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Home My WebLink About01-06237 l:r~,~1 , , , , ~~ ~ ~ ~~~~ ~ ~ ~~~~~ m ~~~~~~ ~ ~~ ~ ~ ~~~~ , " IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY STATE OF PENNA. MARY ANN SHUTTY 6237 Civil 2001 Pia i ntiff No. VERSUS ROBERT M. SHUTTY , Defendant , , , DECREE IN DIVORCE , , , , , l)~~ 70 , IT IS ORDERED AND 2004 AND NOW, , , Mary Ann Shutty , PLAINTIFF, DECREED THAT , , , Robert M. Shutty AND , 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; ,Vo~ All economic claims raised of record are resolved by the agreement reached by the parties at the November 18, 2004 Master's Hearing. A true and correct copy of the transcnpt of , , , , , , , , . . pro . , , , ~~~~~~~~~~~~~~~~ ~ ~~~~~~ ~~~~~~~~~~ , , . . , , , . , , , ',~ I.~ I ~ ~, . ~.. rr"~'-..t'~'-" T"~ , , . . , , . . , , , . . . , . . . , , . . . , , , . . . , . . . . . . . , , , , , , . . , , . . . , , . . , , , . , . . . . . . . . . . . . . . J. . . . . . . . , . . . . . .. . ;<':"Ji.":':~~~~~_j"':"' "--j "-'~J\~~~~,i ~:';"'i~~t'-<'--~.._;"~"..,,,-.= "",.".'" "~_'" ',,",~,,~, of<.;"";''-''''''' ~',;,;"" "';';.,,-', ",>~,.'" ",-!;-- '" ~;h" ,.. ~, ~~ ;5> ..,; . , .:-t'. , ~ ' , . . . /,;2 . -3 '(}t/ (}d-~ ~~ .~ 4"~ /;1.3 cf/ ~ ~ % ~" ., . :", MARY ANN SHUTTY, Plaintiff IN THE COURT OF COMMON PLEAS OF ,CUMBERLAND COUNTY, ,PENNSYLVANIA vs. NO. 01 - 6237 CIVIL ROBERT M. SHUTTY, Defendant IN DIVORCE THE MASTER: Today is Thursday, November 18, 2004. This is the date set for a hearing in the above captioned divorce proceedings. Present in the hearing room are the Plaintiff, Mary AnnShutty, and her counsel Theresa Barrett Male, and the Defendant, Robert M. Shutty. Mr. Shutty is not represented by counsel. This action was commenced by the filing of a divorce complaint on October 31, 2001, raising grounds for divorce of irretrievable breakdown of the marriage. Mrs. Shutty filed her affidavit and waiver with the Prothonotary on November 12, 2004; Mr. Shutty has given the Master a signed affidavit of consent and waiver of notice of intention to request entry of divorce decree dated today which will be filed with the Prothonotary by the Master's office. Therefore, the divorce can be concluded under Section 3301(c) of the Domestic Relations Code. The complaint also raised economic claims of equitable distribution, alimony, and counsel fees and expenses. The parties were married on July 23, 1977, 1 ,v>;;n"rJ~ ^ ~'I ~':~ ,,' I . - ~ ~ , ']; and separated on October 3, 2001. They are the natural parents of one child who is emancipated. After discussion this morning, the parties have reached an agreement with respect to the outstanding economic issues. The agreement is going to be placed on the record in the presence of the parties. The agreement as placed on the record will be considered the substantive agreement of the parties, not subject to any changes or modifications except for correction of typographical errors which may be made during the transcription. The parties will return later today to review the agreement, make any typographical corrections as required and then affix their signatures affirming the terms of settlement as stated on the record. Upon receipt by the Master of a completed agreement, the Master will prepare an order vacating his appointment and counsel for wife can then file a praecipe with the Court requesting a final decree in divorce. Mr. Shutty, would you give us your address? MR. SHUTTY: 608 Plaza Apartments, Lebanon, Pennsylvania 17042. THE MASTER: Mrs. Shutty, do you have an address for the record? MS. MALE: We prefer not to disclose her address at this point. 2 ".:""ry,~.~ ~, " ~= ~'I e, I -~~ . C"''''~j;;'~~ ,..L THE MASTER: That is fine. Ms. Male, do you want to proceed with the statement of the agreement on the record? MS. MALE: Yes. Thank YOUr Mr. Elicker. 1. The parties have agreed that the National Vision Administrator's 401(k) plan, which has an account balance as of today's date of $20/342.93 will be awarded in ,its entirety to wife. We anticipate doing this by a Domestic Relations Order which wife will be responsible for preparing and submitting to the plan administrator. Mr. Shutty will cooperate in signing any documents necessary to effectuate the transfer. It is further understood that the transfer will be free of any tax consequences unless Mrs. Shutty decides to withdraw the funds which will then be her responsibility for penalty and taxes. 2. Mr. Shutty has agreed to pay as alimony to Mrs. Shutty the sum of $750.00 per month for a period of 36 months. This alimony obligation will begin 60 days after the date on which Mr. Shutty secures employment as a pharmacist earning $30.00 an hour or more. These payments will be treated as alimony for federal income tax purposes. Mr. Shutty will make the payments directly to Mrs. Shutty through her counsel. The payments are nonmodifiable. The alimony obligation will terminate upon the d,eath of either party. It will not terminate on wife's cohabitation or remarriage. 3. Mr. Shutty has agreed to pay the sum of $2/000.00 as counsel fees towards Mrs. Shutty's attorney fees incurred during this divorce proceeding. He agrees to make that payment within 6 months of his securing employment as a pharmacist earning $30.00 an hour or more. He will make the payment or payments directly to wife's counsel. In order to implement the award of counsel fees and the alimony award, Mr. Shutty has agreed to contact wife's attorney when he secures the employment that we have just discussed. Concurrently with entry of the divorce decreer Mrs. Shutty will withdraw with prejudice the support action currently pending in the Domestic Relations section. The arrears to stand subject to ariy further settlement between the parties either privately or through the Domestic Relations section. 4. Prior to today's proceedings, Mr. Shutty sold a 1990 Hyundai. He will retain the $500.00 proceeds which he received from that. Mrs. Shutty traded in a 1994 Suzuki. 3 ~,~ ......."", =1 I" ~ - r ; ,ci~Ii'"<!"4T l..,,_ .0',",<' ''> "" She received $1,000.00 as a trade-i~ value. She will retain that. Mrs. Shutty will retain without any claim by Mr. Shutty the proceeds she received from the sale of the former marital residence which had been deeded from Mr. Shutty to Mrs. Shutty prior to the appointment of the Master. Mr. Shutty will retain without claim by Mrs. Shutty the proceeds he previously had received from the 401(k) plan through National Vision Administrators. 5. Prior to today's proceedings, the parties divided the personal property within the home to their mutual , satisfaction and neither party will make any claim with respect to any of those items of personal property. (An off the record discussion was held.) The parties had an agreement off the record regarding some personal property items that Mr. Shutty has an interest in securing. Mrs. Shutty has acknowledged that some items may be in storage from after the house was sold. She will use her best efforts to investigate the contents of storage unit and any and all items that belong to Mr. Shutty, such as books or CDs, CD player, musical instruments or their cases and accessories, Mrs. Shutty will make available to her counsel for delivery to Mr. Shutty. 6. Except as herein otherwise provided, each party may dispose of his or her property in any way and each party hereby waives and relinquishes any and all rights he or she may now have or hereafter acquire under the present or future laws of any jurisdiction to share in the property or the estate of the other as a result of the marital relationship including with6ut limitation, statutory allowance, widow's allowance, right of intestacy, right to take against the will of the other, and right to act as administrator or executor in the other's estate. Each will at the request of the other execute, acknowledge, and deliver any and all instruments which may be necessary or advisable to carry into effect this mutual waiver and relinquishment of all such interest, rights, and claims. 7. If there are any documents which need to be signed to implement the equitable distribution award or the counsel fee or alimony award, both parties will do so within ten days of the request. Specifically if there are any documents that Mr. Shutty may need to execute he will do so within ten days of my requesting him do so. 4 ,'~ J '- I ',' ~\,~ ~ , THE MASTER: Mr. Shutty, have you present during the statements on the record? MR. SHUTTY: Yes. THE MASTER: Do you understand the agreement as stated on the record? MR. SHUTTY: THE MASTER: Yes. Do you have any questions about it? MRS. SHUTTY: Yes. MS. MALE: Do you understand the agreement as I have stated it? MRS: SHUTTY: Yes. MS. MALE: Do you agree with its terms? 5 "i.J....~~ -, -, "1 ,~ ~"_.,~~ ,'- ~ ~. . ''''<',\'&. " .~,,, .. ,,; MRS. SHUTTY: Yes. MS. MALE: Are you willing to be bound by the agreement that we have reached here today? MRS. SHUTTY: Yes. MS. MALE: Do you understand that once we have this agreement on the record neither one of you will be able to litigate this matter any further - the divorce action, I mean? MRS. SHUTTY: I have one question (An off the record discussion was held.) MRS. SHUTTY: Yes. I acknowledge that I have read,the above stipulation and agreement, that I understand the terms of settlement as set forth herein, and that by signing below I ratify and affirm the agreement previously made and intend to bind myself to the settlement as ~ contract obligating myself to the terms of settlement and subjecting myself to the methods and procedures of enforcement which may be imposed by law and in particular Section 3105 of the Domestic Relations Code. WITNESS: DATE: ~~ 1/;0 f r t ~ w~ Theresa Barrett ale Attorney for Plaintiff ;!u"-tiU&-tt~ It;le /O'f ~ :?v. ~ Robert M. Shutty 6 <, " r I "~, , ~ ,>", " ,{ "_-,, ",,0- P"," <';,/' - P!!f1" c- .~, 0,' ~~'~-I "-, ,~" ~-' t5 iIb , ~ . ", ." """.n,', '" ""~IJlillii~IHlau r"'I'YtTT"l'fj'f'!W 0 ""' = 0 c = ... "ow .r- e ~f-~ ~:f-'; :;;it': --/ 0 :r:JJ ;[;:;'1 "'" ~~~ ~~~!;:', 1'.) :01.. ..". 0 ~t,',' "h ::t~l A;c'; 3: ?):!J ~~2 ~~7 C) ~ Of'11 -'," ~t;j <- .::;,1 w ~X) ~,l -< -'<", ." ,~', "4-,-;,;,~~-f"-:-f~\!'tfJ\Ij'<1'J1;,,qi!\~",~~m~~~~'~fl~!lt:!Il}f>.~~~~) 9~ . ..... Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 171.01 (717) 233-3220 tbm@tbmesquire.com Counsel for Piaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Pia i ntiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - 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 S (3301(c)) (gg01(d)(1)) of the Divorce Code. (Strike out inapplicable section). 2. Date and manner of service of the complaint: Personal service on 11/01/01 per the affidavit of service filed of record. 3. Complete either paragraph (a) or (b). (a) Date of execution of the affidavit of consent required by S 3301(c) of the Divorce Code: by plaintiff: 11/11/04; by defendant: 11/18/04. ;"""ij<,~I\\;.!i1" '~," " ~~~ ~~" .~-- - o ~"" . _ ,.,.~~,,__f- , . - (b)(1) Date of execution of the affidavit required by S 3301(d) of the Divorce Code: N/ A. (2) Date of filing and service of the plaintiff's affidavit upon the respondent: N/ A. 4. Related claims pending: All economic claims raised of record are resolved by the agreement reached by the parties before Divorce Master E. Robert Elicker, II, Esquire on 11/18/04. 5. Complete either (a) or (b). (a) Date and manner of service of the notice of intention to file praecipe a copy of which is attached: N/A. (b) Date plaintiff's Waiver of Notice was filed with the prothonotary: 11/12/04. Date defendant's Waiver of Notice was filed with the prothonotary: 11/18/04. L Counsel for Plaintiff Date: November 23, 2004 2 ""'''<'''-~\f~~, ,_,', ."1 ''1'' I. ". () ~~. ~"'Q\.::':1 .f,\ ',f ~_l ;-;...' (...~,T -;. ~~;~ ~C;! ;-'" (~ ;2, ..oj -<. ::i ...- t.5 ~ !~" ii '~ :;1 ,~ J '~ 'I ';",~ ~ ,,~ ",- ::;l;. ~ rv ,r:' - . q. ~e :<6'~',' t) ") 3'" ~o, 3;\ ~G ,"')f'<1 ';:::-l ~ -;L -., ,.- ':;lC '" .' - t,) UliIl .'_ '1'_ rm-,.,,,"'~~''''__ => f1~-;,. ; ~m;~"',*:'''~''"~'-'1')'~T',~'1f'F0r-~''''~~~!l!l~~~4'4!m~M1'ilf!!~'''!MJ~!.J}ii- ~ MARY ANN SHUTTY PLAINTIFF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Y. 01-6237 CIVIL ACTION LAW ROBERT M. SHUTIY DEFENDANT IN CUSTODY ORDER OF COURT AND NOW, Wednesday, November 07, 2001 , upon consideration of the attached Complaint, it is hereby directed that parties and their respective counsel appear before Melissa P. Greevy, Esq. , the conciliator, at 214 Senate Avenue, Suite 105, Camp Hill, PA 17011 on Monday, December 03, 2001 at 1:00 PM for a Pre-Hearing Custody Conference. At such conference, an effort will be made to resolve the issues in dispute; or if this cannot be accomplished, to define and narrow the issues to be heard by the court, and to enter into a temporary order. All children age five or older may also be present at the conference. Failure to appear at the conference may provide grounds for entry of a temporary or permanent order. The court hereby directs the parties to furnish any and aU existing Protection from Abuse orders, Special Relief orders, and Custody orders to the conciliator 48 hours prior to scheduled hearing. FOR THE COURT, By: /s/ Melissa P. Greevy. Esq. IJr^ Custody Conciliator The Court of Common Pleas of Cumberland County is required by law to comply with the Americans with Disabilites Act of 1990. For information about accessible facilities and reasonable accommodations 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. YOU SHOULD TAKE THIS PAPER TO YOUR ATIORNEY AT ONCE. IF YOU DO NOT HA VB AN ATIORNEY OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FOR1H BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 Telephone (717) 249-3166 """"'~'~ , "'7"'!~r" ~~, ,,~ - l ,~ " , , V'" ---'~ ~~YF,Jh"'-i'I\;C"','J9Ei',jjI"3zlJt;':,"::0'iillf;"d!,~,iJ!I,;k<l\-tl;li"j;T",tiMj-l~"'X>i;:t.,~,,,,^,~~;~,: '!'O'"d::-i;"'~i",.,ij";;;:{";!;:>f'Wt.f.JJk.;fu,!#.$~llnj!i8lliiifl~j,JJ'tt:i!ll.~.'!ilMl!W~liiiii /! It)! 1/11l/ II'f'!)! u~ , 'i~ ~'t,-'()):!\.RY , ' ;,I} ,~I",; r" ~ ,1 C' -, () '1. ")-''' . ,c.. ....:J (-.,'--",\ P;';j\lf,!{'\'1 \ ;..,U:.JI'!TY -. \ ~\)jL./,'\,\,I:'6 , III td.I&Jjt~~4 ~ LJ1~ ~ ~ cfII- ~~~4~ ~ ~"...., 0 ~~ , n?,<" __'~ ." .,,~. ,,~, ^~<~_., ", ~, . '~ ~" -[T ~.~' 1,:: 1: 1,1 ]'! I' , i ' ; ~ ill 'Ii \il . , ()\ NO~200t Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 Counsel For Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. 0l-t..23'hvil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - CUSTODY ORDER OF COURT AND NOW, this day of November, 2001, upon consideration of the attached Complaint for Divorce and Custody, it is hereby directed that the parties and their respective counsel appear before the Conciliator: at on , 2001 at .m. for a Pre-Hearing Custody Conference. At such Conference, an effort will be made to resolve the issues in dispute or, if this cannot be accomplished, to define and narrow the issues to be heard by the Court, and to enter into a Temporary Order. All children age five or older may also be present at the Conference. Failure to appear at the Conference may provide grounds for the entry of a temporary or permanent Order. ""'-'!:-":;'.!!\!~r'IJ~ '^ -, l....,.~ :""""'" c- " - ,.~ ~,~~~ . . . < For the Court, Date of Order: By: Custody Conciliator YOU SHOULDTAKETHlS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 1-800-990-9108 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 information about accessible facilities and reasonable accommodations 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. BY THE COURT: J. 2 'p~ffllm:, .,~ ~. , ~ I" ~! - '.. r , ~~ I"Il1 Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, P A 1710 I (717) 233-3220 Counsel For Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. i{{ 01-" Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - 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 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 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, Cumberland County Courthouse, South Hanover Street, Carlisle, Pennsylvania. ~""~flr"_..,,';",.,, " -~, ' , ,~"', ~" I~ , ~- ~, " "'r",~ ~"'". _~ %' 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, P A 17013 (717) 249-3166 1-800-990-9108 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 information about accessible facilities and reasonable accommodations 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. BY THE COURT: J. 2 ',!..:~~1." '., ," '~'" ,,'~ ,~,~ ....".-- ~, ~'-' - ~ t . ,.--~ Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 Counsel For Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. 01- ~31 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE/CUSTODY COMPLAINT IN DIVORCE Count I - Divorce 1. Plaintiff is Mary Ann Shutty (SS# 176-52-6717) who currently resides at 59 Windsor Way, Camp Hill, Cumberland County, Pennsylvania since in or around 1990. 2. Defendant is Robert M. Shutty (SS# 189-42-0639) whose current residence is unknown, but whose mailing address is 59 Windsor Way, Camp Hill, Cumberland County, Pennsylvania. 3. The parties have been bona fide residents in the Commonwealth for at least six months immediately previous to the filing of this Complaint. 4. The parties were married on July 23, 1977 in Glassport, Pennsylvania. 5. There have been no prior actions for divorce or annulment between the parties. 6. The grounds for divorce are: a. the marriage is irretrievably broken. "v~,,~.....,. ~ r~' - , T . n _,_,~~.,1 b. Defendant has committed adultery. c. Defendant has offered such indignities to Plaintiff, the innocent and injured spouse, as to render her condition intolerable and life burdensome. 7. Neither party is a member of the armed forces of the United States or its allies. 8. 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. Wherefore, Plaintiff requests the Court to enter a Decree in Divorce under sections 3301(c) and 3301 (a)(6) of the Divorce Code. Count II - Equitable Distribution 9. Plaintiff incorporates by reference paragraphs I through 8 above. 10. During the marriage, Plaintiff and Defendant acquired real and personal property. Wherefore, Plaintiff requests the Court to enter an Order equitably dividing all the marital property. Count III - Alimony 11. Paragraphs 1 through 8 are incorporated by reference. 12. Plaintiff lacks sufficient assets to provide for her reasonable needs and is unable to support herself fully through appropriate employment. 13. Defendant has sufficient assets to provide continuing support for Plaintiff. Wherefore, Plaintiff requests the Court to enter an order granting her alimony. 2 'J'''-:w;:r''j'!if' T I,~ , ~ ~ -"T " ;~ Count IV - Alimony Pendente Lite, Counsel Fees and Expenses 14. Paragraphs 1 through 8 are incorporated by reference. 15. Plaintiff lacks sufficient assets to provide for her reasonable needs and is unable to support herself fully through appropriate employment. 16. Defendant has sufficient assets to provide continuing support for Plaintiff. 17. Plaintiff enjoys medical benefits under Defendant's employment benefits. 18. Plaintiff does not have medical coverage independent of Defendant's coverage and cannot afford to purchase it privately. 19. Plaintiff has retained counsel to pursue this action and has agreed to pay her attorney a reasonable fee. 20. Plaintiff lacks sufficient funds to meet the costs and expenses of pursuing this action, including counsel fees and the costs to retain experts to value the marital assets. 21. Defendant has sufficient assets to provide alimony pendente lite, counsel fees, costs and expenses for Plaintiff. Wherefore, Plaintiff requests the Court to enter an order: a. directing Defendant to maintain Plaintiff's medical coverage during the pendency of the divorce; and b. awarding Plaintiff alimony pendente lite, interim counsel fees and expenses; and 3 - '<"~',,,,i:-~,,...__ ,,~oj,,'_,'l"Ill':_ ~_ "'!llI!f ~~ ~, '".,.,~ , ~i>' , c. thereafter awarding Plaintiff such additional counsel fees and expenses as the Court deems just and appropriate. Count V - Custody 22. The plaintiff is Mary Ann Shutty, residing at 59 Windsor Way, Camp Hill, Cumberland County, Pennsylvania. 23. The defendant is Robert M. Shutty, whose current residence is unknown. 24. Plaintiff seeks custody of the following child: Name Present Residence Date of Birth Kevin Shutty 59 Windsor Way Camp Hill, Pennsylvania 04/30/85 The parties adopted the child during their marriage. The child presently is in the custody of Plaintiff, who resides at 59 Windsor Way, Camp Hill, Pennsylvania. During the past five (5) years, the child has resided with the following persons at the following addresses: Name Address Dates Mary Ann Shutty 59 Windsor Way Camp Hill, PA 10/03/01 to present Mary Ann Shutty Robert M. Shutty 59 Windsor Way Camp Hill, PA 1990 to 10/03/01 The mother of the child is Mary Ann Shutty, currently residing at 59 Windsor Way, Camp Hill, Pennsylvania. 4 "^;,^",.~~"'l""'" c_ ,~,r: ,~ I "~~ ,~ !' ~j; She is married. The father of the child is Robert M. Shutty, whose current residence is unknown. He is married. 25. The relationship of plaintiff to the child is that of mother. The plaintiff currently resides with the following persons: Name Kevin Shutty Relationship Son 26. The relationship of defendant to the child is that of father. Defendant currently resides with the following persons: Name Unknown Relationship Paramour 27. Plaintiff has not participated as a party or witness, or in another capacity, in other litigation concerning the custody of the child in this or in another court. Plaintiff has no information of a custody proceeding concerning the child pending in a court of this Commonwealth. Plaintiff does not know of a person not a party to the proceedings who has physical custody of the child or claims to have custody or visitation rights with respect to the child. 28. The best interest and permanent welfare of the child will be served by granting the relief requested because Plaintiff has been the child's primary caregiver and nurturer. 29. Each parent whose parental rights to the child have not been terminated and the person who has physical custody of the child have been named as parties to this action. 5 ':"'''f~:,~ , . ~" ,~ ".-., , ' ~ -.1 ~- , Wherefore, Plaintiff requests the court grant her custody of the child. L~'L Theresa Barrett Male, Esquire Supreme Court # 46439 513 North Second Street Harrisburg, Pennsylvania 17101 (717) 233-3220 Counsel for Plaintiff Date: October 29, 2001 6 ~',;'!'0!\';'"t~ , ," ~,~ ':I--~-;- ~' " ~ ~ " " , ,.~,.~"- VERIFICATION I, Mary Ann Shutty, state upon personal knowledge or information and belief that the averments set forth in the foregoing document are true. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~ 4904, relating to unsworn falsification to authorities. J!:;~hu~j!1 Date: /(;)/30/';1 Ojl:~"'7'~I':WJJjU_:::: 11'. o~~" - ~ - ",,1J1l'1 - "1 '., ~ ~ "0 " . .JIIL, " ~"""f~,'!"""~,~.,.., "',,,", -,:;" .~,' _ G ~~ ~ ~ ~ f2 --- .p. 9-.J -.0 DIl"'c'- ""l. ~ ~ ~ & ~ DOO' ~Ct) IC()~C~ I I v DC) f!!&v ~ ~ ~ if- J-~ ?-: r- ~ -- -- ~ ..\l CY (') c:.:: iH/r ~_:,t ~~ ' fe. ~J; ,--~,', ~~:::, ~ ","- - " ~".I ~ 5~ ,<~5 '2 ~) ,'\) r,; c:-: ':~ :::( :::."") C") -~~1 .;'....) ',,:"',~,,;c (+> '-") ::;',,--j' ....:] ~.. , C"I~~~' ~l'iilO"~",-I!!: 'H ,F ",~~~,~'K:lj't"-::',"'-,"$";,-C"; ',",I'':F """'1'-""1' !""'fi!.;",Iqt"l~f;J< ",>'Vi' "" ~ i ;;"1' - ">llr0,'l ,",,-'I<'~'i-K,lY'!t~ ~ Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesquire.com Counsel for Plaintiff o C :?'"