coverage and to coordinate medical benefits. . Declaration of Spouse Health Coverage Fonn: This is a form that documents whether or not a spouse has health coverage available to them through their employer. The form will be retained in the employee's official personnel folder. Coordination of Benefits Fonn: If a spouse does have medical coverage with their employer, this form must also be completed, It will be retained in the employee's official personnel folder and will be helpful if problems occur with the coordination of benefits. Detailed instructions for completing this form are also attached. Both of these forms are due to the Human Resource Division by Tuesday, September 30, 2003. Forms should be sent to the address listed below: Department of Agriculture Human Resource Division, Room 204 2301 N. Cameron Street Harrisburg, PA 17110 Employees who do not have a spouse or dependents listed on their medical coverage may disregard these forms. If you have any questions regarding either of the.. forms, please feel free to contact Wendy Warner, Benefits Coordinator, at 717-787-1065. Thani(~' }u. Attachments m " DEFENDANT'S ! EXHIBIT IJ~ 2301 NORTH CAMERON ST. HARRISBURG, PA 17110-9408 . 717-787-4854 FAX 717-772-2780 'd""'~-J;,,~_II' _ _ L_~..". om" PENNSYLVANIA EMPLOYEES BENEFIT TRUST FUND DECLARATION OF SPOUSE HEALTH COVERAGE Active Employee on July 31, 2003 The Trustees of the PEBTF require infonnation regarding gronp health coverage available to the spouse of Commonwealth employees. Spouse enrollment in the PEBTF requires primary coverage under the spouse's employer's group health plan, if there is no cost to my spouse to enroll or if there is no financial incentive to waive coverage. This information will only be used to confirm spouse health coverage and for coordination of benefits purposes. Employee Social Security Number Spouse name Spouse Social Security Number My spouse is not currently employed ontside the house, or is self-employed My spouse is employed by: Name Address Phone number Spouse Employer's Health Coverage _ My spouse is currently covered by his/her employer's group health insurance: Name of Health Plan or Insurance Company 1dentificationIPolicy Number _My spouse's employer does not offer group health coverage for which he/she is eligible. _ My spouse is eligible for gronp health coverage through his/her employer, but has declined such coverage. _ My spouse's employer requires an employee contribution to pqrticipate _ My spouse's employer offers a financial incentive to decline coverage. _ Other (explain) Signature: I declare that the foregoing infonnation is true and correct to the best of my knowledge, information and belief, I understand that the PEBTF reserves the right to suspend or terminate my PEBTF group health coverage if it concludes I have provided false or misleading information in this Declaration. I understand that if my spouse's employer offers group health coverage at no cost to my spouse and with no financial incentive to decline coverage, my spouse must enroll in his/her employer's plan. I understand that if my spouse does not so enroll, he/she is ineligible to be covered as a dependent in the PEBTF. Finally, I understand that my spouse's group health plan from hislher employer is his/her primary insurance plan, and PEBTF coverage is secondary. If my spouse should change employment or his/her eligibility for health coverage should change, I am required to notify my local Human Resources Office and complete an updated Declaration of Spouse Health Coverage. Date Signature ofPEBTF Member PEBTF-lI (Act on 7-31-03) PEBTF Coordination of Benefits Form ~ This form should be completed by the employee 1 1) EmplDvool>ala. . .. Socia\Se,C'\,l.T\ty# rame (Last plus suffix, First, MI) IDate of Birth Y~st1 .. 0 Does your spouse have other Insurance coverage? No If you answerod yes , presse complete the following: lC2l Spouse"$ Data Social Security # IName (Last plus suffix, First, MI) I Date of Birth - -..