~; \Jt'ii q..1Lf'J ""-^ ~ ,; ~~~: ~~, Pc: 2: :;J , "" = ,= -""' z a <:.: ~, ,,- ~T'l --I ::c rn~ -om :[10 C).L '-IU '::::C:::H 0('5 ;;;::rn ,,J .;""::! :t -< N ;:t:'!I- ::r= OJ <.1'1 .j;:' COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE AFFIDAVIT OF CONSENT 1. A complaint in divorce under S 3301(c) of the Divorce Code was filed on October 31, 2001. 2. The marriage of plaintiff and defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. S 4904, relating to unsworn falsification to authorities. Date: November 1\ ~~A4 Mary n Shutty ,2004 .'-,';"',,'j(}:g;;;~lI1 ;,'" ~ "" ,',CO' '__, ,~~, ~ - Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesquire.com Counsel for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE AFFIDAVIT OF CONSENT 1. A complaint in divorce under S 3301(c) of the Divorce Code was filed on October 31, 2001. 2. The marriage of plaintiff and defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. S 4904, relating to unsworn falsification to authorities. ~~ Robert M. Shutty Date: November /~ ,2004 .<.j",~-- _-'?~=_H. ',,' ~""1~-, I -- ~ " , 1f5{; # (J ;g; s: :c::: co r.o) ....J ,..,,,,',,,, ,'~ _'~n,"," _"",;:,"~~~,I ~ t~" '__'._ ..J,),l!!!~~~Oi\'W'W'if"ili"""<!'f,"",~~~jil("W~tf"i~<-f.'V\FWlfl"f,~J"'i,","i!",'f*"11!:;'1(~,",";;r~~~0"f"",FW0'f~~~ ..... = 5~ :;Jr.: I~ :;: ool>t:'': ~ 3 C:? en .J:- o -n --I :r. -n en?:::: ~n>-n :i'Jc.J ~.~~ :'~;'\ '-,D -,< N Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesquire.com Counsel for Plaintiff COURT OF COMMON PLEAS OF DAUPHIN COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY: Defendant CIVIL ACTION - DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER S 3301(c) OF THE DIVORCE CODE 1. I consentto the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the prothonotary. I verify that the statements made in this affidavit are true and correct. 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: November --11-, 2004 11 g '~A_?IJt;, Mary n Shutty -',f"'!\""'i!;'~!W9-". ~" .-", _. ,~~ "I 'I - r'~ , , ~~ . ., , '"'-++''.''' '",'","'+ ",,+,n'"++''''111Inrll~IW1Dljilliini'r''''tll'i'1' i5. f)/u 1nn " .' ' " ++. " ',n ,. r ~!'1l';~"""'" ,"'~',' ,'"':-'r....~ L !~J!l!J"..., '" _,~~,,>> ". ',~" ~IKl"JRq.,*',""l,:f'+f',~"p,"""-;;.."~jf;3-!"!!i\~~t~ll:'%'i<H(?~~~!~'!'\<i!,~*'"~J.i~!\\!~~ Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesquire.com Counsel for Plaintiff COURT OF COMMON PLEAS OF DAUPHIN COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY: Defendant CIVIL ACTION - DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER S 3301(c) OFTHE DIVORCE CODE 1. I consent to the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the prothonotary. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. S 4904 relating to unsworn falsification to authorities. Date: November ( 'if , 2004 ~~ Robert M. Shutty .- ''m'l!''1!", - ." ",' ~ ,'~.. _j "," _ '" ", I''.'" 1 ", ;,', j' "",- I ;,," ~" -,.,.--. 11.\J,rm~!f1 ~ '"""<"',,~=' t5 1/ (2.1L ,-:> t:-:;;:l :T~ ..~.~" ,,,,,~. I~) ~''-C: c:,::, 0'0'1] TI ~Jin~w Cl ~n .-1 :t~p r-f1r...::'- -ncn ~0 ':~~,7J~ '2")1'n ,'0 -. " ~l~' ~-~'" .;~;! ~u .,~~_,~,~""~="~:Mlif~'Ijj~"\J;\'f,h-"W~'H*&f~"\*"'~*~'""H'f%."I',,,,,~Wi'-"i',",'Y:,;~n.,*,,4H~'jWi~'ili'll~~!~(i1~1'Ef1~"J.~~~~;- Theresa Barrell Male Supreme Courr # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 Counsel For Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. 01- 6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE/CUSTODY AFFIDAVIT OF SERVICE PURSUANT TO RULE 440 Document Complaint in Divorce and Custody Date of Service November I, 2001 Place of Service 4415 Lewis Road, Harrisburg, PA 17111 Manner of Service Personal service per the proof of service attached as Exhibit 1 ~~ I Theresa Barrett Male, Esquire Counsel for Plaintiff Date: November 7, 2001 "O''-''"~li!l;;I,^ _ co, _ '., _~ _..~,~, I"'"'" I' ~~ I'" ~ " '" - ~~~,'~~ I""''!';''~ ~, Ii I .. PROOF OF SERVICE (Requesting Agent) THERESA BARRETT MALE COUNSELOR AT LAW 513 NORTH SECOND STREET HARRISBURG, PENNA 17101 (Type of Document) COMPLAINT IN DIVORCE; AND CUSTODY AND SERVICE LETTER. (Witness Fee) ,,),1 (Case No. & Jurisdiction) CUMBERLAND COUNTY, PA NO. 01-6237 (Plaintiff) MARY ANN' SHUTTY (Defendant) ROBERT M. SHUTTY """,- ". ., '.' .'; 'i (A~Cllpted ,ay) ", f<c\u.r--i M S leu. 4+~ '-HIS LeWIS r<d H:z.rr-l":,bu'j,?cz (To ae Served On) , '. ROBERTM. SHUTTY ," ;1".,1 4,415 LEWIS ROAD HARRISBURG, PA 17111 , (Date Served) ./fie tH: rn ~ /,.,2C' c.7 ( (Process SerVer's Report) (Time) 1:;10;,,,,,, (Process Servers Name) L...JJ"J J k!Qr:ru , Description: riMale [ ]Female !>iWhite Skin []Black Hair HBlackSkin [ ]Brown Hair [ JBrown Skin [ ]Blonde Hair [ JYellow Skin [ JGray Hair [JRed'Skin ~ed Hair Ldl'l'vA1~;;~; being duly sworn according io law, deposes and says that helshe is process server herein named; and that the fact herein set forth above are true and correct to the best of their knowledge, information and belief. J) '')-w"' /J~ ~ ' :LPMV r, ' ~s~ Server , [ JWhite Hair [ JBalding [ ]Mouslache [ JBeard [ JGlasses [ ]14-20yrs H:/1-35yrs [ J36-50yrs [ J51-65yrs [ JOver65yrs , [JUnder 5' []5'Q~'i5.'3~' , [ ]5'4"~5'8" ~'9"_6'0" [lOver6' ' , + JUnder lOOlbs , , f Jl.OO,BOlbs [ ] 131 ~160lbs lM!.61-200lbs . []Over, 200lbs Sworn tOh and subscribe before me this ...iR,Lday of oU{ 07 oO-i-. ~~.n~A~ N ry Pubhc Commission Exp. , ,--',,",,,,,,),-",, :__: ~ ~'ll: ''1':1" --~, .-'~' '."" ] Ii ',~: ,;1', "- "' ~ . ,. <~_ ~ffl,~ 1~"'"C"" =-- ~ ~ '~,.,""--.,. ,.~ -- ',--c^~~'o/I~'" ',~";:"'-","",:c"A<"";;f"nN''k'J1~'~'" . r+'"~<:~1r"IT~'~~\'r.~!'rlii'jr~;"""":~';;~""f':,;:1t~;;~; , '"/C) T ~ 'J ~ cz f' ~ t- .:;-~ L "C) C ~~f~:; Z:.J~ ~( :~:t""':, :;;." c~~ ?.:: -; -< ... c) C") 'T.': \~(} (:'"" , , .., " ~~ ""',.",.__'="....,~~~*':!ffl\~;~#-,:1i('~t\'ii~'iJ:ffiffi1i!iil.~,~ii.~~Plli'1~1~~.~~ij"Mn~;I!J'~~l ~, .;f'r: c: '" '" r~ -- ...::' '{'i,iii''''''''') Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 Counsel for Piaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Pia i ntiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE PLAINTIFF'S MOST RECENT TAX RETURN AND PAYSTUB PURSUANT TO Pa.R.C.P. 1920.31(a)(l) '~P"F!hi1;",,"~ --~, ,~",", ~ I, " ~f I ,. -- '" ! ., ,-"".,=" dTotalnumberofexeclalmed........................................ . 7 Wages.-.Ups,elc.AIlachForm(s)W-2............................... 8a T8llIlb1e 1_ AIIach Schtldule B ft requlred. .. . . . . . . . . .. . . . .. . . . . .. .. . . . . bT-.mptInliwstDollotjnc(udeOlllinella...........1 8b 9 Ordlnarydlvidends. AIIach ~dule B ft required .. .. . .. . . . . . . . .. . . . . . . . . .. . . 9 10 TaxaIIlerelunds,credits,oroffselSoIstateandlocalil1Clllllllllll\lS(seeirm1ruc\ions}............... 10 11 A1bnony_....................,.................... ','" .... 11 12 Business Income or (loss). A1Iach Schedule Cor c-EZ . . . . . . . . . . . . . . .,. . . ; .: .. .' 12 13 Capltalgainor(loss).AIISchDftreqd.ftnttl'ellli.ckhera .................. ~D 13 14 OII18rg8lns or (losses). Atll!!lh Fonn 4797 .................... .....;....... 14 1!ra IRA _uIlons. . . . . , . " . Lm1 I ti T8xable arnoUDn_, liIsIis).. 1Gb 11h1.Penslonsandannullles....1J!!I "b Taxableamounl(_Insbs).. 1Gb 17 RenI8I real estate. roxaJlIes;.1!8I1nerShfP.S, S <lorpora1lons, trusIS, SIC. AIIach Schedule E. . .. 17 18 Farrnlncomeor~oss).AUai:hScheduleF.................................. 18 18 UnempJoymentcompensatlon......................................... '19 2lla-Sodaf-.rilrbmefits,... ~ I b Texableamounl(seelnsbs).. 2llb 2:1. 0lII0r income ,21 22 AddtheamOUiiiSin1ii8lef-iiiOOiiiiiiiif';;:iiii8s7lhro-h21:-ThiSIi--iOi8I~.-:. 22 23 EducaIorexpenses (_In~ns) : . . . . . . . . . . . . . . " 23 24 IRA deducllon (See ~iJns} . .. . . .. . . . .. . . . . . . . .24 25.. SludenIIoan Interest deducUon (_InslrucIIons). . . . . . . . .. 25 26 Tulllon and fees deducUon (seelnsllUcllons). . . . . . . . . . . .. . 28 111 Anlher MSA deducUon. AlIach Fonn 8853 . . . . . . . . . . . . .. 111 28 Moving expenses. AIIach Form 3903. . . . . . . . . . . . . . . . .. 28 28 0ne-haIf of seI/-empIoymeJ)l tax. AIIach ,Schedule SE. . . . . ., 28 30 Self-employed health Insurance deduclion (seelnslrucllons). .. 30 31 Self-employed SEP, SIMPLE, and quaDfied plans. . . . . . . . .. 31 32 Penelfy 011 ee~y wI1hdrawel of savings. . . . . . . . . . . . . . . .. 32 33a Alimony pailf b Recipient's SSN. .. ~. 33;' 34 AIldlines23thrcllVl33a............................................... 34 35 SUbIraIllllne3 fro U This Is Income. . . . . . . . . . . . . . . . .~ 35 BAA ,For Dlacloaure, Prtvacy Act, and PapeMork ReduCllon Act Notice, _Instructions. FOlAOll2 12<26102 Form 1040 Label (llee-l U8lI the IRSIIIIleI. OII18rw1s8, please print or type. pl8!Jldenl/8l EleclIOII C""lJ8Ian (seellisfnlil1ono.) RUng Stetus Check only OIIe boX. Exemptions ft more 1han live dependen1B, see lnsln.lcl1ons. Income AII8aIl "._ w-z_.w..zG .~~ Form(al1~ If llIlI_wllhh8ld. ft you did nol get.a.W-2,._ 1iI0trucU0ns. Enclose, but do nofatl8ch, any ~enl AlsO, r"::S1:'V. AdJusted- Gross Income )-!;~,~,y@T,1,'ll;"fl'i ;.4l11im<~,[,,~,~ lRSuse -Dordwtlear Inlhlsspace. . 20 OMS No. 1545.0014 YourliOClalsecarlfrnumber SBO'J.'TY M1 Lasl name 176-52-6717 Spousn__number __~ond_UyouhB".P.o........._ 59 WINDSOR WAY CIy,_orpo9l_.uyou.......__..._ --.... A Importantl A You muat enter your social security numbar(s) above. staIa ZIP..... CAllP BILL PA 17011 You ~ Nllle: ChaQklng 'Yes' wD1 not change your tax or reduce your refund. ~ Do ,or ft ' a ,1ntreUn,wanl$31o Ololhlslund?......... Yes No Vee 1 SIl1gle 4 X Heedof~~~peISOIIJ;J,See 2 Maniedfllingjoinlly(lMlIIhnlyooehadinoome) ::;::=l~~~~~ 3 MlI1ried flUng soparalely. Enlerspouso's SSN _ & full name here . ""lONIlf S SBUTTY name here. . ~ G 0 QuaIlIylng wldoW(8I) WIth dependent child (year spouse died .. ~ ). (See lnsInlcIIona.) Ga~~~:r~~.~~~.~.~~~~.~.h.~~..... }~:r~. b . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :n:... . (2) Dependent's (3) DePendenl'8 (4) '" U ..., ..-: C Dependenla. 80cIeI security relallonshlp ~ ..... number 10 you laX'::.. _you... 1 ArsI name Last name ....., . dlflnot ...- you ""1B,_ or_ (BIBh\SIIB). . ~"':=,.. ...-'...... No 1 14 247. 27 671. 270. 210. 27 401. Form 1040 (2002) --~"!_II!!~Il!l!If:, I ~~ =""'~-" - ,~"~"~ ,,~-~,,"'- ~ ',~ ~~, ~~~ .' . -.... -_.- ..--- Tax and Credits StjIndard DeduttIOR tor- BPellp/ilwlio cIIeCk8d any boX onUne 31a GI' 37b 01' wtK>can be, aIIliiled lIS a dePerldent,see lnslrueuons. B A1lo1hel9: '~ Head of ~, $6,900 Ma,ned lilIri9 ' &, $7,850 ManIed !IIInll ~ly, Other Taxes Payments U you haVe a ,~llyIng ChIld, a!I8Cb Schedule EIC. Refund Dlrecl ~Il? Seo~ llndmlln 71b, 71e, end 71d. Amount You Owe ThIrd Party Designee Sign Here JoInt return? see'lnslrUcllons. Keep a copy fer your reCoRIe. Paid Preperer'a Use Only ^T,;""'"CJ:3"'W " , ,~_~ 27 401. 3lI Amountfrom line 35 (edjusted gJlISS IncOme) . . . , ... .. . . .. .. .. . . - .. . . . .. . . ; . 37aCheCkIl: 0 Youwere65lolder, OBllnd; 0 Spousewas65lolder, 0 BlInd. Add 1I1e number of boxll8 checkBd abOVe llIld enter 1he _ her.. . . . . _ . . . .. .. 37a b U you are manled1l1il1ll seplII'IIIely llnd your spouse IIamizes d8d\IClions. .. 0 GI' you were a duHtilus auen, see insInIl:lIoiIs and CIteCI< beIB . . . . . . . . . . . 37b, 3lI lIIimi10d deducllens (fnlm Schedule II) or your slanlIanI dedudioll (see left margin) . . . . . . . . . . . . .. 1I8 ,3lI Sublractllne 38 from line 36.. ............. ............... _........... 38 40 U line 3618 $103,000 or less"mulllply $3,000 by1l1e 10laI number of exempUons claimed onlnell<<l.UIlne361sover$103;000,see1he\VorlcsheelIn1heillsln1C11Otls........... . 41 Tmlllelm:Gme. Sublra1:t line 40 lromline 39. 1f1ine4Oislllliletllanline39,IlIlblr-O'... _..... .............................. 42 TIl(SllIlinsllS). Chudt if81lYtill is from a DFlIIJ1(s)8814 b o FllIIIl4912. ........ -.... -.. ... Allemellvll mllllmum tax (see insIrullllons). A1Iad1 Form 6251. . . . . . . . - . . . - . . . - . . . 44 Add lines 42 end 43 _.... ..,............... - -... -..... -.... .......- 45 foreign lax credlt. AlIach Fmm 1116U required. . . . . . . . . .. 45 48 Credit lor cI1ild and dependent _ expenses. A1Iacl1 Form 244t . . . . . .. 45 47 CredIt fer 1he eldelly or1he dlsabled A1Iad1 Schedule R . . . _ _ /fI 48 EducaIIon CfedIts. A1Iach Fmm ll863. . . . . . . . . . . . . . . . .. 45 48 Re1Irement stWIngs contJlbuUons credll AlIach Fonn 8880. . .. 48 5lJ. Child lax CIedil (eea 1nslrucUons) . . . . . . .. .. .. . . . . . .. . 60 51 Adoll\lOn credlt. AlIach Fmm 88S9. . . . . .. .. .. .. .. .... lit 52 CrediIs fnIm: a 0 FllI1II8396 b 0 Fcrm 8859. .... .. . .... 62 113 01her crediIs. Cheek applicable bOlC(es): a 0 FllIIIl3800 1> 0 =' c OSpecily 63 114 MIl lines 45t11rouoh 53. These8l1lyourllllalcredlls........................ -....... 85 Sublract line 54 from line 44. U line 54 is _ than line 44 .enter -0-.. .. . . .. . . . .. .. . Il6 SeII....ojlIbpl...dlllLA1Iacl1Sd1edu1eSE...................................... Il7 Social SOCUJilJ and Medlcarelax 00 tip income noI RlpOf\edloemplGyer. A1Iacl1 Form 4131 ............ 'll8 rax 00 qualified plans, indIiding:UlAs, and dherlal.iIPiured_A1Iacl1 Form 5329 if required ....... 118 Advance earned InCOlllB CIedil paymeI\1s f1um Fonn(s) w-2 . . . . . . . . - . . . . . . . . . . . . . llO HousahoId empIDymenI taxes. AlIach Schedule H . . . . . . . . . . . . . . . . . . - . . , . . . . . - .. MIl rmes~ This is llIlaIlu. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. CI2 Federallncome lax wl1hhekI from Fonns W-2 and 1099. . . . . . ,&2 757 . .. 2Iil2estiniiltildlaxPBJllllllllSandamountappflGdfnlm2lXl1retum...... 83 Il4 E8med Incmne cnlIIII (ElC). . . . . . . .. .. .. . . . .. . . ... 84 r Il5 Excess social SOCUJilJ and tier I RRTA lax wilhheId (see instrudlons). . . .. Il5 Il5 AddIUonal child lax CI8dlI. A1lach Form 8812. . . . . . . . . . . .. 811 fS7 Amount paldlllith request fiJr ll1lIension 10 IIIil (see instrudlons) . . . . . .. fS7 iI8 OlIterpmtsfnlm: a DFllIIIl2439 . DForm4136 . DFllI1I18885 811 iI8 MIl Unes62 68. These8l1l llIlaI . . . . . _ . _ , . . . . . . . . _ . . . . . _ - . . . . )0 U line Iil is IIIIlI8 tIIan 6ne 61, subIract line 61 fnlm line 6Il. This is the amount you GVelJllid. . . _ - . . . . - . l1aArnounlofllne70youwmllrerundedloyOU.........;................... . .. b RouUng number. . _ . . . ~ c Type: 0 CheckIng 0 Sevings .. d Account number; ... . . . 72 Amount of 1i1l870 you want 'ieol1D 1tlD3eslima1edlu..... 72 'l'a' AmountyGUawe. Sublra1:tlinelilfnlm line 61. For details 00 how 10 pay. seelnstruclions. ..... ..... .. 7lI 14 Eslima1ed1Bx _inllfJuctioll8 . . . . . . . . . . . . . . .. 74 Do you wmII to allow ano1her person to dIsCUss lhIs return wI1h 1I1e IRS (ilee instlucllOns)? . . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . _ . . .. 0 v.... Cample18the followihg. ~nee'S .. Phone Personal IdentBlcatlon 0llm8 , r\9. .' :' numbBr(PIN) .. ~Iel -""".2'_fl8I1W\1.1-..lIlaIl....9lClllII1nedIlllorelUm..........-_...._nte, ....loll1ebeo1almy...l701edQeand _ .1hoY...h__....__al_(alher__~_...aII_al__h8SlIl1Y__ -_ Dale YlullCCUjlOliln 0avUme__ . ,/ M "\ . a . 63CBURCH WORK _ sign. Dale_llCCUjlOIiln . 14 594. 12 807. 3 000. 9 807. 983. 983. 983. 983. 284. 1041. 58. 58. I!J No ~. Alm's1llllllO Self-Pre ed ~. ~.:!e"" Dale ClHIft EIN PIIoneIlll. Form 1040 (2002) FDlA0112 12/28102 ,:" __,.'1' " . , -I'~ ,- -~'''~~~.'^~~ ~:.::v (99) Neme(s)shoWnonFom1OcO MARY ANN SliU'l:'l'Y lledlcal C8IIIIon. Do not Include expeR88S reimbursed or paId by olhel's. and 1 Medlcalanddenlalexpenseo(S1lIliomroliolls)................... = 2 EnteramounlfromFormI04O,Une36.... 2 88$ 3 Mulllplyllne2 by 7.5% (.()75). ......... ............... 3 4 SublrlICIIlne3fromllne,. 1f1lne31smore1hannn1l1,enter-o, ...................... 6 SlaIe and local Income taxes. ... ..... ......... ..... .. 5 548. 8 RellIestaf8taxes(seelns1rUclIons)..................... 8 3 047. 7 Pe""lRaI properIylaxeS . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7 8 OIhertaxes. LIsl type and emount . _ _ _ _ _ _ _ _ _ _ __ Other taxes 10. 8 10. 8 Adiiir.-S-ttii'oiiiiiia.-::-.-::-:-:-::-.-::-.-::-:-:-::-.-::-.-:........................ 10 HomemtuillleleslandpoinlsreporforlIBJIllIonForm,lll98............ 10 9 526. 11 Home ~elntereelnotreportedfDl'OO on FOrm 1098. IfpaldlD th8penlO11lrom whmn Y!lII bolight th8 home, see InsIrircIkms 8nd show that person's neme, ldenlilylng number, and eddress . :4;; SCHEDULE A (Form 1040) T_ You Paid ~) 1- You PeId SEE S'DIT (See li1struclIons.) Hole. Personal 12 IntereeIIs 13 not dedudlble. 14 GIft8 to 15 Charity n you made 18 a gm and f: a benellt n,see 17 JnsIrUcIIons. 1. Cesul!ltY and 1heIl Lciese8 18 JobI!XpeneM 211 andM_ 0Urer UIaoeI"-" Dedueltona (See InslIucllon8 ~r:nses here.) Other Miscellaneous DecluctIona Total Iblmlzed Declucllllll8 OMB f4Q. 1546-0074 Itemized Deductions 2002 07 .. AUeCIt to Form 1l14O. , .. See InslrUCtlons for Schedule A (Form 1040). 3,605. ---~-------------------------- 11 PaiiitS mt ~ ~ y.; Oii rom. ioii,Sft il.sils fOr opClNi'Os -: :-.-: :-.-: .. 12 InWSIment inI8Iest.AtlacIl Form _If required. (See ioslIs.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 13 Add Bnes 101hJough 13 ........................................,...... GlIl8 bycasll or dIeck. Ifl'OO mede any gm of $250 or more, seelnslrucllons................................ . OIber1hen by cesh or __ If any gill of $250 or more, see InsIruclIons. You _ alf8ch FOrm 8283 n ..-$500.................................... . Canyoverfrom pIIor)'$8t . . . . . . . . . . . . . . . . . . . . . . . . . .. 17 Add lines 15th 1l...................................... ......... 10,225. 442. or1helt lIS. AtlacIl Fonn4684., SeelnsJruc1lons. . . . . . . .. . . . . . . . . . . . . . . U1n1mbursed employee ~h..... -lob travel, unlon dues, job educitlon, etc. You mi181 alf8ch FOrm 2106 or 2106-EZ n requlJed. (See lnsInictions.) .. ------------------------------ lI!'!.l'~J]II_ ~l,!)2L~.Q~-]l! __ _ _ _ _ _ _ _ _ _ _l!.70. 21 Tax pnlpll!lt1Ion fees . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . 22 Other expenses - _, safe deposit box, eIc. LIsl typeand8m6unt.. ____________________ 28 Addfines20through22............. __............. 24 Enter amount from Form 1040, line 36. . . . 24 27 401. 25 Mulllply line 24 by 2'lb (.02) .. .... .................. .. 25 548. 26 Subtraclllne251\'om line 23. RIlne25lsmolll1hennne enter-o.................... %1 Other -1\'om list In 1be /nsIrUcIIons. LIsltype and emoulll .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 322. 28 Is Form 1040, fine 36, ..- $137,300 (0_ $68,650 If MFS)? ~ No. Your deducIIon Is not 1Imifed. Add 1be amounts In 1be fer right column for lines 411mlugh 27. Also, enter this lIIIlllllnI on Fonn 1040, line 38. o Yee. Your deducllon may bellmlled. See InsIIucIions for 1be emountfDenter. } BAA For PapenvlIl'k Reduction Act NlIIlce, _ Form 1040 Inswellons. FOIA0301 10fl8lO2 Schedule A (Form 1040) 2002 'i;;:",,';q"~~'~'~1JM~~. ~ _,i1, VT, JilJiJ;,~ .l!fL , W "1~ " ^ 1 "'" ~~W\, - ~~ -....IhIT_"" (99)' --- Name{$) shoim an r8Ium MARY ANN SHUTTY See the Ins\rUctlons for Form 1040A, line 41, or Form 1040, line 64, to make sure that Before you begin: (a) you can take the BC and (1)) you hava a qualllylng child. . II you take the EIC even though you are nol eligible, you may nOl be allowed to lake the credlllor up to 10 ye8I'S. See the Instrucllons for details. CAunON: . II wlil take us longer to pro~ your retum and Issua your refUnd II you do not fill in all lines that apply for each qualilylng child. . Be sure the child's name on line 1 and SOClaI securtly number (SSN) on line 2 agree with 1he chlld'8 SOClaI ~rttY callI. Olhel'Yllee, at1he flme we p_ your retum, we may I1lduce or dleallow your EtC. II the name or SSN on tI1e cIilld'e social securlly cant Is not COmlct, call1he SocIal SecurIty Adinlnlslr8llon al1.800-772-1213. Eatried Income Credit Qualifying Child Information CompfeIe and at/aCIr to FomJ 104l7A or 1040 only I/JIlIIIIrs... a qua/if1fng chHd. 0t.U3 No. 1545-0014 SCHEDULE EIC (Farm 1040A Of 1040) 2002 43 VoursoclalsecurlfynOfllb8r 176-52-6717 Qualifying Child informatIon Child 1 Child 2 1 ChIld's name -...... .......... Rnl...... ..... ..... If you have ",ore than two quaIIlylng chUdren, you only haVltlollsltwotonetthernmdmumcredll.......... . KEVJ:N S SHUTTY 2 Chlld'e SSII The d1lldmUSl have an SSN all d!lflned In the Rlrm1. ...F!JmI1040tnshuclIons unIlis8 the cIll!d wlIJ,_ aijd CIIllllIn l!OO2. K your d1lld wall boml!l!ll~tlI!1/OO2 am/,dldnot haW 8fI SSN. enlllr'QI$d' on, tIiis One and a\tach a copy o1lhe 159-72-3048 cIllld'e.cetiIlIcale....................... . 3 CbIId'ayaarotbldh . . . . . .. . . .. . . . . . . . . . . . . . - 1985 - - 1/__='. t984, 11 bolD atIer ;1::::-3/' 1984, sfdp Iines.fa and ; go 10 Ifne 5- _lines.fa Mil ; go to Ifne 5. 4 If the child WIIIl 110m befoIe January 2, 11ll14- a wasll1a c:hIId under age24atll1a and 012002 and o V... o No. o V.... DNo. alilUdelll? . . .. . . . . . . .. .. . .. . . .. . . . . . . . . , Gorob5- Coarlque Go rob 5- CcIIdIallll b~':::-.:u"~~~~....... . Dv8ll. DNo. Dyes. DNo. C_ue The child Is hot a C<mfI1Jue The cIllldls not a quaJlIyIng chilli. chHd. 5 ChIld's nohdlOnehIp to you l:: 8w-r::~~'~~~1. ~~: ~~~: . _ Son 1I ,,', N!I!JIll!IrotlllOlilhs child RvadWltltyou In theUnlled ~durlni 2lIo2 , . K the chIIlI'~ _ you lor IIIOIe Ulan hall 012002 bullNs lhan 7lR011ll1ll, _7'. . IIlI1achild.bom or died in 200.2 and your home wasll1a ':, ,home lor lI1a _ ume lie or she wasallVedilltn92llll2,_'12'.............. . ~ rnon1hS months DonotenterlJlOlVlhBn 12monJhs. Do not enter more IhBn 12 months. ~ You may a~ be abls 19 take lI1a addIIIonel child IIll( cradlttt your child (8) was under age 17 alll1a end 01200.2, lb) Is clalmad es TIP your dep8fi!leOt on Dne 6c of Rlrm 1~4OA or Form 1040, and (0) Is a U.S. cI1IZan or resident allan. For more detalla see the Instrullllc>1l$lor llne 42 0' Form 10401\ or One 68 01 Form 1040. BAA Fllr papanriorkReductlon Act Notice, ... Form 1040A lII' 1040 Ilt8tl'uctlona. Schedule EIC (Form 10401\ lII' 1040) 2002 FllfA7401 10129102 i<WI~r:(,lJ ,.,',' ,', ~ 1 - ~ -I I - ,~_ ~" " Fonn 2106-EZ UnreImbursed Employee Business Expenses OMBNo.1545-1441 =-=J.:'Y (99) VO\l"..... .. AtIaclI to Form 11140. "",,-m_,..__ CHURCH WORKER 2002 54A SocIal security llUIJIber MARY AI!lN SBUTTY You May Uae TIlle Form Only If All ollhe Following Apply. . You are an,employee deduc\lng ordinary and necessary expenses 8lIrIbutable 10 )lOur job. An ordinary expense Is one that Is common and aooepll!d In )lOur field 01 trade, busln8$S, 01 profession. A necessary expense Is one that Is helpful and appropriate lor )lOUr business. An expense cIoeS not have 10 be requlnld 10 be considered necessary. . You do not get reimbursed by)lOur employer lor any expanses (amounts )lOur employer Included In box 1 of your Form W-2 are not considered reimbursements). . If you are claiming vehicle expense, you are uelng the standard mneage rate for 2002. CllUtlon: You can use IIle standard mileage raIB tor 2002 on/lf It: (/I) ~ oWlJlld IIle whlcIB and used tlte standatrlmHe/lg8 Tale lor tlte tfJSt yelll' you p/a(:8d the vehJc/e In service or(b) you /sased the vehicle and used the standard mileage rate tor tlte portlo/j ofllle lease perIOd alter 1997. _figure Your Expenses 176-52-6717 1 VlIhlcIe expense using Ihe standard mDeage rate. Complete Part II and mulUply line Sa by 36-112' (.365). . . . . . 1 365. 2 ParIdng fees, l01Is, and tnmapartaIion, including -. bus, eIc, 1haI cIId _ irMlIve owm/ghttravel or commllllilgloandfrommrl<."