- SDouse's Medical Policy Holder # Carrier Name -Icarrier Address Coverage Start Date Coverage End Date I~a~er Phone # ICarTier Contact Name petlll(tn(tmBS(l..Psr,FIISt,Ml}._a1I'ec:liwda~oflbo:s<tOR'Olooswho""'CQ......"junderlho~"pOIicy_1IA>D""'aboCOYetOd~f'l<Inrlh&PEBTF: Name: Relationship: Effective Date: Name: Relationship: Effective Date: Name: ~elationshjp: . "Effective Date: .- Spouse's Dental Policy Holder # Carrier Name ICarrier Address . Coverage Start Date Coverage End Data l~erPhone# lCaniercontactName fLbtll><l""""",(Lost.Fl"'I.MI),_<llfu~ckltesCfltta""onmIIoCS'OI!>OM't-"""'MOcitind..rthospOu""'&poI\cy'nrodwh:)""'D!soccvorodUl'ldcrtllOPE8TF: Name: Relationship; Effective Date: Name: Relationship: E:ffectiveDate: Name: Relationship; Effective Date: ~"~" -.." _. .- Spouse"s Prescription DruQ Polfcy Holder# Carrier Name Icarrier Address Coverage Start Date Coverage End Date I~~er Phone # lcarrier Contact Name Ustlholll\ll1llOlj!.ll'll.F1r.rt,MIJ,sndaf!cerlvodlllooolth03,,~whomoDDVCroduridorlhoEpDllSD'spollcylltldwhollrDaI'lDDOVOf'l)d~lIdorIhoPEBTf: Name: Relationship: Effective Date: Name: ~elatlonshlp: Effective Date: Name: Relationship: Effective Date: - -.--'- _n_ -. Complete the following section iithe parents are singlez divorced or legally separated and you am reporting COB Information for dependent children which Is provided by someone other than the Employee or spouse. (3) Other Co:verage for aapeiide-nt chlfdren provided by !Someone other than thu individual$ listod in Sections 1 or 2. (see oU1el' ~k1&iftepofling on more than OM chid) Social Security # IName (Last plus suffix, First, MI) IDateofBirth Natural/Adoptive Mother's Blrthdate: Natural/Adoptive Father's Birthdate: Who has primary custody of the child? OMofhe' DFather OJoint OGuanJ~n - Has a court order established that one parent has primarY responsibility for the child's health care expenses? DYes DNa Name of Parent/Guardian with primary responsibility: Medical Coveraae Policy Holder # Carrier Name -ICanier Address Coverage Start Date Coverage End Da-fu- ICarrler Phone # ICarrier ~ontact Name Dental CoveraGe - polley Holder ft. Carrier Name ICarrier Address Coverage Start Date Coverage End Date ICarrier Phone # ICarrier Contact: Name Prescri lion Dm Covera e Policy Holder # Carrier Name Icarrler Address Coverage Start Date Coverage End Date Icarrier Phone # ICarrier Contact Name All PEBTF contraetswllh heal1tl care plans contain a Cootdirlatioo ofBonolits (COB) provision. I decrarathat the Infonn;IUon being provided on this fotlTl Is true and acc~rate. ll!ndllrstand and agroo \h.3ttho PEBTF has tl10 right to Suspend ortetlTllnate my PEBTF heaRh coV()rage andlorcclle<::t any ovorpaymllntofbeollfllslfitcondudes I Iwve provided fllls.9or misleading Infonnalion. Date PEBTF-2a06J03 Signature (303\ Dependent children who do not rQslde with thB- employee ... .,,"--. - ._~ "",- Social Security # lNam~ (Last plus suffix, First, Ml) lDate of Birth f./afuraVAdopfive Mother's BfrthdEte: jNaturaVAdDptlve Father's Birthdate: Who has primary custody of the child? DMother DFather DJoint OGuardian Has a court order established that one parent has primary responsibility forlha child's health cafe expenses? DYes DNa Name of ParentlGuatdian with primary responsibility: Medical Coverage .. Policy Holder # Carrier Name Icarrier Address Coverage Start Date Coverage End Date lCarrler Phone # Icanier Contact Nama Dental Coverage . ~---- Policy Holder # CamerName -Icarrier Address Coverage Start Date Coverage E:rid bate ICarrier Phone # ICarrier Contact Name Prescriotion DruQ COVerage Policy Holder# Carrier Name ICarner Address_ Coverage Start Date Coverage End Date Icarrier Phone #I ICarrier Contact Name 3.b)' tJependent children whO' dO' not f'8slde With the employee Social Security # I Name (Last plus suffix, FIrst. MI) IDate of Birth Natural/Adoptive Mothers Blrthdate: INaturaVAdoptlve Father's Birthdate: Who has primary custody of the child? OMother DFather OJolnt OGuardian . Has a court order established that one parent has.prinl"ary responsibility for the chjJd's health care expenses? DYes ONO - . Name of Parent/Guardian with primary responsibility: . Medical Coverage Policy Holder # CanierName ICarrler Address Coverage Start Date Coverage end Date ICarrler Phone # Icarrier Contact Name Dental Coveraae ~. Policy HoIder# Carrier Name ICarrier Address Coverage Start Date Coverage End Date I Carrier Phone # ICarrler Contact Name Preseri on Oru Covera e Policy Holder# Camer Name ICarrier Address Coverage Start Date Coverage End Date ICan-ler Phone # Icanier Contact Nama 3.cJ Dependent children who do not reside with the employee . . Social Security # IName (Last plus suftlx. First, MI) IDate of Birth Natural/Adoptive Mother's Birthdate: INatural/Adoptive Fathers Blrthdate: Who has primary custody of the child? DMother DFather DJolnt 0 Guardian Has a court order established that onctrent has primary responsibility for the child's health care expenses? DYes No Name of Parent/Guardian with- prirrll,iry reSponsibfllty: " Medical CoveraQe .. Polley Holder # Carrier Name ICarrier Address Coverage Start Date Covel3ge End Date ICartier Phone # ICarrler Contact Name Dental CoveraaQ . 0 Pmicy Holder # Carrier Name learner Address Coverage Start Date Coverage End Date ICarTier Phone # ICarrier Contact Name Prescription Drug Coverage .. Policy Holder # Canier Name leamer Address Coverage Start Date Coverage End Date tCamer Phone # Icarrier Contact Name , ,-^~j-~~ ~- '",' , ~ ",.!!l!, .~" -"~-~.~ ---- ) Coordination of Benefits (COB) If the spouse ofan employee hired on or after August I, 2003, is covered by any PEBTF health care plans, and he/she is eligible for coverage under another emnlover's plan(s), the spouse shall be required to enroll in each such plan, which shall be the spouse's primary coverage, lIIl condition of the spouse's eligibility for coverage by the PEBTF plan(s), without regard to whether the spouse's plan requires cost sharing or whether the spouse's employer offers and incentive to the spouse not to enrolL In addition to the new hire spousal eligibility rule, mentioned above, effective October I, 2003, if the spouse of any Commonwealth employee (excluding new hires) covered by any'PEBTF health plan also is eligible for coverage under another emnlover's planes), the spouse shall be required to enroll in each such plan, provided that the plan in question does not require an employee contribution by the spouse or the spouse's employer does not offer an incentive to the spouse not to enroll. If a spouse has other employer coverage, regardless of whether they pay for that coverage or not, that plan will be the primary coverage and the PEl3TF plan will be secondary. Note: This does not "pply to those employees who have other coverage through the PEBTF. For example, if two PEBTF members are ma1Tied and have elected coverage under their own PEBTF policy, there is no coordination of benefits. Children of those employees may only be covered under one of the PEBTF contracts. Primary dependent coverage will be determined by the COB rules currently outlined in the contracts that the PEBTF has with the various health care plans. In most cases, it is the parent that is born earlier in the year who is primary for dependents. In order to make the appropriate determination as to which plan is primary for dependents; employees must complete the PEBTF-2a form. Section (1) - This section is to be completed with the Employee's information Section (2) - This section should be completed with the spouses information and list those dependents currently covered under the spouse's policy. If other coverage exists for dependents, which is not provided by the employee's current spouse, please complete section 3. Section (3) - This section should be completed for dependents that have additional coverage provide by someone other than the Employee or employee's spouse. COB information should be reported to your Human Resources Office at the time of enrollment and whenever there is a change to you or your dependents coverage. .,.:J..., .1._ 'L ,.