... ".................... ....................... .... 2 3 Travel expense while 8!N&yfrom home ovemfghl, Including lodging, airplane, car rental, etc. Do_lnc:ludemealsand~. ,... ... ........... ..,.... ..........."......... 3 4 IlusIIl8sf expenses nollncludod 011 lines 11h10ugh 3. Do not Include IIllllIis and entertainment. ..... ................. ........................ 4 467. 5 Meals and entertainment .'1Il enses: $ 75.x 50% (.50) (EmpIoyeessubjecllo Deparlment ofTransporIlIlIon (DOT) hours of seMce nmll8: MlIIiI>Iy meal expenses by 65% (.65) InslelId of 50%. Fordelalls, seelRstrucllone.). . . . . . .. .. . .. .. .. .. ... . " . . . . .. . . . .. . . . . . . . .. . . . . 5 38. 8 1-'::== Md 1lne811hrough 5. ~r here and 01) UnellBotScll....JJaFonn 104l1). r:; .":. ,illaIeorlOcal 90llllilllnlllll~~~d=:inglllll$. arid I uals wIIh dIsabIIIfIes: 8 870. ,1hj.~ forsiieclal ruleS on Wll$l1lenter amount}". . . . . . . . . . . . . . . . . . . . . . . . . . . . . _'Information on Your VeIllcle. Complete this part 0II1y If you are c1abn1ng veltfcIe expense on line 1. 7 When did you place your vehicle In serviCe for business use? (month, day, year). . . . . . . . . , . . . . . . . . . . . . . . . . , . . . 8 Oflhe 10IaI number of miles you drove your vehicle during 2002, enfer the number of miles you used )lOur vehicle for: alluslll8sf __________~~~q b~~ ___________~~q ~r_ 8 Do you (or your spouse) have another vehicle llva11ab1e lor peDlOII8I use? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Wll8yourvehlclellYallableforpersona/useC\UilngOll'dUlyh0UJ8?................................ 1111 Do you have ll\4denlle to eupporl)lOur deducllon? .. .. .. . .. .. .. .. . .. .. .. . . . .. . .. .. . .. . . .. .. . . bUOY; '1sIhee'll!lenl;eWdllan?........"............................................. BAA For Pllplilwork Aeductlon Act NOIice, .....plUllIe 1n8lrucllone. .. J.!/J.~Q.2.~. _~Jl2q X No No No Yea No Form 2108-EZ (2002) FDfA7501 1 UI8I02 "j:,t~'W"-----.:''l! ",-- ,'- , -, - : FomI4562 Depreciation and Amortization (Including fnforl1lat/on on listed Properly) ~ See llllpaI_ iI1SbIIcIIiIlI8. ;. AIIacb to vourlal; nlIurn. OMB No. 1546-0112 ~~~~ Name(S) shaWh CIII f8IUm MARY ANN SIIllTTY BusInee8 or aotMlY to WI\ICh thIS 10an relalea l!'Orlll,21()6 CltURCH WORKER _l'i~/qn To~e Certain Tangible prop,erty Under Section 179, Note: If you haw anyllSted properly, complete PSTt V before you complete Part I. ' 1 Mexlmum amount. See lnsIrucllona for a hlgher IImIlfor eerlaln b\lSlneSSllS . . . . . . . . . . . . . . . . . . . . . . . . . 2 To1alcoslol_179prope11yplaeedlnll8nlk:e(seelnslrucllons)............................. 3 Th/8SIKlld cosl 01 secIIon 179 proplllll/ beIonJ reducllon In 1IrnIIaIion. . . . . . . . - . . . . . . . . . . . . . . . . . . . . . 4 RedudIOl1In 1ImIlation. Subb8cl1ine Strom line 2. If rAII'O or tess. enter -0-. . . . . . . . . . . . . . . . . . . . . . . . . . 5 ~ar~..:=:.:.~~~.~~~~.~.~~~.~:~r.:,":~~~.~............ & <4_ Cost...._OOSl 2002 67 -"'9 number 17 6-52-6717 1 24 000. 2 3 $200 000. 4 5 Usledproperty.En\er1hellfilountfromHne29............................. 7 TotaIelecledcoslolSf!C1lon t79 property. Ml!ooY!\1!! in <;Q\Umn(c). IlneS II Mil 7. _""", """"", TentallVededUclloo. Enler1heemallaroflne5orllne8. .. . . . . . . . . . . .. .. . . .. . . . .. . . . . . . . . . . . Carryover 01 dl8aIlowed deducUon from line 13 01 your 2001 Form 45& . . . . . . . . . . . . . . . . . . . . . . . . . . . BusineSS income 1ImIlation. Enter 1he smaBer 01 business Income \l1ol1esll1l1an zem) or line 5 (see -I. . . . . . SecHon 179 expense deducHon. Add lines 9 aml10. but do not enter more Ulan Une 11. . . . . . . . . . . . . . . . . . 01 dl8aIlowed dedUCllon to 2003. Add lines 9 and 10 less line 12 . . . . . . .. .. 13 ,.,PO,_ to. .PII11I/ or Part HI /nIiow for I/stB4proMf/y. Instead. uss PSTt V. , .,,'....' ' onAlkMance,and Other ' n notlncllldellsled 14 spedal depI8cIa!iOrl aDowaneeforqualllled properIy(othertlnlRlI8tedproperty) pIaeed In servleeduring 1he tax year (_ instnIlllIona) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " 14 ProperIysubjecltosecUon168(1)(1)eteo1Ion(seelnsbllctlons)................................. 15 18 nDllnclUde HsIed InslrucHona Secllon A 17 MACRS dedU<llIoI>a lOr lIll8SIs placed In service In tax years beglmlng before 2002. . . . . . . . . . . . . . . . . . . . 18 ~r~eIeCllng.:.~se:=u1:<:lf,~c~tI':e~~~~.~~~.~.~~~~.~~~... .. SectIon B - _ PIac!ld,In S!orvIce D 2G112Tax Ve8r Us the Genenil (II) (b}-..... (c)_...~ (II) (II) (I) C_<4_ _ ~""__~_ ... (g}aa~lj_Gh -- 111a3- ........ b5- ........ 07. ........ clIo.. ....... al5- ar ....... f2(J.. ....... 25- .. .. .. . h Residentlsl rental. . . . . . . properly. . . .. . . . .. .. . I Nonresldsn1lalreal. . . . . . 08/02 propeIIy. . .. . . . . . . . .. SecUon C 2OaClassIlle.......... .. b12. ............. 25 rs SIL 27.5 1:S 11M S/L 27.5 8 11M S/L 6 000. 39 r8 11M SIL 58. 11M S/L 2lI021l1X Ve8r fhe AIIemaIIve S/L 12 r8 S/L 40 8 11M S/L SU InsIrucIIonS 21 Usledpropelly.Emeramountfromllne28............................................. 21 22 TlIIaI. Add_IrumIiml:.\H~1lS 141hroDllb 17,_ 19am12l1int:lllumll(lIli ami line 21 EnlIlr here ami 00 lllell/ljlrof)rllJl lilies ofjlllll'1eI1Jn\.1'ailnelship&1lI1II Illltpota\i\D..-seeftah..:lb>........................................ 22 23 For _ sI1ol!m above aml PIaeed In SllIVIce du!iftg 1he CUII'IlIlt year, enter the, " llI1hebaslsldll'lbuillblelosection2$3Acosls................... 23 BAA For PapeIWllrk Aeductlo/l AoI NotIoe, _1nal1VOllcnM. FllfZll1l12 12f12m Fonn 4I8t (2002) ~'%~!jl.'i'l;mr!~,,_ , """"".,.,-., . ^_ o~ ~.' , ill! ~-,,,,,,,di'J'!JI!fPm]"l1!'1f "', ~ ^,-, .......~,. I ,~_,...I 1 ;"'" ., Form4QJl 2002 MARY ANN SHUTTY , Listed Property (Include automobiles, certain oItter _es, cellular telephones, certain computers, and property used lor entertainment, recreation, or amusement.) Nole: For any vehicle for which you are using /he slandard mHeage rate or deducting /ease expense, complete only 248, 24b, columns (a) through (c) ofSsctlon A, all of Sec/JOn B, and Sectton C If applicable. ' Section A recl8tlon and Other Infonnatlon Caution: See ins/ructions for limlls for assen er sutomoblles. 24a 00 ou have evidence to su rt the business/investment use claimed? . . . . . .. X Yes No 24b If 'Yes: is the evidence written? . .. X Yes (a) (b) Ie) (eI) (e) (I) (0) (h) of =(Ust Date~ Busmessl Castor Basls-IOfdePreclatlon Recovery MethodJ DepreciatIon Type h~ In s8fvIce Investment other basis (buslnessJtnvestment period Convention deducllon ve use use only) pernenlBge 25 SpecIal depreciation allowance lor quallflsd llated property placed In service during !he tax year and uSedmorethan50%lna uaftfiedbllalnessuse seelnstructlons . ...... .. .. .... ." ........ 25 a --r--r....r--r 27 Pro. used 50% or less In a ualllled business use see Instrucllons : SUZUKI SIDOSICS .. 1z/15/9J H)'. e}O 176-52-6717 P e2 No (Q - $8CUon 179 oozl 28 Add amounts In column (h),lInes25through27. Enlerhereandonlln.21,page1. ............... 28 28 Add amounts In column i, line 26. Enter her. and on line 7, e 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section B - Information on Use or Vehicles Complete lhls section for vehicles used by a sole proprietor, partner, or other 'more than 5% owner,' or related person. tt you prOVided vehicles I<> your employees, IIfst answer !he questkms In Seclloo C Il>see n you meet an eXG8ptkm Il> oomplelll1lJ IhI& _ Ill< _ vel1k:les. (a). (b} (e) (d) (e) If). 30 Total bIlslnessAnvestment miles driven Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4 Vehicle 5 Vehicle 6 :::O!':e~~~s~~.. . 31 Total commuting miles driven during the year. . . . . . 32 Total other personal (noncommutJng) _drivel>' . . . . . . . . . . . . . . . . . . . . . 33 Total rnIIes. dllven dul~ !he year. Add lines 30 through 32. . .. .. ... . . . . .. . . . Yea No Yea No Yea No Yes No Yea No Yea No 34 Was the vehicle avaITaIlre lor pel1lona/ use durlngoff-dutyhours?.......... ..... 36 Wes the vehicle used a!'.rimarllY by a more than 5% owner or ref d person? . . . . . . . . 38 Is ano!her vehicle available lor personaluse? . .. . . . . .. . '" . . .. . . . Section C - Questions for Employ...... Who ProvIde Vehicles for UII8 by 1belr Employees Answer these questfons to determine II you meet an exception to completing Secllon B lor vehicles used by employees who 1/'8 nol morelhan 5% owners or related persons (see 1nstrucIIorls~. Yea 37 Do you maintain a written paDcy stalementthal prohlblls all personal use of vehicles, Including commullng, by yo", employees? . .. . .. .. . .. . . . . . ... . .. . . . .. . . . .. . . .. .. . .. . . .. .. . .. .. . .. . . . . . .. . . . .. . . No 38 00 yatt rneIrrtaIn a wrItl8npol\cy stal&n181111hat pro! ,Iblls personal use- of _; except commtlIIng, byyattr employees? See Instrucllons lor vehicles used by corporate officers, directors, or 1% or more owners. . . .. . . . . . . . . . . . . . 38 00 you Ireat all use 01 vehicles by employees as personal use? ........ ..... ...... .... .................. 40 Do l'Ju provide more!han ffva vehicles to your employees, obtain Information Irom your employees about the use 01 the vehcles,andretalnlhelnlormationrecelved7.................................................... . 41 Do yatt meelthe requlremertts COII<:81'flI!1g qllaiTIfed automoblle demoosti'aITOfl us".? (see IfIst1'uetlons). . . . . . . . . . . . . . . . . . Nole: ,If your answer 10 37, 38, 39, 4fJ, or41 Is 'Yes,'do no/complete Sectton 8 lor the covered vehlc/es. Amortization (a) Descrlpllonolcosts (b) Dale amortization begins (e} Amortizable amount (d) Code sectIon (e) Amortization PO"""or po- (f) Amortization forttlfsyear 42 AmOl U.atlOh of costs Iltal durl 2/J02'tax ' 43 Amorllzationolcoststhatbeganbeforeyour2D02taxyear................................... 43 44 Total. Add amounts In column f. See instructions lor where to re ort . . . . . . . . . . . . . . . . . . . . . . . . . . .. 44 FDIZOB12 12/12102 Form 4562 (2002) '<,:'r"'~~~" !l,e, "~~ ..." ',' """'" \ ,.. _~":1!., ~'''''''l' ..,.. ~'1---~ . , ,. ,"""""""""._" ,~ ~'~'~M,~', ,. _ ""',,,,"""~~_""""'~'~""~."_~J",' ." '-"'''.*,_~r. ~, ,~,,~," , MARY ANN SHlJTTY 17&52-6717 l Explanation Statement Fo"",Une: Explanation 01: 11 Schedule A Form 1 G~8 Name IAddres s ROBERT SIIUTTY 189-42-0639 NO ADDRESS KNOWN e,",/~ , ""-, "" ., N:;:: c. a" . ~ ~l:;~; 0. b' ?J :!:l ib'6' ~ii ~ ~ 00 w f ." il Ht;~ I [ ~ : ~ HE "'~ ><: I f ' , 01 CIlI:"':xI j;}- a. f ." i Ii o , trlZ ~ .. ." ~~ ~ I t " , g" . '1-1 t::I = ~ m , Il!N t ,j t< '" iil lit '" I ~ i6~~ t< 0 , ~ t;; ~ t 6 : t" -:>:l ~ ~ t"' h '" . nl lNlII. a.~;", iHl 8. ~ ~~d~t m ,,,, b'1lJ:I .. 61:1 I i oj l~ l;!"'..!'l ., ." '< .:JJ 1JJ::a. m~ a a. ~ I ~ ~El~ ~ I"" H I'" . ""0 ". -J [ el .-J ~ = 0 .'" i H ::: i-iI 0 '" II-' " !:l pi H O,,",H - I '" 'iil INO 0 1 m lON!2i o 1 I-' I ~ ","0 z . -J .. t .: 0 z i r <0 I-' W , "'" 11-'4 I-' ~ ! 6 '10 0 !I' ."," ;;' '''' "C IW. f I. 10 ~ '-J In ~ . 0 I at ~ I I ~ ", ,~ I I-' lru ~ I a : -J I ... .'" r ?J J..., I ! ~ ~ CI' en 1 i :ll I'" ..., !O I'" 1 to I' '" .:... 1'-" -J lru Ii ~ li'~;1 ,,,, I-' ~ ~ .. ... .. .. -J . ~ ~ f",N" I l z f I , .B c"~ . . [I , ~ ~ fi I .. ~ gEl 'I-' [ III ~ t o~O' '0' ,0 ~ I", I I I", J i ;i! i '''' I.' hu if '0 ~ I-J ~.d I , ~ , I 0' 0 Jt~ I ." -J I ~ I ...... .... 0.0" ..... , h~ III ' ~ ~ i .. .0.0................. ...."i.......g - .. 01 . , ~ i .. ch [ l'f tt . l!: '" .. UII ;: ,,,, · j I f f t ~ 'co . i I [0 '" 1'0 " i J I .. ~o! . ~it. 'i;; ~ 0 It' I i a f Ii ~ ", a j., Ii B "t" . f~ ,i~ 01-' '" ~ 'I II ~ Ii i' ~ ~ en '" if Ii" II !~ ~ ... I-' .~ l! t i I"~! '" I-' 0 '" '" '" I j ;; 0. 3'8 ' ~ '!;j , , . " 00 ~ i ! ""ij:,'"t,\'i"'FU".,."I':~.,,, - ',~ " ", ',0, I'" . '-'Y$'I'M,1[f,," )'r--', "",'"c",''' '- , ^"'">7' f , I . ..-,. Copy C For EMPLOYEI!'S RECORDS, I. 2002 OMS ! (See Notice to Employee on back of Copy 8.) 1545- Il Control number 1 Wages, tips, other comPo 2: Federallnoome I:aX wllhheld 48.00 3 Social security wages 4 Social securltv taxwltht\eld b Employer 10 number 48.00 2.9 23-2948222 5 Mecilcare wages and Ups 6 Medicare tax withheld 48.00 0.7 c Smployer'8 name. address, and ZIP code, KENNETH H HICKOK STAMP EXPRESS 1104 CARLISLE RD CAMP HILL PA 17011 d Employee'8 social seClJrlty number 176-52-6717 e employee\:! name'. address, and ZIP code MARY A SHUTTY 59 WINDSOR WAY CAMP HILL PA 17011 7 Social security tIpS BAllocatedJlps 9 Advance EIC payment 10'Dependentcw:.e benefits 11 NonQuallfledplans 128 Code See Inst.'for box 12 1. Statutory emplOyee 14 Other 12b Code A,etirement plan 12c COde Thlttl'-P8I1Yslck:pay OPT 12d qc:K!e , P~ L_ 48.00 1;'34 15State I=nmlr:'etateI.O.l .6ll>. 17_telncorne~ 18Local wages, Ups, etc. 19 Local Income tax 'I20Looalltyname .' 48.00 0.48 JAN:.JUN , "l~~"';;';'; F.Drnt W-2 Wage and Tax Statement Oept. of the Ti'easury - IAS ThIe informslkln Is belng fUrnished \n the IRS.lt,YOU ar& required tc. file a tax return a naglloence penaltY/other ~on may be Imposed on you Ifthrslncome Is taxable and you i'8if to report It. . ,"" 131804 Office of Financial Administration Diocese of Harrisburg POBox 3651 Harrisburg, Pennsylvania 17105 Phone (717) 657.4804 Fax (717) 657-8757 Period Ending 4109/2003 Check Number 893236 Pay Date 4/16/2003 Marital Status s Dependents Claimed 01 Additional Withholding .00 Federal .00 State REGULAR HOURS 60.00 REGULAR EARN 769.23 Name MARY ANN SHUrrv Soe See ,I, 176-52-6717 Current Year to Date UniVDeot 131 804 GROSS PAY 769.23 6153.84 FEDERAL WIH 71.13 569.04 FICA TAX 58.85 470.80 STATE TAX 21. 54 172.32 CITY TAX 12.31 98.48 UCTAX NET PAY: $605.40 '10~ """'l h..v,,- f!"is wI',/, fl.". So. Office of Financial Administration Diocese of Harrisburg PO Box 3651 Barrlsbnrg, Pennsylvania 17105 Phone (717) 657.4804 Fax (717) 657.8757 60-1273/313 DATE CHECK NO. 4/16/2003 893236 PNC Bank, N. A Southcentral PA TO TIlEORDER OF: PAY *****605 'lJo[{ars aruf 40 Cents $605.40 131 804 MARY ANN SHUTTY 59 WINDSOR WAY NON-NEGOTIABLE CAMP HILL PA 17011 '~rw:q,.,lI~,.< ';"~~';' ~ ~ , .. -" ,-,,",,' ~ , -'" ,~ ~,~,~ :$,,~.~--~- ,. .' .1 - ..", (") c' 9, c: c.) .",- :~l -C' . r-::; rr; --, ~,,- f"~) I"', :,~' :? ~:~ . , ( -.) ~";: '" --" , ~--C! .~- -, :;.,L;' ':"J : :> :"1'1 " .'~ .~ :.." :::J r 'J ,< (I'jiij!ij~1tiF1i~1.r,r'\P.""~f:H''"t;ii>ifq,'jlf,iVi,,N"'F~!'i''''lh,,",,''\~~R'1;''p,'"""'::;"~"'G'~"'If"'U{jJ-"!~g.'J'j1!,!~m~~~~;' ""--!~l!\m"J_ Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 Counsel for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Pia i ntiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE INVENTORY OF PLAINTIFF Plaintiff files the following inventory of all property owned or possessed by either party at the time this action was commenced and all property transferred within the preceding three yea rs. Plaintiff verifies that the statements made in this inventory are true and correct. Plaintiff understands that false statements herein are made subject to the penalties of 18 Pa. C.S. 9 4904, relating to unsworn falsification to authorities. ,it, ~2JJ~5 Plainti~ 1" ~~. , I " . ~~ ~_'llI"l''''''''''''' ASSETS OF THE PARTIES Plaintiff marks on the list below those items applicable to the case at bar and itemizes the assets on the following pages. ( 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. Inheritance ( 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, workman'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 ( ) 20. Disability payments ( ) 21. Litigation claims (matured and unmatured) ( ) 22. Military/V.A. benefits ( ) 23. Education benefits ( ) 24. Debts due, including loans, mortgages held ( ) 25. Household furnishings and personalty (include as a total category and attached itemized list if distribution of such assets is in dispute) 26. Other 2 ,,"'j$~--~na_ _ f,l =, 'I , ~~ ",,~.q, '. MARITAL PROPERTY Plaintiff lists all marital property in which either or both spouses have a legal or equitable interest individually or with any other person as of the date this action was commenced: Item Number Description of Property Name of All Owners 1 59 Windsor Way, Camp Hill Joint 2 1990 Hyundai Excel GLS Husband 2 1994 Suzuki Sidekick Wife 2 "1999Hyundai Excel Husband 5(6 PSECU Accounts Joint 19 National Vision Administrators, Inc. 401(k) Husband 3 q" , C"", ~"'o.'" ~".~, ",,'I '. ~I _ NON-MARITAL PROPERTY Plaintiff lists all property in which a spouse has a legal or equitable interest which is claimed to be excluded from marital property: Item Number Description of Property Reason for Exclusion 1 139 Laurel Drive, Fredericksburg, PA Husband acquired post- separation 2 2002 Dodge Stratus Husband acquired post- sepa~tion 2 2002 Dodge Ram Husband acquired post- separation 2 2003 Suzuki Vitara Wife acquired post-separation 5 Allfirst Bank accounts Husband acquired pos- separation 4 i--~7i~-t,\m, ,"~,_" " , '[',~; I~ ~ '-I~" ',.-, ,'-r-~ : '~ " "f0'~, PROPERTY TRANSFERRED Item Description of Date of Consideration Person to Number Property Transfer Whom Transferred 1 59 Windsor Way 04/19/02 $1.00 Wife 2 1994 Suzuki Sidekick 04/03/03 $1,000.00 Trade-in 2 1999 Hyundai Excel Unknown Unknown Trade-in 19 National Vision 401(k) 10/01/01 $39,000.00 Husband withdrew 5 ,~,- LIABILITIES Item Number Description Names of All Names of All of Property Creditors Debtors 1 Mortgage VMB Mortgage services Joint 1 Mortgage PSECU Joint 1 Mortgage TBM, Esquire Wife 2 Car loan Charter One Wife 25 Visa PSECU Wife After separation, Husband filed a Chapter 7 bankruptcy petition docketed to In re Robert M. Shutty, #-03-02298. The U.S. Middle District Court entered a discharge order dated 08/14/03. 6 ,"r.\'~l= ~ ~ ~ ~,= ,. "'I~, " ~ ~ '~""'C""""',""'" . ~ ""'-"'--"'0" ,~ ~'.~~ - (-) r;: ,~.. [}~( 2..:.: - , C; - ~' ~I':: "".:.,,-- 5>' 'rurc 'CJ C,,) o -11 ~"'=: .-:J '-~- "Ti ('::;;.: 'nl . ;,'; C,:1 :';(-:l !'\.) ;~t, ":-1 '.'1";'::;; ,--fJ ;:~. :.0 -< ::::0 :.11 (,.J ~~ :1", ~ ~HnJllM~~,,","'v,;{'j'!"r,~j)'~;-~WIi;"'1-":';;<;'7P,,,;,'.'f'i!!~~"'~ili~~MIl'W1if~~I~~~~~~!!l'~ ,;:",,1'; , ''''01'?~:~.., '. Theresa Barrett Male Supreme Court It 46439 513 North Second Street Harrisburg,PA 17101 (717) 233-3220 Counsel for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY , Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE INCOME AND EXPENSE STATEMENT OF PLAINTIFF n-=: ~ if! Cf! )::r" ~t~ ?:; -< :..-::J. ,;,,,,] .--., ,,' '5'1 ,,"'" ,', c::J <:: , ~~~1 _._, ,-'~1 "C) _ C) - (', ~';'.:~~ ~~-?t rn -;:.,. :.tJ -<: t"...) "r:- ::;;::t' _',e' OJ J' I":> I verify that the statements made in this inventory 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. )Jp,,/+2J:4 Plaint' ' In theCllurt of Common Pleas of CUMBERLAND County, Pennsylvania Phone: (717) 240-6225 DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARUSLE, PA.. 17013 OCTOBER 20, 2003 Plaintiff Name: MARY A. 8HUTTY Defendant Name: ROBERT M. SHUTTY Docket Number: 00900 S 2001 PACSES Case Number: 430103963 Other State ID Number: Fax: (717) 240-6248 Please note: All correspondence must include the PACSES Case Number. Income and EJq)ense Statement TInS FORM MUST BE FILLED OUT , (If you are self-employed or if you are salaried by a business of which you are owner in whole or part, you must also fill out the Supplemental Income Statement which appears on page two of this income and expense statement.) INCOME STATEMENT OF ..l1A,ey ANN SHUTT"'\' Section I: Income and InslU'ance INCOME: Employer ~IITHe 1)l2aL 'PA.e'SH 0" ST. -PI4T"'~'~' Address ll2, STI'lTlS <;'r,ui1.T Type of Work 'PA~\~H MII\Il<-1l!v Al\ln i?e.Lt6Io~ ICOUCf4t IDiU I'lLu,sEl\I Payroll No. Gross Pay per Pay Period $ Pay Period (wkly.. bi-wkly., etc.) ITrA,H€!:> Itemized Payroll Deductions: Federal Witbholdina $ Social Security $ Local Wage Tax $ State Inco~ Tax $ Retirement $ / Savinas Bonds $- Credit Union $...- Life Insurance $/ Health Insurance $ OIher Deductions (specify) $ $ $ $ Net Pay per Pay Penod $ , OTIlER (Fill in Appronriate Column) INCOME WEEK MONTH YEAR ln1trest $ $ $ Dividends' Pension , Annuity Social Security Rents Rovalties Exnense Account Gifts , Unemvlovment Workmen's Comoensation Oilier , Other TOTAL '$ ,~ ,~ TOTAL INCOME $ , PROPERTY Ownership * OWNED , DESCRIPTION VALUE H W J Check~ Accounts l'$CL'A,. $ v J?e"",,,,,~ ,"""'* Savings Accounts f'SecL.! , 'DiLl, 30- V ~rG""-"" s\\V,"'~s Credi.t Union --- Stocks/Bonds ------ Real ESlate lIOu.sJ:. \40.,000 ./ Oilier TOTAL 1$ * H=Husband; W=Wife; J=Joint Service Type M Form IN-008 Worker ID 21200 ~.'IW"t =,"> , ~. "-' .'~ " - 'I ~^ , ,~ " IncOme and Expense Statement PACSES Case Number 430103963 , Coverage · INSURANCE COMPANY POLICY # H W C , HosDila! 11, .\ Mlc:.C.\aS';r~llole !))nr6<'" "I' H~"reIS&I~ AH il~S2.&11l .j ...}. ~, Blue Cross Other , , Medical Bk..Sl..,<-tO pia., 31 Z J v Blue Shield Other aealth/Accident , , Disability Inccme , Dental tA,,;teJ (o...cord,CL , 1:,7/l V t/ , Other I, SE", /JOT;; f\'lTA,~ec> . H=Husband; W=Wife; C=Child Section ll: Supplementallncum' '-'. Si~orf- Covev~ I)Ob'3.7S' per 'l"<Wtc:r a. This' form is to be filled out by a person 0- (1) who operates a business or practiCes a profession, or o (2) who is a member of a partnership or joint venture, or o (3) who is a shareholder in and is salaried by a closed corpor-atic Attach to this statement a copy of the following dQcuments relating to the corporation or similar entity: (I) the most recent Fedeml Income Tax Return, and (2) the most recent Profit and Loss Sta~ment ,F~i~~' I, Qd0.J'f f1W?~ 8E;Cl'laSe, f<EV/f. wAs d{!:OfPed.~(Y! 130B'.:; h~I'ILTli II\I,S" MY 13055 pj~l<€t:> (.If' '7HE <:0,/ fRill; E , Se HE IS l""'<ING ' cJrgS'1.Ljq]>4!ie ,GU,I<lt2:n;~ 7D cfJuE..e kt:ulll l{NrIl.. :x C;2.r'/'I'I' Lite :serr'-e'i>; TJ-lIS IS NoT t9 BeNEPIT. /ILL iJ7HM EMl'l<ivm /l-l1I.5T ?iN fTJJf. rAMI V( Ll:JveK.J46i3. IAIH;., b. c. Name of business: Address and telephone number:' d. Nature of business (check one) o o o o o (5) other Name of accountant, controller or other person in charge of financial records: (1) partnership (2) joint venture , (3) profession (4) closed corporatioo e. f. ADnual income from business: (1) How often is income received? (2) Gross income per pay period: (3) Net income per pay period: (4) Specified deductions, if any: Service Type ,M Page 2 of3 Form IN..()08 Worker ill 21200 I'~r~ ,~,L'="O ~, ~,' :; , ~ """""" - 1-1 Qu Sf - , Income and Expense Statement Section III: Expenses PACSES Case Number 430103963 InstrUctions: Only show extraordinary expenses in this section unless you filled out Section II on page two. The categories in BOLD FONT are especially important for calculating child support. If you are requesting Spousal SupportlAPL or if you assert your case cannot be determined according.to the guideline grids or formula, this section must be fully completed. /1.\16. It\!G. (Fill in Appropriate Column) EXPENSES WEEK MONTH YEAR Home .', MortgageJRent $ $1, '2. 93.00 $ Maintenance /.jnn.no Utilities Electric $ $i~5 $ Ga, 'liD Oil ~ Telephone ' 7S" , Water ~O Sewer: . ' ?;i' I :ilninlo=-nt Public Transport. $' '," , $ $ LunCh aO.oo , Taxes , ~";;;;"'GAC. Real estate $ $ $ Personal Property Insurance I Homecwner's $ $ $ Automobile gs.OO Life 2.5.00 Accident Health 0Iher Automobile Payments $ $ a3'1.'o $ Fuel 1"'5.0. Repairs ? Medical Doctor $ $ $500.dl Dentist Orthodontist ' '. Hospital M_ 15.00 "l?eclaI needs Xf,v," -13WiS G~I'\~8'; (g\llsses, braces, lEt'" J4tJo. og o';thon"dic~d:'~es '~e~lV'~IiO EXPENSES (FilI in Appropriate COlumn) (continued) WEEK MONTH YEAR Education Private School $ $ $ ParochJal School , College I', &VO - Religious SOO.()O Personal Clothing $ $ , $t.goo.<j9. Food I.:J!J.OO , Ba.rb~rl 75.00 , Credit Payments ISf).1!? Credit Card Charge /00 JI9 Memberships Loans Credit union $ $ :n1. ~ $ Miscellaneous Honsehold Help $ $/!lO,tJV $ G Chlld """e Paper~ooks 1 (),IE- , Entertainment , , Pay TV 39.'10 Vacation . .;J OOO~Jo Gifts II 000, fC' Legal fees 13,000.0 Chantable ronn....'u"nno SOr()<;3 ~~~,?Wd Alimony P-;'vments Other $ $ $ SOAI sct..F'I"IL'''''' "'EIA>r~ $"':;""" (~,.... FbR wote'l< I total ,I WEEK MONTH YEAR I Expenses: $ $ $ I verify that the. statemen~ made in' ~ ~ome and Expense Statement are true and correct. I understand that false statements herem are subject to the criminal penalties of 18 Pa. C.S. ~ 4904. relating to unsworn falsification!o authorities. /(1 n. 03 DiUe Service Type M ,--.t\"'~'Alr . ,~ "'~ ~\~ Plain' or Defeudant Page 3 oB Form IN-008 ,Worker ill 21200 1 ' . . tl'f,~ ,,~,." ,,",'-,f' ,"", ~,'=!<"F"', ~, "'~ __ '1_ M'( SO^, IS IN SeMINPlI=y. 'I MeR> Pfl'f Fore 2 su', TS. I (!.fl.SSock, /.(' c\(.'V'it:. Skj vfs $..r'pws, <gO,oo ) 3 P"'1r b\.",-\L pa,v.,'cS(il>''btl'o.ti) Qost-: ikso...t 37S.CO ,.-,;.wWU"""k,tslO 00;.0 , 'Sklv1=. l"'o."o II 3~"" " 'g- 0.00 . , Surplt~~ , ~1',2 S,opo, ' \ '" 00 , q v, " 1'3 \ ~' l' 61 " I1DO.~7, ~ ,.fJ ".<D , .. IIJ" IOV' , I" 'I",' - , , R [ j\iT --- PACSES Case Number 430103963 Income and Expense Statement Section ill: Exoenses Instructions: Only show extraordinary expenses in this section unless you filled out Section II on page two. The categories in BOLD FONT are especially important for calculating child support. If you are requesting Spousal SupportlAPL or if you assert your case cannot be detennined according to the guideline grids or fonnula. this section must be fully completed. (Fill in Appropriale Column) EXPENSES WEEK MONTH YEAR Home Mortgage/Rent $ sa f 0.,00 $ Maintenance Utilities Electric $ $ /.JO.(}Q $ Gas , Oil Telephone , 150.09 Water Sewer Bmolovment Public Transport. $ $ $ Lunch .t)t;.oO Taxes , Real estate $ $ $ Personal Property Insurance Homeowner's $ $ . $/6$.QD Automobile ?;q'l'~ Life M.ao , Accident Henlth !, Other Automobile Payments $ $ .23i./1P $ Fuel 1 :JS.op Repairs Z Medical :Doctor $ $ $ -svo.09 Dentist Orthodontist-- I lIospital Medicine , ~~18l neeos $oN - 8ttfit.~-; GLA$5fS (glasses, braces, ~~"'D orthonedic t1evices e-AUJ6/>leO J{SfJ.'" ~ EXPENSES (Fill in Appropriate Column) (continued) WEEK MONTH YEAR , Edncation Private'SchoOl $ $ $ Parochial School College , /7.~"'O''''' Religious 5"({J. '" Personal Clothing $ $ $1. ~a>..g. Food 8D.Q!2 Barberi 75,O.E " l-fgirdre"'''''''' , , Credit Paywcnts , Credit Card /500,0>- Charge Memberships Loans Credit Union $ $ $ , , Miscellaneous Household Help $ EO.oo $' $ f!j. Child care Papers/books J-/O.Q$ Ma<razt.....s Entertainment Pay TV .. , 2.$.09 Vacation 2IOQo.QS' Gifts Ii oco.~ Legat' fees 13 otJO, '! .L Charitable rnn""hu"OnS ~~er Child unnnrt Alimony Pa"':""'ents Other , $ $ $ SlOt. }JoJ ON ?I""'IO"' J >''' tIIN/"6 I i~:~es: I $ WEEK $ MONTH $ YEAR I I verify that the. slatements made in this Income and Expense Slatement are true and correct I underSland that false ' statements herem are subject to the criminal penalties of 18 Pa. C.S. ~ 4904. relating to uns;'orn falsification to authorities. ! I ' r7' Q3 I-{ ib ));::tl Date Plain~r D~da-; -~7J Service Type M Page 3 00 ';'!J;~;:lL"..., -, , ~ l' Form IN-008 Worker ID 21200 .. THERESA BARRETI MALE COUN'ELOR AT LAW THERE.SA BARRItTT M.A.!.!!. 513 NORTH SECONO STREET HARRISBURC, PENNSYLVANIA 17101 SUS,t.,N C. ApPLEBY, ..~l JONA1liAN J. MALE. I.W"'L ASS"rA.!IIT August 23, 2004 (717) 233.3220 FAX (117) 2n-68~2 E. Robert Elicker, Esquire Office pf the Divorce Master 9 North Hanover Street Carlisle, PA 17013 AnN: Tracy Colyer Re: Shutty v. Shutty (# 01.6237 Civil Term) Dear Tracy; Can you confirm that the defendant, Robert M. Shutty, has received the .Order and Notice Setting Hearing" in this matter? Thanks. Sincerely, Jesa Barren Male '4- TBM/sea VIA FACSIMILE - No Hard Copy to Follow Z d 988lWl09 'ON/l9:Sl 'lS/I9:Sl VOOZ 8Z 8 (NOW) WOBj j~-, ,0,'. _ , .~"~..,.,"""", , '" ,r~, .,-~ - -rl"':' " r'- -~~ ~, ~ ~ HP Lased et 3330 County 7172407890 Aug-23-2004 13:53 Fax Call Report Job Date Time Type 414 8/23/2004 13:53:32 Receive 0:20 Identification Duration fROM (WilN) ~ ~~ m~ )~:~1;Sl,1~:bl/NO,!10mm~~ p ,....Hl.". "~'l. "In''''',,, "NOI<4 101 (, ~,j '[lHflOS1H ..VI-I ' J.3"~.1" UNO::>~~ 11,1 MC'N <, < '~;[p:I'l:>1lUl';;:; ................. ,11:',U:iH ~~V'J1~ 0 ",'Jd<lll ::I~V"1d X J.N~l'lW{):> 3SV!t14 0 41l1H\.lIH HOd X J.rl11!lHn 0 tu:A~~t.(Z9-tO# 'U..... il:JlmIItiD 1IIIOA ,{un\!S'....{unqs '.. IQIwnN ;t.)NiDI!I:t!lll ..Ra1tH , ..lAG::>> 9tllanT.l_ aew....O 'ON 'll'J.O.L t(J()'Z'(Zlm3nV - St~9-OW:-t.~t. W1IwnN BDIW nlllllW:=-OAjO;lf1JO;:>gJU IANVoIIMO::>> Cl681.-0\rZ-Lll. '8HWnNXW. :t;tIOJ,bIJ.t NllV :>J!n0S3U'mp!T3)J;1qo'l1'3 "" ~b'II ';PN lmRQ~;U;U ...... UI:llHS 1V.L-,unSNVll:J, 31tNIS:>ViI 31:1lnbs3: "3'1VN ,L.L-31:1\lVll VS311':lH.l. Pages 2 "_.,,,0,'.'=";':" "- '" ~ ',",' ;!!l-id"i,~,"" M@ :,:',:, ,,:,: ',' ',) n v e n t Result OK c ~{\: , ""' THERESA BARRETT MALE, ESQUIRE FACSIMILE TRANSMITTAL SHIlET E, Robert Elicker, 11 Esquire A'lTN: Tracy Colyer FAX NUMIERJ 717-240.7890 COMPANY: Office of the Divorce Master PHONE NUM.Ii.. 717.240-6535 ReI Shutty v, Shutty 'I'Ont: Theusa Barrett Male, E.."9uire To: he.. August 23, 2004 TOTAL NO. OF PAGES INCLUDING COVER. 2 SENDER'S REFERENCE NUMBER: YOUR RI!FIiRlNCE NUMBER. #01-6237 Civil To:rm o URUlJN'I' " POR J\llvmw o Pl.EASE <:OMMllNT "I'UiASE REPLY o PLEASE RP,<:YCLIl NOTESICOMMIiNTSI See attached letter. \~ ~ ?--y '0\ ~,~\ f\I\,>-IYv<\-;.':s lli-t.~ ~ W2 ~ 1f\A>D ~O ~~ \N\'\\1 {I\~, ~ ~ ~ ~\'.) \w\~ ~(:j Cz. ~~\~ . so NORTH SI!CONn S'l'llRET . HAlllUSnURG, "A 1,101 PH(JNI~: 717.2:\:l..li2u' t;A,X: '1,-2H-Gg62 I d S881vUlOS 'ONIls:8I'lS!ls:8t VOO~ S~ 8 (NOW) WOHl "l1f'-W'"",,~.,\ ,_.r6I' ,-, __:f: Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesquire,com Counsel for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE PLAINTIFF'S MOST RECENT TAX RETURN AND PAYSTUB PURSUANT TO Pa.R.C.P. 1920.31(a)(1) ''''~,J"'*,~~lf . 22 Add the amOlinisirlthe far ri- hi coiUmnfor lirie. "7 ihrou h 21.TiiiSiS' - ur 10001liteome :-. -:-- ~ 22 23 Educator exp~ses (see instructions) . . . .. . . . . . . . . . . .. 23' 24 IHA deauctlon (see instruCtIons). . . . . . . . . . . . . . . . . . . .. 24 25 Student loan ihterest deduction (see instructions). . . . . . . . .. 25 ~ Tllitlnn Rnrl ~R rlArhlMinn (RAA inmf"llntinnR\ 'R 27 Moving expell$es. Attach Form S90a . . . . . . . . . . . . . . . . . ~ One-half of se~-employment tax. Attach $qh"dule SE. . . . . .. 28 ;:. '~::Z:~~;~~~~t;~'~:~~C~~~~~~;;::~(;::.:~i::::::: ','~,' < 31 Penalty on early withdrawal of savings. . . . . . . . . . . . . . . . . 1311 32a Alimony paid b ~ecipient'. SSN. .. ~ . . /32al 33 Add lines 23 thrOljgn32a. ...... ............ " .,:.c. ... ..... .. ... .......... 33 :\4, Subtract line S' from line 22, This Is urad ulliliif'~ 'iooo_. . . . . . . . . . . . . . . .. "'.34. BAA For Dl.c1oaure; PI1VIICY Act, .nd 'Paperwork Reductlon Act Notice, see In8lnlctlon.. FDIA0112 O1/1elO4 , Form 1 040 Label (Seelnstl\lOllons,) U.a the IRS IlIbel. Otherwise, please print or type. p....ldentlal E1ectlOll C8Inpslgn (seel_na) Filing Status Check only one box, exemptions if more than five dependents, see instructions, Income Attach Fome W-2 and W_2G ha.... AlSO aIl8eh FOrm(e) 10ll9-R II lax wae withheld. )!. yo~ did"u,ot .' 'bt~""".t>w_".~ inStrUCtions~-- EnciOS<l, but do not attacl1, any peyment Also, please U$e ~"'~"I'l"^\I A~I.._....... .. .-,--..-- Gross Income .< ~.lJ,k,,,<.,,,,,.,,,",,"""~ liT! Department of the Treasury - Internal Revenue serVIce 11S. lridividuallncome Tax Return Forthe Jan'I'. j}ec-31 2OO;,'or 01l1e(1Bx ear b 'nnin Yourflrsl name MI Last name elnthlss ace. IRS Use 20 MARY ANN l1:a~tmtum,spouse'Stlrstt\atne SHUTTY M\ Last name _.._a1SOC1lrilyn...... Home address (number and street), If you have a,P,O, box. see instructions. .. Importantl .. You muat enter your social security numbar(s) above. Apartment no. Vou Spouse .... Nol\I: Checklng :Yes' will not change your tax or reduce your refund. ' II"" Do' UOr urs use~min eolntreturn.want to otothlsfund?,.........~ Vea No Vea 1 Singie Head of household (with qualifying parson). (Sea Instructions.) If the qualifying person is a child 2 Married filing jointly (even if OIIfy one had income) but not your dependent enter this chlld's 3 Married filing separalBly. Enter spouse'. SSN above & full neme hera. ~ name here. . ~ 5 Quaiifying widow(er) with de dent child. (See instructions.) VoIlraell. if your parent (or someone else) can cleim you as a dependent on his or } ~~ic"r::~. her tex return, do nolcheck box6a, . . . . ... .. . . .. . . . . . .. . . . . . . . .. . . , . .. ....... .. . N..of chlldiren on 8cwho: . lived . witt, yOu , .-. , · dldnot live with you due to divorce or .......UOn (seeJnstrs). . . DeJ!endents on8cnot.o.: . entered above , No 8a 1 b 0 Spouse. ,. . ., .. , ... . . .. . . . . . . . .. . .. . . .. .... .. . . . . .. . . , .. . .. . e Dapandenl8: (2) D~ndent's (3lDero;ndenfs (4)" I soel .security relat onship ",,'lW':~ numba(- " to you'," (;sxCrnd~1 f1) First name Last name seelnstrs KEVIN S SBUTTY I Son , , , n 1 Add numbers ., "', ,. , ~ciQ.Jlnes ~ .. 'd"Totafnilrribe~o'f!ll<e ollscranned................................................... 7 Wages, salaries, lips. etc. Attach Form(s) W-2. . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . 7 8a Taxllblalntetesl. Attach Schedule B ifreauired . . . . . . . . . . '.' '.' .. ,. . . . . . . . . . . . . " b Tax-axampl Interest. Do not include on line 8a. . . . . . . . . . .1 8bl 8aOrdlnerydlvidends.AttacI1ScheduleBffrequired......................,...... . hnimtfrhfMt ' I 'A!4.l," "ttM:Ittll~tfii~'. . . . , , . " , , . , . . , . . , , , , , , , " . , , . , , , , . .' "~,...,. 10 Taxable refunds, credits, or offse1s of.tate and iocal incomelBxes (see instructions). . , . . . . . . , . . . . . . . 11 Aiimonyreceived...................:............................., 12 Suslness incOme or (lOSS), Attacn't;cneaUle-(;,Or (;-t:L . . . . . . . . . . . . . . . . . . . . . . . . . : 13a Capital gain or (Ios,), Atl Scn D ifreqd. Ifnotreqd, cknere. .. L............... ~ 0 " b,.~~~l~.pa-.J}l~~'-~.~~.,~.. . . . _ _ . _ . . . . . . . . . . . . , . . . . . J'1~ I, ". 14 Other gains or Qosses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15a iRA distributions " . . . . . . . ~ I b Taxabie amount (see.insjrs). . . 16"Per\S1t>nhil~.etiriuitiss; . . . lJ!!t. . b"Taxabre' ~nwtln!'(seeiriStls)' . . 17 Rental real ~te, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . . . 16 Farm income pr Qess). Attach Schedule,F. . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . 16 Unemployme\iltcompensatlon.......................................... 208 SooIal security ~efits. . . . . . . ~ ' I b Taxable amount (see Inslrs). . , ".. n+ktwi..""....... 42. 13 384. 205. 14 15b '16'b' 17 18 19 20b -,..... 3c7438, Form 1040 (2003) 37 438. ~~T'" '~.. ,I""'"~" ,r_' , ~- -....~...... ,......:; .';.;......", ;--v,';;';';;';;' ';';;-;':'~' ~-~:-.. =-...." ...................~ 35 Amountfrornline34 (adjusted gross income) .............................. .'. 35 ~:::"d 38c11:ban~. r n You were born before January 2, 1939,. nBllnd. Total boxes ,'., '.~ if: L U Spouse was born before January 2, 1939, U Blind. checkad ~ 368 , !Standard I b If you are marrlad fding separately and your spouse itemizes deductions, n Daductlon , ,or,lIOuwere,adual-statusalie,n.seelnstructionsandcheokhere............ ~ 38b,.. 37 ~ized deduclions.(from Schedule A) or your sIalIdard deductiOll.(see left marpin) . . . . . . . . , . . . . . . J~~~:~~ox [38 .~ubtr.~Ii~~~~f;~~ lI~e35. , : .: ~:.:.:.:: . : . " ..... . :. . '.: . . . ..... . .: ." . . . . . : ~6b or who can 7..~ tI U11~ o,).J 10 OPIV"t,Ut;..J \II I!;IDCo, IlIUUlfJly .p.J,V.JU l.Jy UIQ tutor IIUllIlJI::II VII;I^l;IrJll-'~IVllt:llJlal111aU be claimed as a onllne,~d"lfline35isover$104,625,seetheworksheetlnthelnstructions..,.....,..,.. 38 dependant; see 40 Taxable iJloome; Subtract line 39 from line 38. InStructions: Iflimi'39 is II1\\re,thaR~ine038rel1OOl..lJ... . . . . . . . . . . . , . , . . . . . . . . . . . . . . . . . . . . . . . .. 41 Tax(seeinstrs),Check,lf.nytaxisfrom a o Form(s) 8814 b o Form 4972. ...,............. = e'AJl.others. ~ ; .Single or Married. 42 AftemaUve minimum tax (see Instructions). Attach Form 6251. . . ' . . . . . . . ' . . . . . . . . :., . ,'jTlllng separarelY, 143, ACla lines 41 ana 42 , . , , . . . . , . , , . , . . . . . . . . , . . . ; , , . , . , , , . . , , , . . . . " ... 43 $4}50, ' 44 ForeigntaxoreditA~achForrn1116ilrequired:.. .,....... 44 ,,:M.swiAl;l~Ij"!1, ..~',. ~'!'~~~:~~~#~~1-~~:;'?:,:i!-~~:-,"~~~'f~~,.~.~::". . ~~~. j ~~~r~~ - I ~ Credit for the eldertyor the disabled. Attach Schedule R . . . .. 48 .' .'!'.~:~,\e8. . ,47 Education credits. Attach Farm 8863. . . . . . . . . . . . . . . . ", .47. I.o'~v 148 Retirement eavings contributions credit Attach Form 8880. . '. 48 " ~Z~told. ,,"~..~~'~d~cred~t,(~~~in~cti~~~.:.,:'" ... .. . ... .,.... 49 1$7.000 I~" r\I.l,V,fJUVlI\AOUIl.nUQl.IIIVllfIUUtJIa...".,',.,.,.,.... 51 Credits from: a o Form 8396 b o Form 8859. ..... ... ... , . ' . . 52 Oth~Lcredlts. Q!l'!!'k applicable box(es): a.D.form 3800 b U~c USPecify:" , " ",. 52 53 Add lineS 44 through 52. Thes..are your lotal credita, '. . , , . . . . , . . . . . . . . . . . . . . . : 54' SiJbtract line 53 from line 43. Ii line 53 is more than line 43 enter .()'. . . . . . . . . . . . . . . . 55 Self.employmenttax.AttachScheduleSE....,........."..................,.... 58 Sodal securiili and Medicare tax on tip income not reported to employer. Attach Form 4137. . : . . , ' . . . , , . , 57, Tax on qualified plans, induding IRAe, and othertax.favoredaccounts. Attach Fonn 5329 il required. . . . . . . . . 58 Advance earned income credit payments from Form(s) W'2 . . . . . , , . . . . . . . . . . . . . . . . 59. He",'elwld~mploymenitaxes..Att_&lheduleH.,. . .. ...... .... "....,...,..: ,59, 80 Addlines5H9.Thisis ourlDfallal.....,.....,..........,.,.............. ~,60 81 Federal incQme taxwtthheld from Forms W-2 and 1099. . . . ~. 81 1 944.' 82 2003 estimated tax payments and amount 'applied from 2002 return. . . , ' .' 82' 83 Eamadlnc;om..redft(EIC)...... '................ 83 r SA 'Excess soaahecurilyand tier 1 RRTA tax will1held (see instructiuns). . . ,. ,84 85 Addi1ionel c~iid tax credit Attach Form 8812. . . ' , . . . .. . .. 85 88 Amount paid \,!Ith request tor _sion to file (see instructions~ ; . . . .'.. 88 '87 OtherpmlSfrom: a'[]Fomi2439 b,[]Form4136 C'[]Form8885 87' 88 Add,lines:51thro h57.Theseare ourtolal nb..."....,........, ..,........ ~.. :"fJiJ~i~~}',,~~~~:~!~m;,N,-lh.tqr-t"{I~..i~:Clfttl,~~W~,"1W~,)~.~~Dl,~~,i,~~~., 70aAmountofline69youwantrelundedloyou ... ... ... .,.... ....' ... ... .... .. .. b Routing number. . . . .. ...1231381116 I .. . Type: ' OQheoking [] Savings. .. dAccountnumber,..... 0453316101 ' 71 Amountofline!59 u'want iielUo ourlOO4estirnaledlal. .. . .: ,~71 Other Taxes Payment8 If you have a qualifying child, ettach SchedUle EiC: . "'.'~f~d&- Dlrectdeposlt? See InslruCllons ,"d.i\';;....n;i":ll ~&;, 700, and 70e!. ..';.-:tie~*-:' You Owe Third Party Designee Sign Here ~olnt return? v""...llr...II1.lV<'....'lo;l, ,_...~ ,,,,"- ... ..... 37 438. 27 563. 9 875. ,.6 100. 3 c775~', 378. j"/'tj. 378. O'~ O. 1 944. ',~;.:,,a,4~J.;.,~, 1 944. .,v.;...,..:,"'"...,;...~.."~:......J,.".,............,.....~..,.,., ~__-.. ,~,~,',!, .," ,,:r ,;'",:.';....;"...., ~.... .;,.."..;.. ;;' ~;;;;~Mt:~~;~;;;~~;;~~~;;.:'~..u.~.:~.U~'.~'V.~.~'~~;,u~GLr';v,."""". '__ Do you want to a1IGwanother person to discuss this return wtth lI1e IRS . (s..instruCllons)?."..............,......,................ . DVea.Completethefollowing. '~NO Designee's ... Phone Personalld&ntlIIcalkin name , ' no, ~, ... number (PIN) .. Urlder penalties of pEl~wy, I declare that I have eXamined thIS return and accompanying schedules and statements, and to the best ot:my knowledge and belle1, UteY are true, eotrect, al\d oomp\e\e, 0e0Iara1.1on 01 prepal'eT (o1her than taxpayer) Is based on aII1nlormatlon of_which preparer'tuis any knOWledge. '~ Your signature I D~e I ~~~::I1~~_.-.....~._ ,I Daytime phone number ~ ......&..1................1.10 .,............." Keep a copy spouse's signature, It a JoInt return, both must sign, 1~!)?~'.Eecor~..t,.. Prepare's .. s1nature JlII'" Paid Preparer's Use Only ""!\~'\'t,~~~, Spouse'S occupatlon Dale Cheok If self-em d Finn's name Self-Pre ared (orvou..' .. 'self.employed), Il'" . addres8,and ZIP ood" ElN Phone no, FDlA0112 01116104 :-'lflBV<D.U, ~ '''''!''..~~~'''''''' .."...,.. -,.~.,~"., " Form 1 040 (2903) ~" Deparlm<lnlollJie T",asury (99) Internal Revenue SeMoe Name(s) shownon ~ 1040 MARY ANN SHUTTY Medical Caution. Do not Include expenses reimbursed or paid by others. ....... :.:....::"'"':......:~""~:V^t'...,..,.....~..""':"..~....:.:..,....;,......,.".,.".,' SCHEDULE A (Form 1040) Dental Expena.. Texea You P.1d (See instruotions.) IIII-VI_' You Paid (See .......+.......+1........\ Note. t-"ersonal interest Is not ........1",.,..;10,1_ Gift. to "IIWI', II ~~ m~de ...l:f"...."... got a benefit for' it, see instruotions, ~a.!!,!1ty and Job Expen... and Moot Ulner Mlacellaneous Deduction. (See lnstruotions.) Mlscellaneou. Deduction. Total itemized Deduction. Itemized Deductions OMB No, 1545-0074 2003 07 ~ Attach to Form 1040. ~ See Instructions lor Schedule A (Form 1040). 9,901. 2 Enter amount from Form 1040, line 3~ . . .. 2 3 Multiply line 2 by 7.5% (.075). .. . . . . . . . . . . . . . . . . . . . . . . 3 4 Subtractlineslromllnel. II line 3 Is more than line 1 enter.(),....................... 5 State and looailncome taxas .. .. .. . .. .. . .. .. .. .. .. .. . 5 1 043. and address ~ ... ;:.:..:.: .:..:.~.:::.-:': ~.:.::;::: ~.:..:..: ;;-.;;~...;.:;~:.:::.:; . , , , , . . . ' . . . . . , . , , . . , 7 Personal propertyla><es . . . . . . . . . . . . . . . . . . . . .. . . . . . . 8 Other taxas. List type and amount ~ other tax~l!.____________________Ll. 8 11. S Addiine.-5Ihrough8............ ... .............. ......... ... ... ~. :::. 4,205. .. - IV ;';U1110Illtyilll,OlW~QIlI.lIN1IIW.1~\t1UtuJVUVIlIV'1Il rvoN..........., 11 Home mortgag,dnterest not reported to you on Form 1098- II paid to the pefilon from whom you bought the home, see ;.......r' ....,f;......... ......,.1 ...h...... tfo.... ...,...........'.. ............. ;~",,,,,;".j.........., "Y\h^.. , . ~... . 12 Points not reported to you on Form 1098. See Inslrs lorspcl rules. . . . . . . . . 13 Investment interest. Attach Form 495211 required. tC'....;......_, ,..-.....-..,..,' ...."....... . ...,. ..,.., 14 Add lines 10 through 13. . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Gifts bv cash or check. If vou made any alft of 9;250 or more. see instructions .... .,......,........,.. ,., .., .,. 16 Otharthan by cash or check. "any gill 01 $250 or more, see mstnlcuons. Yau must anacn t"orm ts~ IT over$500...,.................. ......... ..... . 17 Carrvoverfrom oriorvear. . . . . . . . . . . . . . . . . . . . . . . . . . .. 17 18 Add lines t5 through 17. . . . . . . . . . . .'. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . n 1111 l.,.,asua or men lOSS 65 , 1\ttaCl1 r-orm 4Ots4. ' ;:,ee InSUUCIlons, . . . , . . . . . , .- , . . . , . . . . . ,. 1" 20 Unreimbursed emplovee expenses - job trevel, union dues, In"" 4t"I1l....Ctl,;"... .,..... AHa,..'" J;:"""r"., "in,::: nr "1n~t:7 if required. (See Instruotions.) ~ 1,071. See Statement 351. -~---------------------------- 21 Tax preparation lees .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351. ~"'''''-'-'l'''''''''''''''''' ............,........,..................1"'"""',.......",...,...,........ lypeandamount ~ ____________________ See Statement 12.784. 23 Add lines 20 through 22 '" ... ....... .... .. . .. . . .. .. 24 Enter amount from Form 1040, line 3.. .. ~I 37 , 438. :ia) Mu~plyllne;.::4oy~'7CIl.U~J,...,..,',.,..,.,"',.,'" ~ If:Ii';J'. 26 Subtract line 251rom line 23. II line 25 is more than line 23 enter -(), . . . . . . , . . . . . . . . . . . . . 12.784. 13 135" 12 386. .,.,. fif+o.~.. _ ff'nm lieA' in th.e. inotl" ,""11'\"'0 I lot nino::. eonn am"". In. . -------------------------------------------- 28 Is Form 1040, line 35, over $139,500 (over $89,750 ff MFS)? 1Vl..1_ v"".. ,.1...;1, ...-.H^" i... "",..... li""it",A ^ AA +h", """"" .nt,.., in tk", f.... ..i,.ht ;"""Il '""", for liMS 4 through 27. Aiso, enter this amount on Form 1040. iine 37. o Yea. Your deduotion may be iimited. See instruotions lor the amount to enter. --, j- BAA For Pap_orl< Reduction Act Notice, see Form 1040 Instructions. FDIAo301 10116103 Scheflule A (Form 1040) 2003 ,.~'r;r-%'lf<i>:'r?:~"'11!!i~ _ L, ,U ,..",""""'" ~.., ..,~ ~" """""'. ?~ SCHEDULE D (Form 1040) . - OMS No. 1545-0074 Department of 1tIe Treasury !ntemal-Revenue Servk:e (S9) Name(s) sIloWnon Fonn 1040 MARl/' 1lJ!1lIl, (>HUTTl/' $l'iort-Termca it.IGalns andLClSses Assets Held One Year or Less (8) OeeodpUonol (b) DateacqulnKl (clOat.BOlo (d) seteapnoe (e) Coal orolner IlaSte (I) Geln ..(1...) property (EXaJ!!DIe: (M~ day, yr) (M., day, yrl (aee InslruolJons)' - (aeelns1ruo1lona) J"uf,~ -':=J) fODshares xv.tco 1 Capital Gains and Losses . Attach to Form 1040. . See Instructions for Schedule D (Fonn 1040). . Use Schedule D-1 to 11_ additional transsctlons for lines 1 and 8. 2003 12 (g) .-MaY 6 gain or(loSsr (see beloW 2 Enter your short-term totals, if any, I , from Schedule 0-1, line 2. , , . , , , . ' , , . f--1- '" I OUII .non--term UIIeB pnl;O lIfI1oum.. 1_ Add lines 1 and2Incolumn(d),.",." ~ 4 Short-tenn gain from Form 6252 end short-term gain or (loss) from Fonns 4684, 6781,and8824....",...."..,.,.: ,....,.", .',....."."..,." 5 Net short-tenn gain or (loss) from partnerships, S corporations, estates, end trusts frnm ~mArtl dAtA\" K..1 5 Short.tenn capital lOSS carryover, Enter the amount, if any, from Iin~!l9f yollr "- , 2002 Capttal Loss Carryover Worksheet . . , . . . . . . . . . . . . ' . . ' , . . , . , . , , . , . , 7 aCOmD,ne lines 1 tnrOUgn 5 In column (g), II tne resUlt's a lOSS, enter tne result. Otherwlse,enter-o-.Donotentermorethanzero....., ... ., ,.".".....,.,. bNeI,8hort-lerm cilPltal aaln or (loaal. Combine lines 1 tnrouQh 6,In column (f) ',' , . , . ' . b Lon . Term Ca '1t~1 Gains and Losses Assets Held ,More Than One Year (a) Oeeodptlonol (biD..........;. (cl_soId (d)s...ap... (e)OostorOlherllaS'a (I) Gain 0.(10") IJrop&rty(Example:. (MOo day, yr) (Me, day, yrJ (889; Instructions) (see jnstrucUons) for the entire year 100 ShaI'eiI XVZ CO Subtract (e) from d) 8 Hoine Sale ctin ,Reali ed 08/01/90 12/01/03 199 000.00 173 976.00 25 024.00 Section 12 Exclu8i0 (g) po_ay. gain or(loser see below 24 819.00 -24 819.00 -24 819.00 ^ ........_~ "~"r I....... ...__,....--.._1_ r~ __.. iroms'chedui,,"o:{iine9:'.', -::". , , . , , , 10 ToIllllong-term _ price amount.. J-\UU lllltfl:i 0 HflU 1;t 1IlWlUHlll \U} ,.",." J.:;J::t vuv. ~. , 11 Gain from Form 4797, Part I; long-term gain from Fonns 2439 and 62$2; and "i long-term gain or (loss) from Fonns 4684, 6781, end 8824 . . . , . . ' . . , . . . . . , . , . . , 12 Net long-term gain or (loss) from partnerships, S corporations, estates, and trusts from Schedule(s) K-t . . . , . . , . . . . . . . . . . . . , . , , . , . , . . . . . . , . , . , . . 13 Capital gain distributions, See Insirs. , , , . . . . , , . . , , . . . . . . . . . . . , , . . , . , , . , . . . . 14 Long-term capital loGS carryover. I:nter tne amount, n any, from line 1301 your 2002 Capital Loss Carryover Worksheet ...."."..,.,',..,..".."...., 15 Combine lines 8 tnrouoh 13 in column (0), If zero 'Or less, enter -0-, , , . . , . . . , , . . . , . 18 Net long-term capltSI galn or (I08S). Combine lines 8 through 14 in column (I). . . , . . . . NUl: ~u lU r-tul III un ' l::l t::.. ~Include in column (Ill all gains and losses fr~m coIumn.<fJ from sales, ex~hanges, nr oonversions (including iTlslallment payments received) aIblr May 5, 2003. However, do no! Include gmn attnbutiible to ,nrecaptured section 1250 gal~ 'collectibles go",. and losses' (as datlned In the instructions) or ~Igible gain on qualified small business stock (.ee,instrs). BAA For PilpenvOrk ReductIon Act Notice, see Form 1040 Instructions. Schedule D (Fonn 1040) 2003 FDlA0612 01/16104 :;'{.iP;fv~_~ ill ~ '"',~,.,. _ ,I" ,,- ~, ~ -.... - ~ ;;";"~o.i:.,..,:Z ';-u.."./;~~;:'.t:;;Zt.:, ,""'~-':'-,', ~j,'..~ 'z;:.:..:.~:..; Taxable Gain or DllductibleLoss 178 Combine lines 7tiim1t16 and enter the resu~. If a loss. enter -0- on line 17b and 00 10 line 18, If a oaln. enter.megamont-orm1040,Hne13a,andgotollne17bbeIOW...,............. .'................ b Combine lines 7a and 15. If zero or less, enter -0-. Then complete Form 1040 through line 40. . . . . . . . . . . . . . . N.n-..lflirlQ. 1Anf~M,:arIi1l,a n Ie. ~ns:lin nl'\U'll' hs:l\#lnll::lllfl,:lrf rfivlrl,anrlQ nn Fnrm 1n.4n lin,:oQh r!nrrmlp,tj:l. Part IV below. . Otherwise, skip the rest of Schedule D and complete the rest of Form 1040. ..0 If II...... 17.. i...... I........., ....n+..... hn...... "'...-I ^.. 1:.......... <tn,IIt' II",.... 1-:1.. th... .........II..,..f I'~\ +h.....'^""... ...../h\ lib.') n('lf'l\ (or, ifmarrledflling'eeperately, ($,1,500)) (see Instructions)'. , ....:...::. ... ...... ~ :'. '......... ... .' Next:. If you have qualified dividends 0.0 Form 1040, line 9b, complete Form 1040 through line 40, and then commete Part IV below /but skiD lines 19 and 20\. . Otherwise ski Part IV below and com lete the reslof Form 1040. 1II11111hax Computation Using Maximum Capital Gains Rates If line 16 or line 17a Is zero or less, skip lines 19 and 20 and goto line 21. Otherwise, go to line 19. 19 Enter your un~ecaptured section 1250 gain, if any, from line 18 of the work~heetin Ihelnslructions. . . . . . . . . . . . W 205 'I 20 Enter your 28l{, rate gain, If any, from line 7 of the worksheet In the mstructions, . . . . . . . . . . .. , . . . . . . . . . , ~I , ... II.. ... ...... __....... __.. _.... ,.. "". .,_...... _..... __._.... _ _ ._____._,._ ..... _ _n__...... .... '._ .... _ .__ ...____....___ - &. "'_n"_ AI. _ ___ __n_.. ". __...... .__ n__ _ _ ...... .. ....- .... _..- -... ----,.-..- ....--..'-....--....--, --.......-..- ....- ...._...-......-..... ........ ...-...-.....-..-...... ....-.- ........ -...--......- -......... -.. ...._-- end 53 bslow, and skip all other lines balow. 21 Enter your taxable income from Form 1040, line 40. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .. 21 , , 2~ t:nterm9am8I1erOTUneltiOfllnel/a,OUtnOtlessmanzero"",."..,.,... ~.. 23 Enter your qualified dividends from Form 1040, line 9b. . . . . . . . . . . . . . . . . . .. 23 flA AM,li........t')t)......At)'2 I)A ,~ lU:>. o. "l-'oIV,vvv" ,,,w,,'-'<ot """l::f JUlI"'1 u, ........."'y,,'l:l ,.,..........\...." -.., r..,....... 25 Amount from line 4g of Form 4952 Qnvestment interest expense). . . . . . . . . . . .. 25 26 Subtractline25fromline24.lfzeroorless,enter-0-......................................... 27 Subtractline26fromllne21.lfzeroorless,enter-Q-........,................................ 28 Enter the smaller of line 21 or: . $28,400 if single or married filing separalely; or . $38.050 if heed of household If line 271a greater than line 28. skip lines 29 through 39 and go to line 40. 29 Entertheamounlfrom line 27 . '. .. .. . . . . . . .. . . . . . . .. . . . . . . . . . . , . ... . , ...- vv UUI."rQ,",~Il'IQe.I:IIIVIIII"IQ'V,II"'QIV""'IQO;:l,lCftnQI"V""C:UI\.l~U~vmlQ~"..,.,., 31 Add lines 17b and 23". .,.............,.... .l.!!J 32 FntArthA amirller of UnA::if) or IinA 31 . . . . . . . 32 33 Mulllplyllne 32 by 5% (.05). . . . .. . .. . . . . . . . . .. . .. . .. . . . . . . . . . . . . . . .. . . . . . .' . .' . .. . .. If lines 30 and 32 ere the same, skip lines 34 through 39 and go to line 40. I I .,.. ..:Il..rIJUct,",Lm'l:#~C:: rrVllt UIll:#.;)\} , . . ., , , , . . ',' , , . . .. , . , . .. . , , , . . . . . , , . 35 Enler your qualified 5-year gein, II any, from line 8 of the worksheal in the Instructions. . . . . . . . . . . .. 35 36 Enter the amallerof line 34 or line 35 ., ... .. ......... ...... ...... .. 36 37 Multiply line 36 by 8% (.OB). . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . ~q'.'-",,,,,, MO...oo "... -. 1_.1 ...--- ..-. ....- ...... ,,_...... ,-..... , . . . . , . . . . . . , . , . , . . , . , . . . . , . , , . . , , , . . I __ I 39 Multiply line 38 by 10% (.10). ........................,.............................. If lines 28 and 30 are the same, skip lines 40 through 49 and go to line till. . 40 Enter the smallsr of line 21 or line 26. . . . . . . . . . . . . . . . . . . . ., '"r'" ",;"., ' 41 Enter the emount from line 30 (if line 30 is blank, enter .0-). . . . .'; :' t. . :';', :;::~' 43 Add lines 17b and 23... .. .. .. . .. .. . .. .. ... 43 44 Enter tile amount from Iina 321if line 32 is blank. enter .0-\ . .. 44 45 Subtract line 44 from line 43. .. ..... ...,..,.. 45 46 Enterthesmallerofline420rline45......,...,.......,........... 4f IVlurnplyune4t:lcy 1:)'10 t. 10). """,...",.,..",.."",.......",..",."."".",. 46 Subtract line 45 from line 42. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 49 49 Multiply line 45 by 20% (.20). .......,.........,..................................... 49 50 Figure the tax on the amount on line 27. Use the Tax Table or Tax Rale Schedules, whichever applies. . . . . . . .. 50 51 Add lines 33, 37, 39, 47, 49, and 50. . . . . . . . .. , .. . . . , . " . .. . . . . . . . . . . . . . .. . . .. .. . .. .. .. 51 52 Figure the lax on the amount on line 21. Use the Tax Table or Tax Rete Schedules, whichever applies. . . . . . . .. 52 53 Tax on all ,taxable Income. Enlerthe smaller of line 51 or line 52 here and on Form 1040, line 41. . . . . . . . . . .. 53 378. "If lines 23 and 25 are more than Zero, sea instructions for the amount to enter. Schedule D (Form 1040) 2003 FOIA0612 01116A>4 ............~,_.... "......,.. "...""",........... . . . , , , . , . , . . . , . . . . . . . , . . . , . . . , , . . . . .H~:l~.\!.j,_,~,~,!!I~ - I . < ,- Department ollhe Treasury Int8mal Revenue servtce riliine(s) shOWn on return MARY ANN SRUTTY 'J Caution: YoI!. cannot tak9 boIh 8lI educaf/on ctedJt and ,the witton and fees dedUClfon (Form 1040, Hne 28, or. Form 1040A, lfne 19) for the same $lUdent In the same year. nu Ii::J ~nNI':. ""BUllan: ruu clUJnor U:lf{~ Ifl~ n (;fWI( fUf mUf~ trltul A U:lX l:l/::I /U( UIfJ lIfIfflf1::1Wwm. Education Credits {.Hopeand Ufetlme l.earning Credits) .. See instructIons. . .. A\laCh to Form 1040 or Form 1040A. OMB No. 1545-1618 Form 8863 2003 50 Your social security number. ... 1 (e) Student's neme (as shown on page 1 of your tax return) __ ___l'H:.s!.n~'!!.e______. Last name ~~~I~_~__________ SROTTY (b) Student'S social security number (as shown on page 1 of yaw: tai retum} (c) Qualified expenses {see Instructions). Do not enter more than $2,000 for eacli student. (eI) Enter the smaller of the amount in column (0) or $.1,ooCl (e) Subtract column (d) from column (c) (I) Enter one-half of the amount In oolumn (e) 2 1)1)1); 1 1)1)0. 1 000; 500. i:. 1-\UU Ul~ tllllUUnl.l:l1f1 WIUIIU1:::i \U} tlIlU 1IJ. . . . , . . . . . . . . . . . . . . . . ~ .1 uuv. ;JUU. 3 Tentative Hope credit Add the SI)1ounts on line 2, ooIumns (d) .and (I). If you are taking :lI:v;:l..u~~~.br:.~ob..ldAnt:.ao.to.p.o.d'..u:~d.~J::JA:to..P.m:l.11 Lifetime Learnln Credit 4 (e) Studenrs name (as shown on page 1 of your tax return) 1_'iIlll_ CautIon: You cennot take-the Hope Cl9dit ancttfleJifetiI71B learning creditfor the same student in tJ:1e same year. First name Lest name (b) Student's social secunly number (as shown on page 1 of ur tax return (c) Qualified expenses (see Instructions) 5 Addlheamountsonline4,oolumn'(0),andenterthetote1....................................... 5 8 Enter the amallor of line 5 or $10,000. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 8 :z :r.41at.a&(O.I.(tQ.tb:r.w.~Qr.r:'li"'I;'I.f.ltQdit. .fIIIl.llti.r.ll.)l,lir:II;I,.S.I:uI.~J.~(:tb;u:lr.t.(,'fr.dr.d~I;lr.t.,W. ~.. :t .. Allowabl, Education Credits 8 Tentative education credits. Add lines 3 and 7. . . . . . . . . . . . . . . . . . . . . . . . . :'.: . . .'.' . . . . . . . . . . . . . . .....-....>0-._.--"-"--....__..........."'. ..,---",,,,... _.....__...............". .I~"".... '. .--.. " .. ................-........."."....",....". ..........................., ........ ....,......,..~.-_........... -:"0:0.."._ 1 500. 9 Enter: $103,OClO If married filing jointiy; $51,000 il single, head 01 household, orqualifyingwidow(er)..... ... .. .. . . .. .. .. ... . .. . .. .... . . . . . .. . 9 -- 51'000. 11 Subtract IlneJQ from line 9. If zero or less, atop; you cannot take anveduoationoredils .. .. . .. . . . . .. . . . .. .. . .. . . . . . . . . . . . .. .. . '.. 12 Enter: $20,000 II married filing jointiy; $10,000 if single, head 01 household, or qualifying widow(er~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . 13..562.. 10 000. 13 If line l11s equai to or moralh. an line 12, ente. rthe amount from.llneeorilll!e l+!PIllO~l1ne 15. IllIne 11 Is less than IIna12, divide line 11 byline 12. enter the re$Jll1.alfllqilitlll(~to at ieast three pi.l\COS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . : . . . . . . . . . . . . . . . . . . . . . . .. 13 x 14 Multiply line 8 by line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . .. ~ 14 15 Enter tha amountfrom Form 1040, line 43, or Form 104OA, line 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 15 18 Enter the total, if any, 01 your credits from Form lCl4O, lines 44 through 46, or Form 104OA, lines 29 ~m...........................................,.........................a 1 500. 378. 17 Subtractllne16fromllne15.lfzeroorless,stop;youcannottakeanyeduoatloncradlts................ ~ 17 378. 1.8 .EduqllllaO ~1t$.,Enterthe,~!i1an'i"Of line .14 or line .17. here and 9n form 1 040, line 47, . or Form 1040;ll,,'nne3t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .'. . . . . . . . . . . . . . . . . . . . . . . . . .. ~ 18 378. 'SsePub.970 for the amcuntto enter il you are filing Form 2555, 2S55-EZ, or 4563 or you are eXcluding Inoome from Puerto Alco. B.AA For PJlperwOl'l< Recluctlon ~ct Notice, see Instructions. . . Form 8863 (2003) FDIAS601 11114/09 ':~)o<!ff:IiiiI,~ '0'.' '__' .."" _ ..~".. ~ . ~ - ~ , '" Form 21 06-EZ~ Unrelmbursed Employee Business Expenses OMB No. 1545-1441 O,pa1lin!I1l oI~' T..eeury (99) lrdemal Revenue seJvlce ~ Attach to Form 1040. Qccupallon .In which you Incurred expenses 2003 54A /' your name SOCIal securlty:number MARY ANN SRUTTY CRURCR WORKER Vou MayUse ThIa l'ormOnly" All of the Following Apply. . 'Iou are an employee deducting ordinary and necessary expenses attributable to your job. An ordinary expense Is one that is oommon and aocspted In your field 01 trede, business,. or profession. A neoessary expense Is one that Ie helpful and appropriate for your business. An expense does not have to be required to be oonsldered necessary. .. 'You do not get ieJrnbursed by your employer tor any expenses (amounts your employer Included in box 1 of your form W-2 are not oonsldered reimbursements). . . If you are claiming vehlcle expense, you are using the standard mileage rate for 2003. CautIon: You can use the standard mileage rate lor 2003 onlY U: fa' you owned the vehicle and used the standard mileage rate lor the lirst year youplaoec1 the vehicle in service or (b) you leased the vehicle anr:t usecl the standard mileage rate for the POrUon. of the iease period after.1997. _ tlgure YOUr I:xpense& 1 Vehicle expense using thestendard mileage rate. CompleteP!'rt1l andmultlplylin e8aby36.(.36)........... 1 2 Parking lees. tolls, ~ transportation, Including train, bus, ate, that did not involve overnight travel Of commufinglo and from work. ................................. ...... .............. .. 2 3 Travei e~nse while away from home ovemigh~ Including lodging, airplane, oar rental, etc. Donotlr1Oludemaals8l1Cl_............................. _.................. 3 4 Business expenses not Included on lines 1 through 3. Do not Include maaIs and enterlalnment ........... ...................... ..... ........ .. 4 5 Meals and entertainment expen~: $ 80 . x 50% (. 50) (Employees subject to Department ot TransportstiOn (DOT) hours 01 servioe limits: Multiply meal expenses by 65% (.65) Instead 0150%. For detels, see Instructions.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '.' . . . . . . .. 5 54. 257. 40. 6 TotaJexpanses.Add lines 1 through 5. Enter here and on line 20 of Scheclula A (Form 1040). lf9El':basitl state Of Io!:aI gowrl1lf!enl offlolals, qualified ~mIng artiste, and indilliduals-wlttrdlsabllities: . .:U:n:;1 Ult::tIl~UUUUll~ IUf t:IlJtrt.ili:tIIUIt:n:$U11 Wlllt::llt:lLUt:lllltl' UIR:f i:tlln,.llJIIL.].,. . . . . . . . . . . , . . . . . . . . . . . . . . . . . . J II) t _Information on Your Vehicle. COl1)plate this part only If you are claiming vehicle expense on line 1. .l..1J.'. 7 When did you place your vehicle in service for business use? (month, day, year) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Of the total number of miles you drove your vehicle durtng 2003, enter the number of miles you USad your vehicle tor: aBusiness ____________1,!?:Q. bCommuting __ _ _____ _ ~_ jI.Q:Q. cOfher_ 9 Do you (or your spouse) have another vehicle available for personal use? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Wasyourvellldleavallllbletorpeieonalusedurlngoff-dUlyllOurs?................................ 11 a Do you have evidence to support your deduction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . b If ''{es' lollle eVidence wrllten.?.. .. : .. .. .. .. .. .. .. '. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . .. .. .. '. .. .. .. .. . .. '. .. .. .. .. .. .. .. .. .. .. .. .. BAA For Pap.wOtk Reducilon Act Notice, see separate InSlrucilona. ~ .9YjQjlQ.,oJ. _ I.J.?!!. Vea No . Yes ..No X VM. No .Yea . Nll Form 2108-EZ (2003) r FotA75Ot OMllIO'$ -'~r~.1~\ " , ,.'. ~ .., -'-, .. Schedule A 'Lines 20, 22, .27 Miscellaneous Itemized O~iomfStatemelit ~ Attach to return (afterall IRS'forms) 2003 Statement Name(s) shown on Return MARYWa illii.iTTY Employee Business Expenses - SUblect to 2% Limitation 1 Dec!uctlble expenses from Form 2106, line 10 less deductions for - performing artists and handicapped employees oIalrned elsewhere. . . . . . . . ... . . 2,c-Excess,edUcator expenses from the .Educator Expenses Worksheet. . . . . . . . . . 3 Union and professional dUes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Professional subscriptions. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Un~orrns and protective clothing. . . . . . . . . . . .. . . . . . . . . .. . . . . . . . . . . . . I 6 Job search costs. ........ '" ... ... .., .j... . .. ....... ... ........ 7 Other: ..:;: n.l .,." 1 2 3 4 5 6 3!i1. 00 , .' , - . L ".I 8 Combine lines 1 through 7 (to Schadule A, line 20) . . . . . . . . . . . . . . . . . . . . . . 8 351. 00 Miscellaneous Expenses - Subject to2%l,.lmitation Investment + Check !he box in investment celum,! " an investment expense expense 9 Depreciation and amortization deductions. . . . . . . . . . . . . . . . . . . . . . . . . - 9 ...!.. 10 Casualtylthaft iosses of properly used in service~ as an ernpioyee. . . . . . . . - 10 11 REMIC expenses, from Schedule E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...!.. 11 12 Investment expenses related to Interest and dividend Inoorne. . . . . . . . . . . ...!.. 12 13 Expenses related to portfolio income, from Sohedule(s) K-1 . . . . . . . . . . . . ...!.. 13 14 Miscellaneous deductlons, from Schedule(s) K-1. . . . . . . . . . . . . . . . . . . . ....;.. 14. 15 ExceSs deductions on termination, from Schedule(s) K-1 . . . . . . . . . . . . . . --.: 15 16 Investment counsel and advisory fees ...... . ....... ........ ..... ...!.. 16 17 Certain altorneyand acoounting fees. ...................."...... ...!.. 17 12,634.00 18 Safe deposft box rentalfees ........... .. . ......... . ..... ..... ....!. 18 19 IRA custodiaUees" . . . .;-,' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....!. 19 20 Loss Incurred irom'total,dlistribution ohll-tradillonaHRAs. . . . . . . . . . . . . . - 20 21 Loss inOllrred from total distribution of all Roth IRAs. . . . . . . . . . . . . . . . . . I-- 21 22 Tl!X Preparation software and ll!x publications. . . . . . . . . . . . . . . . . . . . . " L-. 22 150.00' 23 Other: r-- I-- 23 . l"- . . . P- . , , ~Ii.i, ~1 . ' f-.;. 24 ..... .. r- 24 12,784.00 Combine lines 9 through 23 (to Schedule A, Iins .,' . .. . . '." ...... ..... Other Miscellaneous Deductions - Not Subject tol~ Umitatlon 25 Federal estate tax paid on decedent's inoorne repl)/tad on this return . . . . . . . . . 25 26 Impairment-related expenses of a handicapped employes, from Form 2106. . . . . 26 27 Amortizable bond premiums on bonds acquired before 10/23/86. . . . . . . . . . . . , 27 28 Gambling losses. . . . . . . . . . . . . . . . . . . . .. , . . . . . . . . . . . . . . . . . . . . . . . 28 -29 ,easualtyltheftlosses-ofincome--producing-proparly. . . . . . . . . . . . . . . . . . . . . . 1-29 30 Other: . 30 , . ~;. " . 31 Combine lines 25.30 (to Schedule A, line 27) ',:;~:. . . . . . . . . . . . . . . . . . . . . . 31 , :".;('. i:-"';iffio~(!!f=;:,:rlli}~ I ~._ . I~ ~'" ~ "131 :804 Office of Financial Administration _-.,Diocese of Harrisburg PO Box 3651 Harrisburg, Peunsylvania 17105 Phone (717) 657.4804 Fax (717) 657-8757 Name MARY ANN SHUTTY Soo Sec # CUrrent UniUDeot 131 804 GROSS PAY 1075.50 FEDERAL W/H FICA TAX STATE TAX CITY TAX UCTAX NET PAY: 60.93 82.28 33.02 17.21 $882.06 Year to Date 15858.46 872.87 1213 .14 486.85 253.73 Period Ending 7/14/2004 Check Number 9Z2~59 Pay Date 7/21/2004 Marital Status S Dependents Claimed 04 Additional Withholding .00 Federal .00 State REGULAR HOURS 80.00 REGULAR EARN 1075.50 .. Office of Financial Administration Diocese of Harrisburg PO Box 3651 Harrisburg, Pennsylvania 17105 Phone (717) 657-4804 Fax (717) 657-8757 TO THE ORDER OF: .'i;P\_~~'ilK ~.'r.-'"-'~'r.r ~.' ".' _, ". 131 804 MARXANNSHUTTY PAY I~"-~ 60-1273/313 DATE CHECK NO. PNC Bank, N. A. Southcentral PA 7/21/2004 979659 *****882 ~o{[ars atuf 06 Cents $882.06 NON-NEGOTIABLE , ." - . ~, ,'~ ,,'!l'!~1f1 ., M, . ~ ",J1l"'!QI!I..!;t. ,~.. .. '"~ '1 -,."",,,,".,,,;,,".,. ~~ - ~~, r--> (,,-::;) c-? .r." -:r."'" (::: G~) \ (.f' '. (-) 1.."'- '2" 3- Q, .-' :r:-n ,\.1f~ -()r:'Ci ~,~) c. ",'b '~-"l'" Y;2~~~ f':'? '~i. ""'1J ::$. <.J'I GO 0', m'fl!l~tl!~~~.jiffiii'i1~j,'~'~"'~''"'I''''-f'~:;'''0',?r,F{",,":''';''T ,.,..~"';;:-~"j~~%'P':E''';;*i'1i''l',"g<j.Titi''hil',@!,W;;;:''iflR-1iliW~~}~~~' THERESA BARRETT MALE, ESQUIRE 513 North Second Street Harrisburg, PA 17101 August 5, 2004 Prothonotary's Office Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17103 Re: Shuttyv. Shutty (#01-6237 Civil Term) Please: 1. file the enclosed plaintiff's tax return and most recent paystub pursuant to Pa.R.C.P. 1920.31(a)(1) 2. return the time-stamped copy in the enclosed envelope. Cc: E. Robert Elicker, II, Esquire (w/enc) Please call 717-233-3220 if you have any questions. '.m~.~l, ~. _ ~ " "^', ~ " , . I "" ~~ yo .~ ~ ,'-.'~ -= \. - -- Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrtsburg, PA 17101 (717) 233.3220 tbm@tbmesqulre.com Counsel for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE PLAINTIFF'S MOST RECENT TAX RETURN AND PAYSTUB PURSUANT TO Pa.R.C.P. 1920.31(a)(1) :*<'-~~~ ,~.~ ., ~-~I~~ ~ ~ Fonm 1040 Label (Sealnstrucl.lana) u.. tha IRS '"beL OthelWise, please print or type. Presidential ElactI"" Campaign (Seelnstruct/Ona.) Filing $fatus Check only one box. Exemptions If mora than five dependents, see Instrucllons. Income Attach F0l1118 W-2! and w..~G hare. Alao attach FOnn(I) 1099-R II tax WI8 withheld. If Y04 did not ,. ,.~?~.-.....f$'_~" InStrUctions. -- Enclose, but do notattacm,any payment. Also, please use ~"'f!"'o..tU^" A~;.._.._... .....;.,-_._- Gross Income .''''~~flg~ ; Deim*lent o1ltle Treasury - Internal Revenue Ser1irce I};$. Idlvlduallncome Tax Return For1l1e r Jliri.,', Oec3i 200t,'0f other tax ear 'nnl Your OBI name MI Last name 2003 IRS Use Only-':Drinot Wrtle or lelnthls ace. r 20 OMB No. 1545-0074 Your ~ ~CUrlty number Spouse's8Clclal98CUrlty number MARY ANN II a /Oktl return. spouse'sflrst name SRUTTY Ml Last name Criv'-tOWriorpoiri:itliC8. IfyOiJ'tiave-aforetgn ~ _'-~1oI1S. . Importantl . YOu must enter your social security number(s) above. Home-address (number and slreet). If you haVe a.P,O. box, see Instructlons. Apartment no. 30 Self-employed:SEP, SIMPLE, and qualified plans. . . . . . . . .. 30 31 Penalty on early withdrawal of savings, . . . . . . . . . . . . . . . . . .31. . 32 a Alimony paid b Recipient's SSN. .' ... I '32 a[. 33 Add lines 23 thro'!llh32a. ............... .'. ,....::.:................,......, 33 34 Subtract line 33 from line 22. This Is ur ad IIlbii('ffil;,,'income. . . . . . . . . . . . . . . .. .....34, BAA For Dl8c1osure, Privacy Act, and Ipaperwork ReductIon Act Notice, 8ee Instructlon8. FOIAO'" O'NIlI04 atwi'. ZIP Code ... Note: Checking 'Yes' will not change your tax orreduCe jIOur refund. . You Spouae ,. Do. or ur s use If fI1l a oint return .want $3 to 0 to this fund? . . . . . . . . . ..... Yes No Yes 1 Single Head of hOusehold (w1thquallfylng person). (See Instructions.) It the qualifying person Is a child 2 Married filing jointly (even if only one had income) but not your dependent, enter this child.. 3 Married filing separately. Enter spouse's SSN above & lull name here. ., name here. . ... 5 Quail Ing widow(er with dependent child. Sea instructions.) Yoursell. ff your parent (or someone else) can claim you as a dependent on hie or } ~~~ her tax return, do nOlcheck box6a. . . . . .. . . . . . .. . '" . . . .. . . . . ... ... . .. ...nd...... b S 88. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ::"'I3:.n (2) Dependent's (3) Dependenfe (4)'.n eo...., c Dependents: soclal~rt.ty relatitoOnshlP ..f1'/!l)'~~ ..!.va<! nUlTllJOr.. you tax oredn whu you. .'. . see lnslrs . did not lIVe With you due fD.dJVoroe ~~.. De~nclent8 . onBcnot.,.: . . entered above . 6a 1 Arst name KEVIN S SBUTTY Last name Son . .. " ~d numb... . cf,;<......' ' .~. ",."...,;. .tidh ".1. 'mod. .. ., ~1In" , .. "'lv,c:ul'1umJ;IUrUISI\9111 scal ......................................".... !i'dYe... 7 Wages, saJaJies, tips, eta. Attach Fonm(s) W-2. . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 8a Taxable Intsrest. Attech Schedule B if.reQulred. . . . . . . . . . . . .. .. '.' . . . . . . . . . . . . " bTax-axampt Interast. Do not Include on line 8a. . . . . . . . . . . " . 8 b" eaOrdlnarydlvldends. Attach Schedule Bffrequlred. ............................. hQilll'lfddf\tl:l I ...""1..... . ~\tltl"lIil:1uiij "',' . . . . . o' . . . . . . . . " . . . . . . . ". . . . . . . . . . '-' 1 '~~......, , . 10 Taxeblerefunds,credits,oroffsetsofstateandlocallncometaxes(seelnstruclions)................. 11 Aliillonyrecelved....................;............................. 12 I::luslness Income Or(lose). Attacn'tioneaUle-c.; or (j-t:t: . . . . . . . . . . . . . . . . . . . . . . . . . . 13aCepllalgainor(loss).AttSChDffreqd.lfnotreqd,ckhere................... .. 0 b,.~~~~:.~!~~,~~'t:_",..~ . . . . . . . _ . . . . . . . . _ . . . . . . _ . . .I1!\ I ~ 14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15a IRA distributions.. . . . . : . , ill..1 I b Taxable amount (see.lnS!rS). . . 16l(Peililibnll' aftiI'shrlJllies: . . . E:1!!I". "b'Taxabre' Ii'nWtln!'(UelitWSr . . 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . . . 18 Farm'inoome.or(ioss).AttaohScheduleF.".......,..................:...... 18 Unemploymetlloompensation.....................................,.... 2GaSocialsecuriWbenstits....... ~ I b Taxeble amount (seelnstrs). .. "4 nM,....I..........." 14 15b "18'b' 17 18 18 2Gb .,~ 22 Add the amOLini81nihe far ri- hi ooiUmn for liiie. '7 iii;OU'ii' 21.1-;;;81" - ur tOt&! Income ~. ~-... 22 23 Educator expenses (seeinstruotions) . . . . . . . . . . . . . . . .. 23' 24 IHA aeductlon (see Instruonons). . . . . . . . . . . . . . . . . . . .. 24 25 Studentloan Interest deduction (see instructions). . . . . . . . .. 25 'II Tllit/nn ~:mrl f~ rlArlur.tfnn (!l::AA InAtrllrnnns=:\ ,,, 27. Moving expanses. Attach Form 3903. . . . . . . . . . . . . . . . .. 27 ~ One'haJf~f self-employment tax. Attaoh Sqhedule SE. . . . . .. 28 ~i' .,j~h~ifi~;(j~in~~mV.~}jst..,;~~,t.;B\.i~cii&i;~':\s~~'iil~a~i: '. . . . . : . ';;'(r- . No 1 1. 42. 13 38.4. 205. 37 438. 3q 438, Fonm 1040 (2003) ."~,~. ~, .'.'r~:'" -,I '~-~ f'~" ~~ ._.....---,~'"-~ ~" , ~-...,...".." -~ "-~ ,.','," . --;..~';._;.,...-... ~'....-................ -_.. ';-'v;;;.i'.~r;......,v.J ...~..... &aIo.... ..................... ~!I.--bmountfromline34(adjustedgrOS$inoome).. . . ., ... ... .............. ... .., . ~::.::." ~8cl!rJ>""k. r n You were born before January 2, 1939,. n.Blind. Total boxes ...., ." If: LUSpousewas bom before January 2, 1939, UBl1nd. checked ~ 38a !Standard I b If you are married filing separately aTld your spouse itemizes deductions, ~ b n ., ;!!,,!!u~on or lieu _ea duel-status alien. see Instruotions and chack here .. . . . . . . . . " . 38" , . I 'v. ' '37 Itemized deduclions.(from Schedule A) or your standard deduction (see left mar~n) . . . . . . . . , . . . . . . ~~.l'dea~~ox [38",~~btra~II~~~~.f,~~~ l1~ess. . ::: ~;,:,:,:: . :.' '. ... ,: . . :: . '.: . .. ',',: . '.: '. ".:." . . : " on llne.aAAor ".Tv 1. IllfO ~ 10 .plV"t,V.:;..", \If 1=<000, IIIUILJI-'IY <oj.V,V..JU loIy UIO LVLQIIIUIIII.A:II VI ClIAOl'lfJUVllO lwtlQUlll:lU ~borWhOcan . on.llneed I.f line SS Ie over $104625 seethewo. rksheetlnthelnstrucllons.. . ........... be c:IEilrneclas a '.. '.' de ndant;see . 40 T~le i~llOme. Subtf!ict line 39 frorn hne 38. I~; "11.lm639lsmore,lhaRlme<8rente'"O".................. ....................... n 41 Tax(seelnstrs).Checkhlylaxlsfrom a o Fonn(s) 8814 b o Form 4972. ................. .1'\Il-01he~: I d 42 Altematlve minimum tax (see Instructions). Attach Form 6251. . . . . . .. . . , . . . . . . . . . ." , ; .SlnQle or nllarre . '.. ~ . .]~~~~peratElIY' I: ;~~:;~;~;!t~~~~~ ;~;6'i;ri.~~i;e~:: ::: : : : : :: 1~1' . . . . . . . . . . . . 43 JI4.smJMfflJDn. " '~'..~~~f'~~~~~~"":'!'~!}~;-.~~*f~~.~.~~.:'.,." _. ... ,,~.,. j ~~~YtJ~ - 148 Credlt for the e1deriy or the disabled. Atteoh Schedule R . . . ,. 48 , :fi.!d~Y!Jer~ . .47 Education credits. Attach Form 8863. . . . . . . . . . . . . . . . .. 47 I 148 R. etirement savlng.s oontributions ore. dlt. Atteoh Form 8880. . " 48 ::::1 48 "Child tex credit(see Instructions} . . . . . . . . . . . . . . . . . . .. 49 ..I..~~~~80'd - '.I";"~;;;m~~;\DUi;':~""';,o[i.F~r~'a859,:::::: ::: :: :.' ~w". ... 52 Olher credits. 9!L"!'Kapplioable box(es): aD.form 3800 . < . . b U~"f c USpecify: . .. .. .. . 52. 53 Addl~ 44 through 52.. These are your lotal credltti. .. . . . . . . . . . . . . . . . . . . . . . . . " .4' Sdbtract line 53 from line 43. ~ line.53 Is more than line 43 enter .()-. . . . . . . . . . . . . , . . 55 Self-employmentlax,AttaohScheduleSE...:..., c.... .:. ... ........ ......... .., 58 Sociel securi1y and Medicare lax on tip inOOlllO not reportadto employer. Atlad1 Form 4137. . . . . . . . , . , . . , 57. Tax on qualified plans, inciudlng IRAs, and olhertax.favoredaccounls. Attach Fonn 5329 if required. , . . . . . . . 58 Advanos earned Income credit payments from Form(s) W'2 . . . . , . . . . . . . . . . . . . . . . . . 58. HOOSeholdempl0\1mllhitaxes..Atlach&:hedule.H... . .. . .. . .. . . . . .. .. . . ,. '. . _. ;.68. 80 Add lines 54,59. This is urtofaltax.....................".........".".. ~. 80 81 Federal lnoome tax withheid from FormsW-2 and 1099. ; ..... 81 1 944.' 82 2003 estimated lax payments and amount applied from 2002 reiurn. . . . .. 82 " 83 Earnedlnl(Oinecredtt(EIC)...... '.. ... .......,..,. 83 SA 'ExJ;esssociahecurity.andtierl RRTAlax wltl1held (see instructions). . . .. .84 85 Additional chlid tax oredil Atteoh Form 8812. ......,...,. 85 88 Amount pald with request fur extension to file (see Instruclions~ . . . , .... 88 870lher pmtsfrom: a'[JForni 2439 b" DFonn4136 c "0 Forni 888587 . 68 Add.lines:61thhJ 67.Theseare ur,lotal- eots... ._. ;.............. ....:.. ;-...... ... ~.. :{fJ~~:~a!;"~~n.'J~m;>':l;i~r-t.,,tj~~~~:!~~,.~~,j't;,~~~~~~.:.. 70a Amount of line 69 you want relundecl to YOU .. . . .. .., ........... ...... .... ~ . bRoutingnumber...., .J231381116i .. c Type: []g,hecklng I!Jsavlngs, . dAooountnumber... '.' ... .0453316101 71 AmountofJine69 'want lIedtour.2004eslimamdtlx.... ...;~ ..71 Other Taxes Payments I' you have a qualifying child, e1teoh ScHedllle EIC: ."<'~~WJ- Dlrect.deposlt? .. ~J" instruel\one . d.i{~i'1r.}1'i'rtr;J, 700, and 7Od. .....,.,;:....~;.~.f'. ........-.... You Owe Third Party Designee SIgn Here ~olnt return? V...OltIOIl....""'VIIQ' .-.-....- 'u ...... 37438. 27 563. 9 875. ..6 100. 3 :175.-:: 378. J'I'd . 378. O:~ o. 1 944 ~ ,1.,',Ail";;.;, 1 944. ..,.",..:~.....,;.......~. '."'~"'J"-"'}"_'.~"""; .:_,_,_. ........ I,., ,_" j _ 0, .,-;..:j.,.. ~"'r ......... ;; ~~~::~~-=~~;;~;:;;:~~~:;~,~,~~~~":~.~...~.~.~..~~~;.v~tE:ri;~" ...... .... ' Do ~u wan\ to allow another person to discuss this return with the IRS.. . (see Instructions)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0 Yea. Complete the following. '1j[I No Desfgnee's Phone Personalld&nWlca11On name .. 'no. ~ number (PIN) .. Under penalties ol pe~ury. I deClare thai , have examined this retum and accompanying scJiedules and statements and 10 the best of my knowledge and belief, tney are true, correct, and complete. Declaration of preparer (other lhan tBll:payei? Is based on a1llnfonnatlon of. whIch preparer has any knowledge. ..... Yourslgnalure ... l~e IYOUrOC<lupallon . .'.' I Dayllnleimone number -~~--_.__ __........_ o' r' ....u.......,..:..:.." hv...'-L'lo Keep a' copy Spouse's signature. If a JoInt return, both must slg'n. f~~Y.:',~:.Eeoor.'!!:..-1.,." Prepare'. .. slnature ~ Paid Preparer's Use Only '~:~!i7J.!,l 1-, Spouse's OCCupaUon Date Fm~~. Se1f~Pre ared (oryoureW .: self.emplOyed), ... . address; and ZIP code EIN Phone no. FDlA0112 01116/04 ~ ' r_',_ I~ ~ "1- , Form 1040(2003) , Oeparlm!lol or Die TIO""ry (99) Inl8maI Revenue serVIce Name{s) -~non F~ 1040 MARY AlIN SRUTTY . MedIcal . Cliutlon. 00 not Include exp~.rel~bursed or paid by others, ....... ~.~....::w: ..,,~ ~v,,~: ""l""''''''''' ~.."" ,,"'........""...../. . . .' . . . . . . . . . . ,. . . . . Dantal Expenll88 SCHEDULE A (Fonn 1040) Taxes You PAid (See instructions.) .111__1 You Paid (See I..........'....."'......, Note. t'ersonaJ interest Is not .................ll..l_ Gifts 10 ",.._my If ~~ m~de ....::1.......,... got a benefit for it, see instructions. !?aa~,!1Iy and Itemized Deductions OMB No. 154&0074 ~ Attach to Form 1040. .. See lnatructlona for Schedule A (Form 1040). 2003 07 and address ~ 12 386. :: :-'..:':': .:~.:~ :.:::.::. ~;.:; :;-.:.~;::;:::; . . . . . . . . . . . . . . . . . . . . . 9,901. 2 Enter amount from Fonn 1040, line 35. . . .. 2 3 Multiply line 2 by 7.5% (.075). .............. ........... 3 4 Subtract line 3 from line 1. If line 3 Is more than line 1 enter-O,....................... 5 State andlocaJ Inoometaxas.. ...... .. ..... ........... 5 1 043. 7 Personal property taxes . . . . . . . . . . . . . . . . . . . . ..' . . , . . . 8 Other taxes. List tYPe and amount .. Other taxes 11. 8 ----------------------------- 9 Add lines 5 through 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ . ::: . 4,205. .. .." - ,V' IIVlIl(llIl",ymr.olW~QlIl.lfNlll~l~l.OUWJWVllllllllllv.JIJ............ 11 Home mortgage Interest not reported to you on Form 1098. ~ paid to the perSon from whom you bought the homa, see i..........'...t;...............f'f..h"'...+h...........~.................... i...^'"<+i.,..;...........n"i......... , ." ... . 12 Points not reported to you on Form 1098. See Instrs foropel rules. . . . . . . . . 13 Investment Interest Attach Form 4952 If required. 1(<"'..:....1-0\ ..;.........,................... .-. 14 Add IInas 10 through 13 . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1& Gifts bv cash or check. If YOU made any alft of !R250 or more. seelnstructions. .............. .......... .. ... ... 18 Other than by cash or check. If any gif1 of $250 or more, see Instructions. YOU mUll attacn f'"orm t:S~ If over$500.. .. . . . ... .. . . .. . .. ... . .. . .. . . . .. . . . . 17 Carrvoverfrom orlor vear. . . . . . . . . . . . . . . . . . . . . . . . . . .. 17 18 Add lines 15lhrou h 17. .. . . .. .. ... .. . . . . .. . .. . . . . . . : .. .. . .. .. . . .. .. .. .. 1 071. . ..........-- 1" t,.,asu or IneTt lOSS as . Anacn t'orm 401:14. . oee InstrUCllons. 20 Unreimbursed arnployse expenses - job traveh union dues, Inh arh"""atlnn iClt... Att!CIM l=rIrrn ?1M 1'\1" "if"l~_~7 If Job Expensea and MOSl Utner MIscellaneous Deductions (See instructions.) -...-... Mi;;';lIaneous DeductIons Total itemIzed Deduction. required. (See Instructions.) .. ------------------------------- E~~E~~t~~~__________________~~. 21 Tax preparation tees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...........,...,,""....,.......... II........".'....".,......,...........,.........,...........,................ type and amount ~ __ __ _ _ _ _____ __ _ __ ___ See Statement 12.784. 23 Add lines 20 through 22 ... . ......... .... ... .. .... .. 24 Enter amount from Form 1040, line 35. . .. ~I 37 , 438 . ~ lVlut~lpIYllne"4DY~'70 {.Ul:!). . .. . . .. .. . .. . . . . . . . . . . . .. :l:O 28 Subtract line 25 from line 23. If line 25 Is more than line 23 enter -(), . . . . . . , . . . . . . . . . . . . . .,.,. nt""eol' _ frnm Hot il"l tn..:. in.:l'h:' ,r<tInno I i<:lt tuno ann amnI'"" ~ --------------------------------------------- 27 28 I. Form 104Cl, line 35, oyer $139,500 (over $69,750 ff MFS)? ~lt..... V ...11.. ri...,.j, ,....i...... I.... "...+ 11.,.,;....,.1. ^...l..t +100.... .............., ,nt... i... +h... f..... ..1....1-.+ .......11 ........ for lines 4 through 27. Also, enter this amount on Form 1040, ilne 37. Your deduction may be limited. See InstrUctions for the amount to enter.. ---, j- DYes. BAA For Paperwo~ ReductIon Act Notice, see Form 1040 Instructions. ","!,,)";WA~~ FblA0301 10/16103 Sch~ule A (Form 104Cl) 2Cl03 - ~- 1-' - ~ ,...~~~.",.,....." ,~ _, ,_'f Dep8Jlm!nl oIlhe T.....ry !_ ReVenue - (ee) Name(s) shoWn on FOmI1040 MARY .Al'INS.IIU'11T:t' . hon-l'erm.Ca . ital Gains and Losses Assets Held One Year or Less (8) DeecrI..;.....O! (I>)oate_!(ea (c) OatesolO (d) Sa~sp.ce (e)CosIorolherbasls (I) Oolnor OOSS) ~'\lsm (Mo.day,yr) (Mo,day,yr) (seelnslructlons),. - (seel,nstrucllons) ~f:t~t1~J 1 Capital Gains and Losses . Attach to Form 1040. . See Instructions for Schedule D (Form 1040). . Use Schedule D-1 to list. additional transactions for linea 1 and II; OMB No, 1545-0074 SCHEDULE D (Form 1040) 2003 12 (g) Post....y SlI'lln (~~ 2 Enter your short-tenn totals, If any, , from SchaduleD-l, line 2. .. . . . .. .. .. f-!- '" 1 VUlI sngRoftllrm H.N pnlOO amuums. 1_ Add lines 1 and2Inoolumn(d)........ LL 4 Short-tenn galn from Form 6252 and short-tenn gain or Ooss) from Fonns 4684, 6781,and8824.................. .-:.......... .......... '.' .,...... 5 Net short-tenn g~n or Ooss) from partnershlpe, S oorporatlcins, estates, and trusts frnm ~rhAri.IIAfA' 1<.1 8 Short.tenn capl~ loss carryover. Enter the amount, If any, from lin~J 91 your. - . 2002 Capital Lose Carryover Worksheet . . .. . .. .. . . . . . .. ... . . . , . ... ... . . 7 at;omblne lines 1 mrougn 5 In oolumn (g). I' the resUlt IS a lOse, enter tile resUlt. Otherwise, enter-IJ...Donotentermorelhanzero......... .................. bNet ahort-term capital aaln er(loUl. Combine lines 1 throuah 61n column (f1 . . . . . . . . b Lon irerm Ca Ital Gains and Losses Assets Held More Than One Year (8)0_01 (b)Oate.cqul..d' (C)Oatesold (d)Sa~Sptlce (e) CosI or ottl.r_ (I) Ooln or (1000) PTOpl!I!rty ~p!e.:, (MOo day, yr) (Mo, da.y. yr) (see.lnslructlons) (see Inslructlons) for the entire year l00Shai'e6XYZCO Subtracl(e}from d 8 Heine .Sa1e. ain .Rea1i ed 08/01/90 12/01/03 199 000.0.0 173 976.00 25 024.00 Section 12 Exc1usie (g) P~BY 5 g.ln or(loss)- ....."" 24 819.00 -24 819.00 -24 819.00 iroiii's'cliiidui."oTilneS:'.'. -::: . . . . . . .1::1::t vuu. ... r-_~__.._.._l__... ....._...._..._1_ 14' __.. 10 TotaIlong-lerm aalesprlce amounts. 1-\UU IIl1f:1::l 0 ~IU l;IlIl.wlWlllllUj . . . . . . . . ....... 11 Gain from Form 4797, Part I; long-term gain Irom Forms 2439 and 82$2; and J:j long-term galn or Ooss) from Forms 4684, 6781, and 8824. . . . . . . . . . . . . . . . . . . . . 12 Net long-tenn gain or Ooss) from partnerships, S oorporatlons, estates, and trusts from Sohedule(s) K-1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Capital gain distributions. See Instrs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Lon~-term caEna"oss carryover. I:nterthe amount It any trom line 13 ot your . 200 Capital ossCarryoverWorksheet......:....'..................... 15 Combine i1nes 8 throuah 13 in oolumn (al. ff zero 'or lass, enter -0-. . . . . . . . . . . . . . . . 18 Net long-term capital gain or (lOll.). Combine lines 8 through 1410 oolumn (I) . . . . . . . . Next: \.::IU lU 1"'1:1.1 L III (,IfI ~ t!. ~Include incoJul]1n (g) all gains and losses ~ column,(fJ froms~!es, ex~hanges, or conversion~ (In~udln~ IlIslalll]1ent paym.ents received) ~r. May 5, 2003. However, de not mclude gan attnWle to unrecaptured section 1250 ga,~ 'collectibles gains and losses' (11$ defmed m the instructions) or eligible gain onquallf,ed small business stock (seeJnstrs). BAA For P8p8lWlirl< Reduction Act Notice, see Form 1040 Instructlona. . Schedule D (Fonnl040) 2003 FDlA0612 01/16104 "*"")iff",,9>'~.?_~.~_~" ,",.,..,. __T ~I , ~ p 1 _ _, ''''-' " ~ :;',~'I~"';~'Z .;- Ull"./~~' '4~ ...~,~; ;;~; ,.~U:~(,oi~:: ;taxable'&aln'or Deductible LaSll 17eComblfle fines 7tiana-1a and enter the result. If a loss. enter-O- on line 17b and 00 to line 18. If a aain. enter,lllegBlnont-onm1040,lme'3a,andgotollne17PPeIOW................. .................. bCombine lines 7a and 15. If zero or less, enter-D-.ThencompleteFonm104Othrou9 hllne40............... N-n.' lflin,::l. 1A ~f ~('tll:llrlldlll n iQ.::l MAin n..'tnll h~\m n11!:lIIfl,:lrf rliuirl,:llnrlc: nn Fnrm 1/1411 Iln,::a Qh nnmrib::dc Port IV below. . Otherwise, skip the rest of Schedule D and complete the rest of Form 1040. -co If Ii"'... 17.. i~ ...1............ ^""+....I'M...... "nA ^" e.......... ..nAl\ u...... "l'.l.. +h.... .....;...11..."""....\'''"'''......1.......,.. ...../10..\ Id:!'=l Mn\ (or, If lTlarrledfiling'separately. ($1,500)) (saelnstiuctione)'. .....:... ::....... ::. :'................ Next:' If you have quallfi9jldiVll:iends on Form 1040, fine 9b, complete Fonm 1040 through line 40, and then oomDlete Part IV below (but skio fines 19 and 20). .' . Otherwise ski Pan IV below and com lete the rest of Form 1040. _tax Computation;.U,lng Maximum Capital Gains Rates If IIn818 or IInel1a lazero ofleas, Skip lines 19 and. 20 and go to line 21. Otherwise, go to line 19. 19 Enteryourunreoaptured seotion12S0gain, If any, from fine 18 of the worksheet In the I nstructions........... .l!!j 205.\ 20 Enter your 28% rate gain. If any, from fine 7 of the workshest In the Instructions. . . . . . . . . . . ... . . . . . . . . . . . ~ , ... ,,_ ~, ..... __...... .... ___w .__.._ .._...... _.... ..n...... . __.__...... ..... ..___....1...& 1.. ...._. ... _...........__.. &_ .._..... ..,. - --. ----......- .......- -- 11_. - .... .. ...._ ." _._ _'" _._ __-,.... ,~_ ......_.,._"._.....~ __.......__ ...._ n_..._.._..... n. ...... ..._u__~......_ ~- ...-.- ~..- _..-_..~ ~- -....-. -.. .,.._-- and 63 balow, and skip all ath..lln.. balow. . 21 Enter your taxable Income from Form 1040. line 40. . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .. 21 , , ~z I::merIJ19SmaIIel'OTUnell:iOrnn91/B,DUtnotI9SSmanzero.,.. .,........... zz 23 Enter your qualified dividends from Fonm 1040, line gb. . . . . . . . . . . . . . . . . . .. 23 ','u ..."" flAl. ^M,I"",-""",,rw-I~ ". 25 Amount from line 4g of Form 4952 Qnvestrnent Interest expense). . . . . . . . . . . .. 25 28 Subtract line 2S from line 24. If zero or less, enter -0-. . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . 27 Subtraolllne 26 from line 21. Ifzeroorless,enter-o-. ........................................ 28 Enter \he amaller of line 21 or: .....- --- .. .. .. ""''"''vvv'' '''CollI ''''''' 1IU11t:! JV"'",,,,, 'i......1I11"'t:! ...........\...." . $28,400 If slngle or mentedflllng separately; or . S;Sa.050 fl heed of household If line 27 Ie grest8l:thenllne28. aklp lines 29 through 39 and g~tollrie 40. 28 Enter \he amount from line 27 . . . . . . . . . . . . . . . . . . . . '. . . . . . . . . . . . . . . --. r.......... V" ':'\,/I,I""\.f~ijll...."'all"'III;,I....o:.u.II''''''VVl;'G''o,olnCllI-v-c;ul'';YVW;;11l;I..;U,......... 31 Add lines 17b and 23". .. .. .. .. .. .. .. .. .... 31 32 FntArIhAsmallerofline30-orline31..... _ _ _. _.,. _.... _.. _.. .'...,. .32 33 Multlp\yline 32 by 5% (.05). :....................................................... ~ IIn.. 30 snd 32 are the same, skIp linea 34 through 39 and go to line 40. I I "... ..,UUtlq\.fLllIll:ll,;)"dIUIIIIIII'CI.:JU.......... ......'..................... 35 Enter your qualified 5-year gain, fl any, from line 8 I of the worksheet In the Instructions. . . . . . . . . . . . . ~ 38 Entertheamallerofline340rllne35.............................. 38 37 MultlPly line 36 by 8% (.08). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . ......,_....._....._. .......H.__ n.__... 1 _... '1 .................. ............. ..-... ........." . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 MultlPlyllne36Py10%(.10).........................,.............................. If IIn.. 28 and 30 are the same, skip IIn.. 40 through 49 and go to line" 40 Enterthesmallerofline2'10rllne26...................... ...,;:. .....,.,.: 41 Entertheamountfromllne30(lfline30/sblank,enter-D-).... .';:'t.. :./,:.;:J~' . ,. .. . .. .~ ...........~'...... ,...... "'T' "".'j '" '''' ........ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Add lines 17b and 23".. .. .. .. .. .. .. .. .. ... 43 44 Enter the amount from line 32 (flline 32 Is blank enter ,O-l . .. 44 45 Subtraol line 44 from line 43. ............... .~ 46 Enter the emallerof line 42 or line 45 ...... .... ...... .. . ... . .. .,. .. 48 Ifl IVlurnplY line ~ oy 10'70 \. lO). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '. . . . . . . . . . . . . . . . . . 48 Subtraat line 4Mrom line 42. . . .. ... " . . . . . . . . . .. . . . . . . . . . . . . . . . ~ 48 Multiply line 48 by 20% (.20). .,.................................,................... 49 50 Rgura the tax an the amount on line 27. Use the Tax Table or Tax Rate Schedules, whichever applies. . . . . . . .. 50 51 Add lines 33, 37, 39. 47, 49, and 5Cl . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . 51 52 Agure the tax on the amount on line 21. Use the Tax Table or Tax Rate Scl,~~ules. whichever ap~lI~ : : : : : : : :: 52 .53 Tax en a11.taxable Income. Enter the smaller of line 51 or line 52 here and on Fonm 1040, line 4 t . . . . . . . . . .. 53 378 . If lines 23 and 25 are more than zero, see Instructions for the amount to enter. . Schedule D (Form 1040) 2003 FDlA0612 01/16104 ';"rr1'c~,,~~ -~,~:=-!'"_ 11 ,"" .- OE!~entoftbe Treaswy .Intemal RevenUe S6lv\Ce rilAine(s) stoWnon return MARY ANN SRUTTY IJ Caution:: ,You, ~not taks,~ 8lI9ducaffon credft and the tuition and fees d9ductfon (Form 1040, One 28, or. Form 1040A. line 1.9) for the sanJB $lUdent In'tbe sam& year. nu c ~i.,u.,. ""BUllon: r(JU cannor li:ftte1 UI~ nu (;ff:IUU IU! ffI()!~ 111I:11IJ U:JX l:l/::J lur UIf:J SII"",::IlucreJfJL Education Credits {Hope and Ufetlme l.earri!ng Credlts) .. See Instruction... .. A\laCh to Form 1040 or Form 104OA. OMB No. 154501618 Fonm 8863 2003 50 Your social securlly number. It 1 (e) Student's name (as shown on page 1 of your tsx return) First name ----------------. Lest name ~~~I~_~______ SHUTTY (b) Student" social securlty number (as shown on page 1 of . your tax: retum} (e) Quallfled ")(pens.. {see Instructions). Do not enter more than $2,000 for each student. (eI) Enter the amaller of the amoul1tln column (0) or $.1,ClOO (e) Subtract oolumn (d) from column (c) (I) Enter one-half of the amount In oolumn (e) --------------- 2 1)00; 1 000. 1 000; 500. i:. 1-\UU Ult:l ttUlUUIIl.l:l1I1 WIUrnm:l \U) tlIlU W. . . . . . . . . . . . . . . . . . . . . ~ .i. vuu. :JUV. ---------------- 3 Tentative Hope credit. Add the amounts on line 2, columns(dl and (I). If you are taking ~,~~~ku:.~~ .a~.d:o.P.Qrt.u..'.ot~~ J'JO.!o.P.w:tlU. L:lfetlme Leernln Credit 4 (8) StudenfS name (as shown on page 1 of your tax return) l_0;.0.IL Caution: You CIIIInot take-the Hope CI9d. if anr:t the JifetiI71B learning creditfor thall8lflelJtudent in the sSme year. First name Lest name (b) Studenfs social secunly number (as shown on page 1 of ur tax return (e) Que1lfied expenses (see Instructions) 5 Addtheamountsonllne4,oolumn'(0),andenterthetotal....................................... 5 8 Enterthe amaJlar 01 line 5 or $10,000. . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., 8 ::z T."'l:\tgfulO.~tb:r:\.$.~~t:r;dr.,,:,.f.ltQr.Ilt. .futr.dtir:'lbil(r:Il;I.ISt~b3l.':l(,'l!%"I.~r.u.Qr.uil.I:lf.\..tf.\..~Qr.t..w. ~. :z .. Allowable l:ducatlon Creelhs 8 Tentativeeduoationoredlts. Add lines 3 and 7, ....................... . c.: . ..,................. 9 ~~~~f~~~~b~~:~f11I~jo~n:~~:::~~~s~n~:~~~~~.o~~:~s~~~I~,.. .... .W -51;000. -..... .......... ...... _...._... ........ . ...... .... ..... "'.......... ,.... . ....... .... ....,., ........... . . . . . . . . . . . ~;' '~'=-e.~ 10.000. 1 500. 11 Subtract Ilne-lO from line 9. If zero or less, stoP: you cannot take 811\( education credits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '. 11 12 ;~~~~~g~J~';;~)e~fil~ngJolntiy;$1.0:~OII.single:h~ad.ofhousehOI~........ ~l 13~562 ., I..... 13 II line l11sequaJ to or more than line 12, enter the amount from line 8 ori_, 14:JIRClllOI(j:1il1915. If line 11 Is less than line 12, dlVldellns 11 byline 12. Enter the re8tlIhllH!~ (1IllJn!IIld1o at leastthree PI.8ll9S) . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . .. . . . : . . . . . . . . . . . . . . . . . . . . . . . . x 14 Mulilply IIns 8 by line 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . .. ... 15 Enter the amount from Form lCl4O, line 43, or Form 104ClA, line 28. . . . .. .. .. .. . .. . . . . .. . . .. . . .. .. . 18 Enterthe total, If any, of your credits from Form i040. lines 44 through 46, or Form 1040A, lines 29 and 30. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . .. 16 1 500. 378. 17 Subtraotllne 16 from line 15. If zero or less, atop; you cannottake any education oredlts. . , . . . . . . . . .. . . . ... 1~ 378. 1JI .edu~lIIloo Clii!1ta.;Entertl1e~!i1aJl'i",Ofline .14 orune 17. here ~nd qn,FQrrn 1040, .lIne 47, orForml0401\,lIne31...:.:....................... .'... ......................... ... 18 378. *Seei.Pub. .970 tor the amount 10 enter ~ you are filing Form 2555, 2555-EZ, or 4563 or you are, excluding Inoome from Puerto Rloo. I!'u For p,aperwoI'\lRecluctlon.\ct NotIce, see InstrUctIons. '. Form 8863 (2003) FDlASeo1 1111M>3 ';';~~*'" <0_ ,," ~- ", ~ I............ ,~ Form 2106-Ek Unrelmbursed Employee Business Expenses OMB No. 1545-1441 De~nt of IIle Treasury Intem~ AeVen...eNte (99) VournlUl1e ~ Attach to Form.104O. Occupatlon"ln which \IOU Incurred expenSes 2003 54A .r 9oclB! securlly: number MARY ANN SRUT:L'Y CRURCH WORKER You May Use 1hJaForm Only.Jf All of tile Following Apply. . You are an employee deducting ordinary and necessary expenses attributable to your job. An ordinary expense Is one that is oommon and aoospiecl In your fiald of trade, business, or profession. A necessary expense Is one that Is helpful and appropriate for your business. An expense dose not have to be required to be oonsldered necessary. .1> ~ou do not get reimbursed by your employer lor any expenses (amounts your employer included in box 1 01 your form W-2. are not oonsldered rstrnbureem_), . . . If you are claiming vehicle sxpense, you are using the standard mileage rate for 201l3. Caution: You can /!Se the standarcl mileage rata for 2IJIJ3 QI//y II: (a) you owned the vehicle and used the standard mileage rate for the first year you placed the vehicle in se{ll/oe or(b) you leased!fle vehicle and used the stsndarcl mileage rate for the portion of the lease periodsfter1997. .. . __ ~Igure YOUr ~pen8ee 1 Vehlcleexpenseu-"I~.gthestandardmlleagerate.CompletePartllandmultlplyllnaBaby36<(.36)........... 1 2 Parking fees. tolls, and transportation, including train, bUs, ete, that did not involve O\/llI'night travel or commufinglo and from work. . . . . . . . . . "0 . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . .. 2 3 Traval8Xl!ensewhUa away from home overnight, Including lodging, alrplane, oar rental, etc. DoDotlr1cludameeJsandentellail:Ul1en................................................ 3 4 BusIness expenses not included on lines 1 through 3, . DonotlncllldemeeJsandelllertaJnmenl................. ..'......................... 0... 4 5 Meals and entertainment axpeoses: $ 80 . x 50% (; 50) (Employs.. subject to Department of Transportation (DOT) hours of service limits: Multiply meal expenses by 65% (.65) Instead of50%.Fordetalls..eeeinstructions.)....................................... ............ 5 54. 257. 40. 6 Totalexp!lllaes.Add IIn. es 1 thrOugh.5. Enter here and on IIna 20 ofSchedule.A (Form 1040. ). (fe&:b~ state or fq9at goWlmtT]ei1l offlclale, qtl8IIfIed ~rnlng arItsls; and IndMdualswllh.dlsablllties: .:::ttla..l./l~ lll=UUUUUlltf IVI t:llJtIUlttl !Ult:ll:f VII Wlltllt:lLU 1::lIn.tn linti' l::l.lIIVUIIt.1. . . . . . . . . . . . . . . . . . . . . . . .'. . . . . . . i Q I __ Information on Your Vehicle. Complete thle part only it you are olalmlng vehlcie expense on line 1. 7 When did you place your vehicle In llElrvlcefor buslnses use? (month,day, year) ...................,.......... 8 Of ths total number of miles you drove your vehlole during 2003, enter the number of miles you used your vehicle for: aBusiness _ _ _ _ _ _ _ _ _ _ _ _l..?:Q 1>Comri1utlng . 900 cOther . 8 Doyoo (or yourepouse) have another vehicle ave1lablefor personaJ u;e'i-:-.-.-:-:-.-::-.-::- :-.-:-:-.-:..........:- 10 WasyourvehlcleavaJlableforpersonaJuseduringoft-dUtyl1ours'?................................ l1a Do you have evJdence to support your deduction? ........................................... b It''l ,'Is e\l1denpewrlltan1. _..:.. _.. ___" .. ...... ........... .... __. .... .. .. .. _.. .... .... .. ...... _ _ ... .. .. ...................... BAA For PaPerwo.k fieducilon Act Notlcs,.ile separate Instrucilons. ~~J.'. .. .Q!I]!V,gQ..O]. _ IJ~Q Vas No . Vas '.No X Vas. No ,'lea. . ..Ilk> form 2108.EZ (2003) FDtA7'5Ot 'O~1fi7m :n'% . . , ,~'. .,. o":"'~ ~-~ , ~ , -~ Schedule A 'Llnu 20, 22,.'Z1 Miscellaneous Itemized Dettu~ons-statemeril .. Attach 10 return (after all IRS-forms) 2003 Statement -.....- - Name(s)ShciYJil o~Retum MARY ANN SHUT-TY Employee Business Expenses - Subject to 2'l1> limitatIon . 1 De<l1ldllble expenses from Form 2106, line 10 less deducllons for perlormlnil artisls and handloapped employees claimed elsewhere. . . . . . . . '.' . ,~-.-Excess.educator expenses from the .Educalor Expenses Worksheet. . . . . . . . . . 3 Union and professional dues. . . . . . . . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . 4 Professional subscriptions. . . . . . . . '.' . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Uniforms and protective clothing. . . . . . .. . . . 'j' . . . . . . . . .. . . . . . . . . . . . . 6 Job search costs. ........... ..... .... . i.. . ...,. ............... ,"';', 7 Other: : ~.. ",. .J 1 2 3 4 5 6 351. 00 'lc r./ 8 Combine lines 1 through 7 (to Sohedule A, line 2()) . . . . . . . . . . . . . . . . . . . . . . 8 Mi8cellaneous ExpenseS - Subject to .2'l1>l,.lmitation Check t/Jebox In investment co/urn/) if an investment expense Investment I expense t 9 Depreciation and amortization deductions. . . . . . . . . . . . . . . . . . . . . . . . . 10 CllSualtylthefllosses of property used In services as an employee. . . . . . . . t1 REMICexpenses, from Schedule E...... ....... .. . .. . .......... 12 Investment expenses related to Interest and dividend income........... 13 EJ<penses related to portfolio income, from Schedule(s) K-1 . . . . . . . . . . . . 14 Miscellaneous deductions, from Schedule(s) K-l. . . . . . . . . . . . . . . . . . . . 15 ExceSs deductions on lerrnlnatlon, from ScheduI8(s) K-1 . . . . . . . . . . . . . . 16 Investment counsel and advisory fees. . . . . . . . . . . . . . . . : . . . .' . . . . . . 17 Certain attorney and accounting fees. .... .. ....... .............. 18 Safe deposit box rental fees ............. .:..... ... ...... ..... 19 IRA custodial:flles.. . . . .;.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 LOSS Incurred iromtotal-dISlrlbutlonofall-traditlonaI-lRAs. . . . . . . . . . . . . . 21 LoSS Incurred from total dlSlributlon of all Roth I RAs. . . . . . . . . . . . . . . . . . 22 Tax preparation software and Il1x publications. . . . . . . . . . . . . . . . . . . . . , 23 Other: " ~.,.Iul, ~';'j , .. 351. 00 X 9 10 X 11 X 12 X 13 14 15 X 16 X 17 X 18 X 19 . 20 21 22 23 12,634.00 150.00. 24 . Combine lines 9 through 23 (to Schedule A, line 1Il} '.. " .. '. . . . . .. . .. .. . . . . .. 24 12,784.00 Other Miscellaneous Deductions - Not SubJect to,,.. Limitation 25 Federal estate tax paid on decedenfs income rep(llted on this return . . . . . . . . . 25 26 Impairment-related expenses of a handicapped Ilmployee, from Form 2106. . . . . 26 27 Amortizable bond premiums on bonds acquired before 10/23/86. . . . . . . . . . . . . 27 28 Gambling losses. . . . . . . . . . . . . . . . . . . . .. , . . . . . . . . . . . . . . . . . . . . . . . 28 -29 -'easualty/lheftlosses-ofincome-producing-property. . . . . . . . . . . . . . . . . . . . . . --29 30 Other: 30 t ~;. . 31 Combine lines 25 - 30 (to Schedule A, line 27) '.;~" . . . _ . .. . . . . . . . . . . .. . . 31 ,...;c',. ""'~" "~' "~,~,,' 11:..'" r' 131 804 Office of Financial Administration ':::Diocese of Harrisburg PO Box 3651 Harrisburg, Pennsylvania 17105 Phone (717) 657-4804 Fax (717) 657-8757 Name MARY ANNSHUTTY Soc See # CUrrent Year to Date UnltJDeot 131 804 GROSS PAY 1075.50 15858.46 FEDERAL WIH FICA TAX STATE TAX CITY TAX UC TAX NET PAY: 60.93 82.28 33.02 17.21 872.87 1213.14 486.85 253.73 Period Ending 7/14/2004 Check Number 91%-5'1 Pay Date 7/21/2004 Marital Status s Dependents Claimed 04 Additional Withholding .00 Federal .00 state REGULAR HOURS 80.00 REGULAR EARN 1075.50 $882.06 . . Office of Financial Administration Diocese of Harrisburg PO Box 3651 Harrisburg, Pennsylvania 17105 Phone (717) 657-4804 Fax (717) 657-8757 TO THE ORDER OF: PAY ';'P,k>;c'''I'''''''~,_ 60-1273/313 DATE CHl:!:CK NO. PNC Bank, N. A. Southcentral PA 7/21/2004 979659 *'****882 fJoftars ami 06 Cents $882.06 NON-NEGOTIABLE THERESA BARRETI MALE r.OUN!'i(I))Jl, AT LAW TI<EJIESA ijAARE:lT MALE 513 NORTH S.ECO....u S'I'Kl!.t;T HAKKISOURC, PENNSYLVANIA 17101 SUSAII C. AP'II.flf(, ,..........". JONATHAN J. MALE. I.E.GAL ASSISTANT June 2, 2004 (717) 233.3220 FAX (717) 233-6662 E. Robert Elicker, Esquire Office ohhe Divorce Master 9 North Hanover Street Carlisle, PA 17013 Re: Shutty v. Shutty (# 01~237 Civil Term) , Dear Mr. Elicker: Robert M. Shutty, the defendant in the above-referenced divorce action, contacted my office today, and provided the following information regarding his whereabouts: 935 East Pittsburgh Street Apartment 37 Greensburg, PA 15601 724-836-1648 Please schedule the pre-hearing conference at the earliest possible date. Sincerely, k~j~ T8M/sca cc: Mary Ann Shutty Robert M. Shutty VIA FACSIMILE - Hard Copy to Follow .,1 Z d LZmLGlOS 'ON/9S: 9 I '18/9s:g I ,OOZ Z 9 (OlM) ~O~J ".,,:t""'''<;1~'1'''1-'''''~~~ >~ ~"<I _ I, !II (Il ,~ ~I " . ~~-, ~"~~~'1 "', ~ 1,' ~.'~,,,.,, 1f THERESA BARRETT MALE COUNSELOR AT LAW THERESA BARRETT MALE 513 NORTH SECOND STREET HARRISBURG, PENNSYLVANIA 17101 SUSAN C. ApPLEBY, PARALEGAL JONATHAN]. MALE. LE.GAL ASSISTANT Charles Carothers, IV, Conference Officer Cumberland County Domestic Relations Office 13 N. Hanover Street Carlisle, PA 17013 February 10, 2004 Re: Shutty v. Shutty (# 00900 S 2001; PACSES # 430103963) Dear Mr. Carothers: (717) 233-3220 FAX (717) 233-6862 Please release the following information on the obligor in the above-referenced support action: 1. Current address. 2. Telephone number, if known. 3. Employer's name, address and telephone number. I need this information so that the divorce master can notify Mr. Shutty of the pending master's proceeding. Thank you for your assistance. TBM/sca Cc:'IS,ti~eltt,\fi:ljekeer, +hd!:sGluire' ., Mary Ann Shutty VIA FACSIMILE - Hard Copy to Follow ;;wr,''''9''--::W;.'1''$"' ". ~,~ ., ~ ~"~I"'"'''' ,,", , "~ Sl~l/~ .{~resa Barrett Male ( . - ~i~';,..~.fi8l~<~*gii~t$i.;:;;:"%+'~2n.fi1i~,\t~ilil'';~i6i';)"0::f.~~f:i~.,,~.;o"~'''~~'~I' '] ;.... ..... ...., .. " .. 0- m o .. .,'1 fi. , .. Ql i ::E '" .... o I'- .... ... 1D ~ W Q)._ U~c: "Ci5~ ~~>- ._ Q) (J) "'>c: WOc: _C:Q) O'"[l. :I: . Ql~.l!! C,I O.!!l .- "C =Z~ Oen(,) ':~:'r ~ o - o I:>f.. ~c;.;: ~ --->~ ~~- 4~ c:r.::- ~ c-(" \" - ..... ..... ..... J'-. ~o: ~"'o.. :c 0 . ~[t~ ~5Q:::l I-~ffi [t-la: Wl!)[t co.....'" O'<t:c [t'<t t _:,-':.:: .e' ' '-''''''~.' .V},0~~~:f~1~~~~:\~'Y1S'rf{k%-'J'\t~Ji?iEl'X;&~~~1~~Ijj~X\~\:\'.W11~~ -= -= ~~ . ~ .~::. C)~ - - -= ..;:. - -= - eI tJ1 ... 01$ ~ of' ... ... ... ... ... THERESA BARRETT MALE COUNSELOR AT LAW THERESA BARREIT MALE 513 NORTH SECOND STREET HARRISBURG, PENNSYLVANIA 17101 SUSAN C. ApPLEBY, PARALEGAL JONATHAN J. MALE, LEGAL ASSISTANT June 2, 2004 (717) 233-3220 FAX (717) 233-6862 E. Robert Elicker, Esquire Office of the Divorce Master 9 North Hanover Street Carlisle, PA 17013 Re: Shutty v. Shutty (# 01-6237 Civil Term) Dear Mr. Elicker: Robert M. Shutty, the defendant in the above-referenced divorce action, contacted my office today, and provided the following information regarding his whereabouts: 935 East Pittsburgh Street Apartment 37 Greensburg, PA 15601 724-836-1648 Please schedule the pre-hearing conference at the earliest possible date. Sincerely, L~~ Tlieresa Barrett Male TBM/sca cc: Mary Ann Shutty Robert M. Shutty VIA FACSIMILE - Hard Copy to Follow ~<,~, ,~,~ , _ " ,,,,"~,"""'! .?"<,,>.-,c,o;~,C~,"&,,,. ,_ .'''. , "I',,' ~. -"'" "",-,' -T'~ - :'$1 ]G1'f <fi ~i. 21'1'2' I v ~ f. ~ ,,-,- I _'.-0 J.i' Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 01-6237 MARYANN SHUTTY, vs. Defendant CIVIL ACTION - LAW CUSTODY ROBERT M. SHUTTY, ORDER TO RELINQUISH JURISDICTION AND NOW, this 4th day of January, 2002, the Conciliator, having received a Request for Continuance on November 30, 2001, and having granted a thirty-day Continuance on that date, having received no additional requests for a Custody Conciliation Conference, hereby relinquishes jurisdiction of the above-captioned matter. FOR THE COURT, ~r Melis eel Greevy, Esquire Custody Conciliator , 'iIi"~'._ _, .~ ,~" '. ',~,. , ~ ." " ,- - , ' '" ." ,". ",~..""," ".J"~,,~.~,".,.,..!..! ^ f"""'.,~- ',,",,', .; ~~. > _.~ -. ,,",,- '_'c,.~,:,,'_ nLHF~.,__m!r.~-~~""""'''~~~1~~~,'} Cp\ B ~ ~. " ;, ~~ }-:)-g- ~;:> 0....,- '" --.? Es 81 ".,~~gi'jlil~~~~~ft5r ~ MARY ANN SHUTTY, PLAINTIFF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. ROBERT M. SHUTTY, DEFENDANT 01-6237 CIVIL TERM ORDER OF COURT AND NOW, this 1\11 day of February, 2002, upon consideration of plaintiff's application for special relief, and pursuant to 23 Pa.C.S. S 3503, defendant is prohibited from borrowing, withdrawing or otherwise removing any funds from his 401(k) plan pending a further order of this court which he may seek. h~esa Barrett Male, Esquire For Plaintiff ~ary L. Kelley, Esquire ") / F~r Defendant . ~ ';:;;[G,y :saa ;~~!1'\r.,p -p..-, " >. __~" ,~_,_,__-_ ',,,',i' 1"_" -- " 'r.~_ /- _..,,_~ 1 '. . , - ';~~~il!~~ro~~lit&~.rf.,,>.~IIi!diii'-'tf';'JJj{jM&1;'~mo!itM~~~& .""['tjijr'-~'!/'~"~"">~" );,'''''''''''~-~'. ".,~~ ;;2 r/~-'e- ", ! P 'jl I! 1 r.. ;"11 j I'f: t;:, CUftl<)i., PE~J\f~;';LI~:f,CCUNn' 1",-.., 1"/\[\.11/1 ~"' ~., <~"~~_r>"',,' ,~~,,_" <.~"H.~ ",~- -'=- .~ , ",: "'....."~ . ^" . >> ;, Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 Counsel For Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE PLAINTIFF'S APPLICATION FOR SPECIAL RELIEF PURSUANT TO PA> R.C.P. 1920.43 AND 23 PA. C.S.A. ~3505 1. Plaintiff Mary Ann Shutty ("Wife") filed her complaint in divorce on October 31, 2001, and raised economic claims for distribution of property, alimony, alimony pendente lite and counsel fees and expenses.! 2. Defendant Robert M. Shutty ("Husband") is represented in this proceeding by Attorney Gary L. Kelley. 3. The parties were married on July 23, 1977, and have one son, Kevin (dob: 04/30/85) who resides with Wife at the marital residence located at 59 Windsor Way, Camp Hill, Cumberland County, Pennsylvania. 4. Husband currently resides at 157 Rosedale, Hershey, Dauphin County, Pennsylvania with his "fiancee" and her child. ! Wife also filed for custody, which the parties resolved by stipulation. 'Yii""",IIl\~" - ~, ,"~ I~ I'''' . .~ ~' 5. Wife is 44 years old, and works whenever she is called from a substitute teacher's list. 6. Husband is 49 years old and works as a pharmacist for CFI. 7. On January 7, 2002, this Court's Domestic Relations Section entered an order for child and spousal support, which Husband has appealed. 8. As of February 8, 2002, Wife has not received any support payments. 9. With the exception of personalty which is of nominal value, the only assets available for equitable distribution are the marital residence and Husband's 401 (k) plan which is administered through or by the National Prescription Administrators Union. 10. On or about January 24,2002, Husband disclosed that he borrowed $39,000 from his 401(k) plan in October 2001, which he claims to have used, in part, as follows: a. he purchased a 1975 Corvette for approximately $10,000. b. he paid about $7,300 to satisfy the loan on his fiancee's Dodge Intrepid. c. he purchased a new vehicle for himself, a portion of which he has financed through Chrysler Financial. 11. Net of the loan, the 401(k) balance is approximately $53,000. 12. Wife estimates the value of the marital residence, net of the first and second mortgages, at $45,000. 13. Through his counsel, Husband has advised Wife that he will not agree to freeze the remainder of the 401(k) account. 2 J,r;~~__,. J"<1,, " . , I^ . , ~ , 'r' , -, , = '-1 " ',;." 14. There are insufficient other assets to offset Husband's dissipation of his 401(k) plan. 15. The Court has authority to enter an order prohibiting Husband from further dissipating the 401(k) under Pennsylvania Rule of Civil Procedure 1920.43, which provides: At any time after the filing of the complaint, on petition setting forth facts entitling the party to relief, the court may, upon such terms and conditions as it deems just, including the filing of security, (1) issue preliminary or special injunction neces- sary to prevent the removal, disposition, alienation or encumbering of real or personal property in accordance with Rule 1531(a), (c), (d) and (e); or (2) order the seizure or attachment of real or personal property; or (3) grant other appropriate relief. 16. The Court also has authority to enter an order prohibiting Husband from further dissipating the 401(k) under 23 Pa. C.S.A. 9 3505 which provides in relevant part: Where it appears to the court that a party ... is about to dispose of, alienate or encumber property in order to defeat equitable distribu- tion, alimony pendente lite, alimony, child and spousal support or a similar award, an injunction may issue to prevent the removal or disposition and the property may be attached as prescribed by general rules. 3 l\:"'r.lj!ll~lIJl.,u ',~"" , ",'. '1 '"I ".,--rn~'" ~.i Wherefore, Plaintiff requests the Court to enjoin Husband from borrowing or otherwise removing any additional monies from his 401(k) account. /L~~~ Theresa Barrett Male, Esquire Supreme Court # 46439 513 North Second Street Harrisburg, Pennsylvania 17101 (717) 233-3220 Counsel for Plaintiff Date: February 8, 2002 4 "''''''~''lI!v, "I 1 ' - .', ,'~. , , VERIFICATION I, Mary Ann Shutty, state upon personal knowledge or information and belief that the averments set forth in the foregoing document are true. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. ~ 4904, relating to unsworn falsification to authorities. M~~r~~ Mary Shutty Date:z...\<3\O"Z... .""~'R:>">"f';'l""""",'P:~,~~^ .~,~,~ -, , . ~ I . '" ~,~ ~," ~~" ^ z~~ PROOF OF SERVICE I hereby certify that I am this day serving the foregoing document upon the persons and in the manner indicated below which service satisfies the requirements of Pa. R.c.P. 440: Service by first-class mail addressed as follows: Gary L. Kelley, Esquire 132-34 Walnut Street Harrisburg, PA 17101 Attorney for Defendant /L~~~ Theresa Barrett Male, Esquire Supreme Court # 46439 513 North Second Street Harrisburg, Pennsylvania 17101 (717) 233-3220 Counsel for Plaintiff Date: February 8, 2002 '~,*j.%Ji;,,,,,, "'"'''',>_ ,,' I"., - .......1'Il .,.- \1U JIlL""", _ '"..-;..,1"'"",~",'~'.~ "<,." O~~. .~." o C- jFlt ....1) " t~ <' :::3 , -'\) (n ""(' S::J j.,-/ -., <>;, c.-,:) r,-.:, . _, ". J '"_~ "' ~ ),U, ,l,~~jlllP!li, """""",~~~-&.I,*~~"""""''''''''-''--l'iii1?i~~~~~~~\it[>if'~~'?.u<~<Rt~tf!,\1lP,!jl,~I~~<'J~(,j bEG 1 2 2001 v{J , Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 Cwose) For Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE/CUSTODY ORDER OF COURT AND NOW, December 11 ,2001, it appearing to the court that Plaintiff, represented by Theresa Barrett Male, Esquire, and Defendant, represented by Gary L. Kelley, Esquire, have executed a Stipulation for Entry of Custody Order which resolves the Complaint for Custody filed by Plaintiff, the Court ORDERS and DECREES that: 1. The parties shall share legal custody of Kevin Shutty (dob: 04/30/85). 2. Plaintiff shall have primary physical custody subject to Defendant's periods of partial custody as more particularly set forth in the attached Stipulation, which is incorporated into and made a part of this Order of Court. ;Vcrp~ fl oleJ U3:. -13-0 I ' ~.s r , 1. o'h,,~., , <- - . ,~ . I - , , - r ~ . - "":1 :;~1i~~~~~~~~~.;m-'~.i1tiii.&.'0'~c"...4i'i"'o,,,,,.,.rj;--''''~~J'~J;!i..!l1i ",MU _. .M..k ,,,. ~M,' . '".,~,''''',''' ;",~. "',,;:,i!i,;=',.,;:,,,' J r ", ~'<(j7" +~ . ~ "=',,", 'k.. . o ~;; ~)C:-- rnn._' ~~i- r::;~:; ~~~, "';',", :::?. ,""-; '" ~ ' ~ c:.") (-) -'\1 .-- -::J :-11 c:~~.l - <,..:. C) .~ ,.- " '.::~~::/;;~ :~ oi.n ::2:. -~.. --",'> S'? :'''',J .r;" I " STIPULATION FOR ENTRY OF CUSTODY ORDER This Agreement is entered into on December /0 -& ,2001 by Mary Ann Shutty ("Mother") and Robert M. Shutty ("Father"). RECITALS Whereas, Mother is the plaintiff and Father is the defendant in a divorce and custody action filed in the Cumberland County Court of Common Pleas and docketed to # 01-6237; and Whereas, Mother and Father are the parents of Kevin Shutty (dob: 04/30/85); and Whereas, Kevin currently resides with Mother in the marital residence located at 59 Windsor Way, Camp Hill, Pennsylvania; and Whereas, by order dated November 7, 200 I, the court, per Custody Conciliator Melissa P. Greevy, set the custody conference for December 3, 2001; and Whereas, the parties desire to resolve the custody action by agreement in advance of the conciliation conference. Now Therefore, Mother and Father each intending to be legally bound, covenant and agree as follows: 1. Legal Custody. The parties will share legal custody. 2. Physical Custody. Mother will have primary physical custody, subject to Father's periods of partial custody, which shall occur at such times and under such circumstances as Father and Kevin arrange. Mother shall encourage and facilitate Kevin's relationship with Father. 3. Holidays. The parties will share custody on Thanksgiving, Christmas Day, and Easter Sunday. Details such as times and transportation shall be as agreed by the parties, with ",'P~""",'l"''''',, ""'i" ~ 1III1r:", y~, o ~"" ~I , I ~ J . ~" -. "" ~.~,,"~,..">, ,. ". -'~ ",', .~, . , input from Kevin. Mother's Day weekend is reserved to Mother. Father's Day weekend is reserved to Father. 4. Summer Vacation. Each party shall be entitled to two (2) non-consecutive weeks, beginning and ending on a Friday, for summer vacation. 5. Entry of Order. The parties agree to submit this stipulation to the Conciliator for entry of a custody orders. In Witness Whereof, the parties have set their hands and seals the day and year first written above. Witness: ~,*" (j~!<<<<Q ~~ ',-I?-d~h*J?l, dJ-+ Robert M. Shutty 2 I"" , "', " ~1!IIfl"""',~",~e...o JJ -'Dt,,",,,,,~"Y,'~~""''' , +'!',u~,~ ., .".,--. -, o ~.~~ 22~t, gj.Sc r~c,'- ";::c. ,"--,.--, .:> ,~:". '. ;;:: =<! un' Irl'lllY ",' " ::-; . , " ~T' r'~) ,'., ':=:1 ~' :,,:-t ()~ .,. ".H~,IRf.~~~W\f,",~'i~~~'[~:".w.;~~!mM1Im~~l~iffl~:'P COURT OF COMMON PLEAS OF CUMBERLANO COUNTY, PENNSYLVANIA MARY ANN SHUTfY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTfY. Defendant CIVIL ACTION - DIVORCE MOTION FOR APPOINTMENT OF MASTER (Plaintiff )(9efeRaaAt), moves the court to appoint a master with respect to the following claims: ( x ( ( x ( Divorce Annulment Alimony Alimony Pendente Ute ( x ( ( x ( x Distribution of Property Support Counsel Fees Costs and Expenses and In support of the motion states; (1) Discovery is complete as to the clalm(s) for which the appointment of a master is requested. (2) The defendant fRas) (has not) appeared In the action (personally) (13;' Ris atlsmey). (3) The statutory ground(s) for divorce (is) (are); 3301(c). (4) Delete the inapplicable paragraph(s); (a) The action is not contested. (b) P.R agreemeRt Ras beeR reaCRea 'NltR respest te the fGlle'::IRg claims; (c) The action is contested with respect to the following claims: alimony, distribution of property, counsel fees and expenses.. (5) The action (iR'/slves)(does not involve) complex Issues of iaw or fact. (6) (7) The hearing Is expected to take..A- (hours) (EIaysj. Additional information, if any, relevant to the motlon:fl /' ." ~ l~~,=)~f/ Attorney for Plaintiff QefeR8ant Date: ORDER APPOINTING MASTER /' AND NOW, November :1.> ,2003, E. Robert Elicker, ii, Esquire is appointed master with respect to the fOllowing cialms: Alimony, Distribution of Property, Counsel Fees and Expenses ~'~~ fJ. -,,!:::~,~~,~~-~ ~" ,,-- -..r - ~ "' '" 'r,"'~'_ ;r~:rm'i(~i'-~'J;;,~,,","\'l1!l\""I",\tE;,.fJl;<'~-i;M,i!eti;,,,,,,;.Wi&"'dnr:i':i)i;;"{"%"'~'d"!rf;;"""';';~k,~,;.:",;;1I;:,;'1if;t~!M!lj~~~mJiW,l~. ~ CC" "';:'- o ~~i:, '(~~i r~~ ,,-" .1 C'J U.! Ci:;J ;:\:: ffil,--:L \-"" ::c':':' \_;~ ~~ c' _. ;.:r1'.: .?:) :i;l;: ') '~ <"."" CUPiI0L:,i";U', :jJUi\lT'( PENNSYLVANiA ..:J' "'" ~:;~ ~.. ~ t::;; .c_ :::J 4' .~~:~~ 10 -2~, 'J;\..-J ::0-0- -, "5 CJ ('') ,:-.;t ~'~ . ,.,,- -' ~". .;' .>. -lni'- ,,-,-- ~"~~~~'~,,. .~ ~.~"" . I :'0"" ~'-" . ~ . , "i'i'~1j;:W ,-,--^-".",,,,-,,. '11!. )'r (\ q, ~I/f- MARY ANN SHUTTY, Plaintiff THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 01 - 6237 CIVIL ROBERT M. SHUTTY, Defendant IN DIVORCE TO: Theresa Barrett Male , Attorney for Plaintiff Robert M. Shutty , Defendant DATE: ~~DeCember 12, 2003 CERTIFICATION I certify that discovery is complete as to the claims for which the Master has been appointed. OR IF DISCOVERY IS NOT COMPLETE: (a) Outline what information is required that is not complete in order to prepare the case for trial and indicate whether there are any outstanding interrogatories or discovery motions. I , .~ ,- , I" . ':iii. "'f '" ~~ ~. (b) Provide approximate date when discovery will be complete and indicate what action is being taken to complete discovery. I)/If?; I DATE L~JJfpL . COUNSEL FOR PLAINTIFF (v') COUNSEL FOR DEFENDANT ( ) NOTE: PRETRIAL DIRECTIVES WILL NOT BE ISSUED FOR THE FILING OF PRETRIAL STATEMENTS UNTIL COUNSEL HAVE CERTIFIED THAT DISCOVERY IS COMPLETE, OR OTHERWISE AT THE MASTER'S DISCRETION. AFTER RECEIVING THIS DOCUMENT FROM BOTH COUNSEL OR A PARTY TO THE ACTION, IF NOT REPRESENTED BY COUNSEL, INDICATING THAT DISCOVERY IS NOT COMPLETE, THE DIRECTIVE FOR FILING OF PRETRIAL STATEMENTS WILL BE ISSUED AT THE MASTER'S DISCRETION. HOWEVER, IF BOTH COUNSEL, OR A PARTY NOT REPRESENTED, CERTIFY THAT DISCOVERY IS COMPLETE, A DIRECTIVE TO FILE PRETRIAL STATEMENTS WILL BE ISSUED IMMEDIATELY. THE CERTIFICATION DOCUMENT SHOULD BE RETURNED TO THE MASTER'S OFFICE WITHIN TWO (2) WEEKS OF THE DATE SHOWN ON THE DOCUMENT. ,,1'<;: .-"",,,,^ , ^':i---", :'~ ,~",;;-~,:",,,,,,,- <, 'c'.'" "_~~,, . -,- -~', -T - ~~ ~ ,',<-- . .~" THERESA BARRETI' MALE COUNStLOn U LAW Ti<rJ\1!.IA BAARE1T M'lr. 513 NORTH SECOND STREET HARRISlIUKG. fENN!YI.vANIA 17101 SUSAN C. ApPLEBY. I'ARALEGAt. JONATHAN J. MAI.E. I,.CCAl. ,,"ISTANT February 10, 2004 (717) 233.mO FAX (717) 233.6662 Charles Carothers. IV. Conference Officer Cumberland County Domestic Relations Office 13 N. Hanover Street Carlisle, PA 17013 Re: Shutty v, Shutty (# 00900 5 2001; PACSES # 430103963) Dear Mr. Carothers: Please release the following information on the obligor In the above-referenced support action: 1. Current address. 2, Telephone number. if known. 3. Employer's name, address and telephone number. I need this information so that the divorce master can notify Mr. Shutty of the pending master'S proceeding. Thank you for your assistance. Si";j.elY, ~~~If~k- +kresa Barrett Male ( TBM/sea Cc: E. Robert Elicker. II. Esquire Mary Ann Shutty VIA FACSIMILE - Hard Copy to Follow Z d 60WLZtOS 'ON/OI:OI'lS/II:OI VOO~ 01 Z Onl) WO~j 0;~~.I;'1P_1 ~i!i',~lllll~ . ~~-= >, ,~1 -, I I ~~ ~ .1 ~~!__o=~__""'),"F,-"'~ '~'" ., .,~ ~~~ = <, .-. THERESA BARRETT MALE COUNSELOR AT LAW THERESA BARRE'TT MALE 513 NORTH SECOND STREET HARRISBURG, PENNSYLVANIA 17101 SUSAN C. APPLEBY, PARALE.GAL JONATHAN J. MALE, LEGAL ASSISTANT December 18, 2003 (717) 233-3220 FAX (717) 233-6862 E. Robert Elicker, Esquire Office of the Divorce Master 9 North Hanover Street Carlisle, PA 17013 Re: Shutty v. Shutty (# 01-6237 Civil Term) Dear Mr. Elicker: Enclosed is my certification that discovery is complete. SiOU ~o~7l(<b- '~arrett Male T8M/sca cc: Mary Ann Shutty (w/enc) Robert M. Shutty (w/enc) ~ .,~,' ,,',~, '",", ," , "- ,.. ",,,,.n,., ",- I " ,~ , '., ...."., ~ .., , ~ = "-""",", --~.,- MARY ANN SHUTTY, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - LAW NO. 01 - 6237 CIVIL ROBERT M. SHUTTY, Defendant IN DIVORCE CONFERENCE WITH COUNSEL AND PARTIES TO: Theresa Barrett Male Mary Ann Shutty , Counsel for Plaintiff , Plaintiff Robert M. Shutty , Counsel for Defendant , Defendant A conference has been scheduled at the Office of the Divorce Master, 9 North Hanover Street, Carlisle, Pennsylvania, on the 2nd day of August 2004, at 9:30 a.m., with counsel and the parties to discuss the outstanding economic issues to determine if there is a basis of settlement of claims, If issues remain after the conference, a hearing will be scheduled at another date. Very truly yours, Date of Notice: 6/7/04 E. Robert Elicker, II Divorce Master PLEASE BRING TO THE CONFERENCE AN INVENTORY AND APPRAISEMENT AND AN INCOME AND EXPENSE STATEMENT. -~Tf_,__._..,.<_._>."<"",,. ,'",- -"', __I" _~__. '__~",7',..,_ :. .. , ".,'"""" ~" ;I~.>:'""",,'!_ "~ - MARY ANN SHUTTY, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - LAW NO. 01 - 6237 CIVIL ROBERT M, SHUTTY, Defendant IN DIVORCE RESCHEDULED CONFERENCE WITH COUNSEL AND PARTIES TO: Theresa Barrett Male Mary Ann Shutty , Counsel for Plaintiff Plaintiff Robert M. Shutty Counsel for Defendant , Defendant A conference has been scheduled at the Office of the Divorce Master, 9 North Hanover Street, Carlisle, Pennsylvania, on the 9th day of August 2004, at 1:30 p.m., with counsel and the parties to discuss the outstanding economic issues to determine if there is a basis of settlement of claims. If issues remain after the conference, a hearing will be scheduled at another date. Very truly yours, Date of Notice: 7/19/04 E. Robert Elicker, II Divorce Master PLEASE BRING TO THE CONFERENCE AN INVENTORY AND APPRAISEMENT AND AN INCOME AND EXPENSE STATEMENT. -- ," '~'. "'I' mO"".'L" r .'" ~~~ !Ill!' & - Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesquire.com Counsel for Plaintiff 0 ", c:::> () C -c:-~) .h,. ."-' -n [r'~fr1 z X C.J ~~ . ..0:: f"Il?-J ,. .0 ."11 C"l :Z7y ~.~~ N ~'~~ :tb . f )_~ Q) 2Sh~ --;.~ ::=' .~ U1 :Xi w --< COURT OF COMMON PLEAS OF CUMBERLAND COUN1Y, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term MBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE NOTICE If you wish to deny any of the statements set forth in this affidavit, you must file a counter-affidavit within twenty days after this affidavit has been served on you or the statements will be admitted. AFFIDAVIT UNDER SECTION 3301(d) OF THE DIVORCE CODE 1. The parties to this action separated in or around October 2001 and have continued to live separate and apart for a period of at least two years. A~~~ 7'"' . "~, - ~, --7"" '.rr-. .~"_ ~M , ~....'~~_~ "'_~_wt" . 2. The marriage is irretrievably broken. 3. 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. 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. S 4904 relating to unsworn falsification to authorities. · f\{ ~2L'~ Mary An Shutty Date: November I \ ,2004 TRUE COPY FROM RECORD 1/1 Testll'(!i)!1Y Wllllrw!, i I>:>fe \i!1tll Stlt 1'IlY" ,; ,00 ~ m s.aV 0'.1 at ~~6d c~-~ 2 .-"c,",j"{H"'~"',~l'!'! - "-~ ",' ~. - ~, , - - ~ - ~~~,'~._"~ ,~-~-=. THERESA BARRETT MALE COUNSELOR AT LAW THERESA BARRETI MALE 513 NORTH SECOND STREET HARRISBURG, PENNSYLVANIA 17101 SUSAN C. APPLEBY, PARALEGAL JONATHAN J. MALE, LEGAL ASSISTANT November 9, 2004 (717) 233-3220 FAX (717) 233-6862 E. Robert Elicker, Esquire Office of the Divorce Master 9 North Hanover Street Carlisle, PA 17013 Re: Shutty v. Shutty (# 01-6237 Civil Term) Dear Mr. Elicker: Enclosed are copies of the letters I sent to the defendant, Robert M. Shutty, regarding the master's hearing and the need for his execution of an affidavit of consent and a waiver. To ensure that the court can enter the decree, I also will serve on the defendant plaintiff's 3301(d) affidavit, which I intend to file later this week. In the interim, please advise if you require any additional information in advance ofthe hearing. Sincerely, L~~f- TBM/sca Enclosures Cc: Robert M. Shutty (w/o enc) Mary Ann Shutty (w/enc) '1: i,j ; <'r:'.l,~r" ",C, '''r", .'"". -,'T..,"'~':~>~",.- ,;,-". ,. ~ "1""_ '-.d" 0'" ,,'. ,. ,j ~" " "i r ,- '~< THERESA BARRETT MALE COUNSELOR AT LAW THERESA BARREIT MALE 513 NORTH SECOND STREET HARRISBURG, PENNSYLVANIA 17101 SUSAN C. APPLEBY. PARALEGAL JONATHAN J. MALE. l.EGAL ASSISTANT November 9, 2004 (717) 233-3220 FAX (717) 233-6862 Robert M. Shutty 608 Plaza Apartments, # 2F Lebanon, PA 17042 Re: Shutty v. Shutty (# 01-6237) Dear Mr. Shutty: In order to finalize your divorce, you must date, sign and return the enclosed affidavit of consent and waiver of notice of intention to request entry of divorce decree. These are the documents which both parties must file in order for the court to enter a divorce decree under section 3301(c) of the Divorce Code. To assist you in promptly returning these documents, I also have enclosed a stamped, self-addressed envelope. If you have any questions about this correspondence, you may contact me. If you need legal advice, please consult an attorney. Sincerely, ~~~ TBM/sca Enclosures cc: E. Robert Elicker, Esquire (wlo enc)) MaryAnn Shutty (wlo enc) '""",~""~,~ .'.' -,'- _ C~ ,., ,? "'-",:,', '''",''r _,c "0'. <.' ;;". ".= '~ THERESA BARRETT MALE COUNSELOR AT LAW THERESA BARRETT MALE 513 NORTH SECOND STREET HARRISBURG, PENNSYLVANIA 17101 SUSAN C. APPLEBY, PARALEGAL JONATHAN J. MALE, LEGAL ASSISTANT November 9, 2004 (717) 233-3220 FAX (717) 233-6862 Robert M. Shutty 608 Plaza Apartments, # 2F Lebanon, PA 17042 Re: Shutty v. Shutty (#01-6237) Dear Mr. Shutty: Per the directive of the divorce master, I haVe enclosed for service on you a copy of the Order and Notice Setting Hearing. This advises you that the master's hearing will be held on November 18, 2004 at 9:00 a.m. at the Office of the Divorce Master, 9 North Hanover St., Carlisle, PA 17013. If you need legal advice regarding this matter, please consult an attorney. Sincerely, -r!:resa Barrett Male TBMjsca Enclosure cc: E. Robert Elicker, Esquire (wjo enc)) Mary Ann Shutty (wjo en c) Via Certified and Regular Mail 'r/-,,,t1~"~\;llt!1 I -- 'j."'~""'-"_'~ '" ."',,~ ., ."'. c THERESA BARRETT MALE COUNSELOR AT LAW THERESA BARRETf MALE 513 NORTH SECOND STREET HARRISBURG, PENNSYLVANIA 17101 SUSAN C. APPLEBY, PARALEGAL JONATHAN J. MALE, LEGAL ASSISTANT November 12, 2004 Robert M. Shutty 608 Plaza Apartments, # 2F Lebanon, PA 17042 Re: Shutty v. Shutty (# 01"6237) Dear Mr. Shutty: (717) 233-3220 FAX (717) 233-6862 Enclosed for servIce on you is a certified copy of Plaintiff's Affidavit Under Section 3301(d) of the Divorce Code. In this document, Mary Ann has certified that the two of you have lived separate and apart since October 2001. I am sending you this letter, with the certified copy of the affidavit, by certified and regular mail to the address provided by the Domestic Relations SectIon. If you have any questions, you may contact me. If you need legal advice, please consult an attorney. SIncerely, j[uJj~/lf~ Theresa Barrett Male ( TBM/sca Enclosures cc: ~L_.l,IiIU",LD.., "'!llIilIi~l1ii Mary Ann Shutty (w/enc) Via Certified and Regular Mail -~'fG-iib';"1""t,'~~ ,~~ ~~,~-- ~ lUll "1 , 'nl Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 Counsel for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE INCOME AND EXPENSE STATEMENT OF PLAINTIFF I verify that the statements made in this inventory 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. JJ"'f~ Plaint' 'r:'~"",""""~ - j ~,~i;! _ . ,~" "..,r I. ",- -'" - ~ " ,_' ~"'<1~~ ,,-, "'~ 1""" In the Court of Common Pleas of CUMBERLAND County, Pennsylvania Phone: (717) 240-6225 DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 OCTOBER 20, 2003 Fax: (717) 240-6248 Plaintiff Name: MARY A. SHUTTY Defendant Name: ROBERT M. SHUTTY Docket Number: 009ClO S 2001 PACSES Case Number: 430103963 Other State ID NumbeI: Please note: All correspondence must include the PACSES Case Number. Income and Expense Statement THIS FORM MUST BE FILLED OUT (If you are self-employed or if you are salaried by a business of which you are owner in whole or part, you must also fill out the Supplemental Income Statement which appears on page two of this income and expense statement.) INCOME STATEMENT OF A4A,ey AN'" SHUT''''' Section I: Income and Insurance INCOME: Employer (~A"lI'leDt2aL 'PAt2'S>-, ,,~ ST, -p"".",\~,<. Address .2.ll. ST"nc S,rU<T Type of Work PAe~sH I4.lnllC;1'ev AJ\ln PE.U8iDVlS EuUCAt IUN I'l,loSiW Payroll No. Gross Pay per Pay Period $ Pay Period (wkly., bi-wkly., etc.) tTT~q-t6D Itemized Payroll Deductions: Federal Withholding $ Social Security $ Local Wage Tax $ State Income Tax $ Retirement $ / Savings Bonds $ ./" Credit Union $ .,/' Life Insurance $/ Health Insurance $ Other Deductions (specify) . $ $ $ $ Net Pay per Pay Period $ OTHER (Fill in Appropriate Column) INCOME WEEK MONTH YEAR Interest $ $ $ Dividends Pension Annuity Social Security Rents Royalties Expense Account Gifts Unemployment Workmen's Comnensation Other Other TOTAL $ 'I: $ TOTAL INCOME $ PROPERTY Ownership * OWNED DESCRIPTION VALUE H W J Checking Accounts PSEC'1k $ I?f.GUU(\f: CC>l..wk ./ Savings Accounts rstci.\ , oiL.{. 31<1 V ~1l6Ll~ SfNiN(,.S Credit Union -- Stocks/Bonds /" Real Estate ~O<<S" ICiq, 000 ./ Other TOTAL 1$ * H ~ Husbaud; W ~ Wife; J ~J oint Service Type M Form IN-Q08 Worker ill 21200 ;"~1"l"~,)y U,~~,l" .. ~ - ., Income and Expense Statement PACSES Case Number 430103963 Coverage * INSURANCE H W C COMPANY POLICY # Hosnital P(\c4^~c.lk.Q,\a$,'<r &'1",.. bi()('",,~ ^t:' H.""ISi?l.tj&, AM I1.S~~.'ll'l V VJ. Blue Cross Other . Medical 8\"..~\<.\& ~311i J V Blue Shieid Other . Health! Accident . Disability Income . Dental 1A",\eJ (on<.ord,cc' b 7/1 V v' Other S1~~ N Oie f\1T~'tl"P. * H=Husband; W=Wife; C=Child Section II: Supplemental Incom S'; n?}"- Covev~ I,O(;,'3.7S per 'l "",r/-c,r a. This form is to be filled out by a person o (1) who operates a business or practices a profession, or o (2) who is a member of a partnership or joint venture, or D (3) who is a shareholder in and is salaried by a closed corporati( Attach to this statement a copy of the following documents relating to the corporation or similar entity: (1) the most recent Federal Income Tax Return, and (2) the most recent Profit and Loss Statement F~i ~ W""'d'- I, qdf.o.ay f>W' ? Uj'''*'''- B"CV<U5& Kevlr; WflS jl'Off'.d. -%e", Bo13'S h'!f/'-TM INS.) My 665.5 pi<~"l> Up 7HF.. co,/ E/2110 E , SO HE 1$ l'AYING cJtgS7. '1Qlp<!1e "u~R-7t~ '7D CfJu-E.,e l~EUJll LINTI!" ::I Q,l?-T 'I'\y LifE SETrL[;'f:>. THIS. 15 NoT 1'1 BENE PiT. /l LL t!7/iE;e El-1UoVEE5 NI6T ?IIY FrJt'. f";tWI U( Lovf../016c. jAl'I-S-. b. c. Name of business: Address and telephone number: d. Nature of business (check one) D (1) partnersbip o (2) joint venture D (3) protession D (4) closed corporation D (5) other Name of accountant. controller or other person in charge of financial records: e. t. Annual income from business: (1) How often is income received'? (2) Gross income per pay period: (3) Net income per pay period: (4) Specified deductions, if any: Service Type M Page 2 of3 Form IN .(J08 Worker ill 21200 W!'IrlJl>>}il~" .~- ',00 J' ~,'= ~~ , .,"-- 1-1 Ou SE - Income and Expense Statement PACSES Case Number 430103963 Section ill: EXDenses Instructions: Only show extraordinary expenses in this section unless you filled out Section IT on page two. The categories in BOLD FONT are especially important for calculating child support. If you are requesting Spousal Support! APL or if you assert your case cannot be determined according.to the guideline grids or formula, this section mnst be fully completed. i1v6. ING. (Fill in Appropriate Column) EXPENSES WEEK MONTH YEAR Home MortgagelRent $ $1, '2.95.Cll $ Maintenance "nO.OD Utilities Electric $ $ i;;,5 $ Gas M Oil .------- Telephone 1$ Water -~O Sewer ~C-,d 30;< Emnlo~eut Public Transport. $ $ $ Lunch ~O.OO Taxes fr.. "'ttGA"" Real estate $ $ $ Personal Property Insnrance Homeowner's $ $ $ Automobile \S5,00 Life 2.5"00 Accident Health . Other Automobile Payments $ $ a3i,'O $ Fuel 1:>6.'"' Repairs ~ Medical Doctor $ $ $5OD.t:9 :Dentist Orthodontist ~ ~ Hospital .' Medicine 15,00 SpOCllll nee<lS K€>JuJ-1JI2!a!5 G"Il%&$ ~~:: braces, /UTH $4fjO, og () die devices '.<i.~ '\6~.0 EXPENSES (Fill in Appropriate Column) (continned) WEEK MONTH YEAR Education Private School $ $ $ Parochial School College " svo - Religious SfXJ.OD Personal Clothing $ $ $" '800 .~!- Food /.:7tJ,co Barberi 75, 00 ~a;rtlresser Credit Payments Credit Card /5'0.1f? Charge /00."9 Memberships Loans Credit Union $ $;)11. ;)a $ Miscellaneous Household Help $ $/dJO,ao $ G Child care Papers/books iO,1l'!. - Mall"ll?:mes Entertainment Pay TV 3<1. qO Vacation )}OOO,J':; Gifts l,tJoo,.t:.. Legal fees 13,000.0 ~~~~~~te . ution<: 50 OcJ .- other Child ~..nnort Alimony Pa~.nts Other $ $ $ I Total I WEEK MONTH YEAR I . Expenses: .. $ $ $ . I verify that the. statemen~ made in. this Income and Expense Statement are true and correct. I understand that false statements herem are subject to the cruumal penalties of 18 Pa. C.S. ~4904, relating to unsworn falsification to authorities. ' II' /7.03 Date Service Type M ;0",1,,,,,,.,,,,,,,,,,,,,,,,,,,.4. no I'l\m ,__0 ^, , , I,""'~"",., "., ~, -, ~t~- Plainti or Derendant Page 3 of3 Form IN-008 Worker ID 21200 '1~ - ,~ SON 5E"F vJD~t-< i<<.iA1'-D ....s~.... f.~,"" fi)R wote'K . "~I ,~. ' ';--,'~;:~1~ " ,~",""-~--~- M'l SON IS IN SEi'lINJ'h<:'(, T MDTl> 'Pit'f foiC. 2 5U" TS, I C-J'l,SSocK, ~ de-rie.. S[.,i rts 'S.-'plus ?JO,co . } 3 f'c\\r b\a.dL p""",-t5(I?;'j')~Ta..ti) (losT: &~so<.. Ie:. 3/$'. ,'" flNft/'fO-l'i.e.. ~D I"''''s.'v~' $.,t-ls hOd, ~\v15 1100.01' - I I 35.'00 , I? 0, 00 Surpl..s ~ 2 \ '-' IJO I,-\S~ ~5- I '3 I ~ l' ..~ I1D~'l ri \00' ~O.!' i, ~, _. - -I, ,~ .." 'l'lrnr'c _c'_ .~. R E f\ii - pACSES Case Number 430103963 Income and Expense Statement Section ill: Expenses Instructions: Only show extraordinary expenses in this section unless you filled out Section II on page two. The categories in BOLD FONT are especially important for calculating child support. If you are requesting Spousal Supporti APL or if you assert your case cannot be determined according to the guideline grids or formula, this section must be fully completed. ~ (Fill in Appropriate Column) EXPENSES WEEK MONTH YEAR Home Mortgage/Rent $ $810.00 $ Maintenance Utilities Electric $ $ I..JO,oCJ $ Gas . Oil Telephone /50.0'1 Water Sewer Emnlovment Public Transport,. $ $ $ Lunch ;)e). 00 Taxes Real estate $ $ $ Personal Property Insurance Homeowner's $ $ - $ ib5,Qj) Automobile l'\q4'~ Life ,)5',00 Accident Health Other Automobile Payments $ $.:l31'1!!J $ Fuel 1;}5,0l? Repairs Z Medical Doctor $ $ $ "1Do,C!9 Dentist Orthodontist- ? Hospital Medicine : Special needs SoN - e,erK."S" GLA<S ~S (glasses, braces, re.". ~""D orthonedic devices R~tIUl6/lle.O J{51J. '!} EXPENSES (Fill in Appropriate Column) (continued) WEEK MONTH YEAR Education Private School $ $ $ . Parochial School College . I') ,'7JD't!<. Religious 5'tP. '" Personal Clothing $ . $ $/, ~il?, ag Food 8lJ,tl!2 BarberI 75',49 Hairdresser Credit Payments Credit Card / SO .qS- Charge Memberships Loans Credit Union $ $ $ Miscellaneous . Household Help $ 30 ,Ii!) $' $ l!J.e Child care Papers/books i-/O.Q!l . Mal1azmes Entertainment Pay TV 2-5' OQ Vacation 21 QOO.C$! Gifts I, oco.~ Legal fees 13 000, '!: -I- Charitable Contributions Other Child Sunnnrt Alimony Pavments Other . $ $ $ set NoTE ON nf. 71"""""' r' :O~1<"" liNIN!!: I i~~~nses: I $ WEEK $ MONTH $ YEAR I I verify that the. statements made in this Income an~ Expense Statement are true and correct. I understand that false statements herem are subject to the crunmal penaltIes of 18 Pa. C.S. ~ 4904, relating to unsworn falsification to authorities. 11,/7,03 Date Service Type M :",",",W,'t"'_" ~ ~"~ ',. ~ , tJ.~::l+11hc' $J;~ Plainti r Defendant Page 3 00 Form IN -008 Worker ill 21200 ^ ~ ~~~ ~ , . "- ~_"~'~,,', ~',^,' ",~,>, . _", ,$, "1"",,~If!~,~" '~'['.' .,,,,,~-~, _'~""'k'.," .,0'., -.-J'.;,.._ ,,;,V>fi~ -"fln~"M~'1r'-ii~';;'r;;~t'~~_"~~.'fit~'t"~P'~iit:'~t:;n'o;,-'t;n~1i(}'~:;,'j :~l29 n ;..< 2t' ~!'~,; ~~ C:":c",." ~~~c: -< ,~ .'-~5 f"",' .r:. o -:'1 _..) -, ~:-;"!I ~y~ -'.':.:".:; + ~~ ~~ .__:. sj -< C!? ':1'\ Iv ,_, ",,,~__, ~',~ "..., ,_"' ~<,~,~~~:f!1;I!'?"""l!l'I"I""*~;"!'~;"7-H\'[%1-"~~l?f~il!!;~/!li~"""~7'~_Jr,;~Jl,~r". ~J~!..j.!R~ ,;-;W~'~'''<'''''"'~' .,-, --, . <" ') MARY ANN SHUTTY : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW v. ROBERT M. SHUTTY : NO. 01 - 6237 : IN DIVORCE ORDER AND NOTICE SETTING HEARING TO: Mary Ann Shutty Theresa Barrett Male , Plaintiff , Counsel for Plaintiff Robert M. Shutty , Defendant , Counsel for Defendant You are directed to appear for a hearing to take testimony on the outstanding issues in the above captioned divorce proceedings at the Office ofthe Divorce Master, 9 North Hanover Street, Carlisle, Pennsylvania, on the 18th day of November 2004 at 9:00 a.m., at which place and time you will be given the opportunity to present witnesses and exhibits in support of your case. By the Court, . Hoffer, President 1dge Date of Order and Notice: 8/9/0Ll By: Divorce Master 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 32 SOUTH BEDFORD STREET, CARLISLE, P A 17013 TELEPHONE (717) 249-3166 ;;>'''f!!Y. ""'" ..'>""""""A,,~."''''-'''' "," ~~"I -,-,- ~ .F _V_, ~\-&::'~_::::".;;ff~RH;';'~ T.. ,,- ." "" lVIARY ANN SHUTTY ~\)~ ~~1 \Nt\1i \f{} O\lLvSS ~\~Wl If'lf IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff CIVIL ACTION - LAW VS. NO. 01-6237 CIVIL 19 ROBERT M. SHUTTY : INDIVORCE Defendant STATUS SHEET DATE: ACTIVITIES: m- ~ ,1/0 /~ Ill;f;(b<( ""'.".',_, ";;"'0 .,,'.,.," ""."''l'0Q)'~",. ~_,_", ,,',~ ""-~ :"'""".,= ",- ,~ , <~~ , MARY ANN SHUTTY, Plaintiff THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 01 - 6237 CIVIL ROBERT M. SHUTTY, Defendant IN DIVORCE TO: Theresa Barrett Male , Attorney for Plaintiff Robert M. Shutty , Defendant DATE: Monday, December 12, 2003 CERTIFICATION I certify that discovery is complete as to the claims for which the Master has been appointed. OR IF DISCOVERY IS NOT COMPLETE: (a) Outline what information is required that is not complete in order to prepare the case for trial and indicate whether there are any outstanding interrogatories or discovery motions. -~j:.;!+'W,-","""c " -..-;-,:~ ' I , . I - " ~=~.~ -,.. '"" ;r:;~w. ,'~:'- .-~,",<-:""." "' ';"i':,:;),- . (b) Provide approximate date when discovery will be complete and indicate what action is being taken to complete discovery. COUNSEL FOR PLAINTIFF COUNSEL FOR DEFENDANT DATE NOTE: PRETRIAL DIRECTIVES WILL NOT BE ISSUED FOR THE FILING OF PRETRIAL STATEMENTS UNTIL COUNSEL HAVE CERTIFIED THAT DISCOVERY IS COMPLETE, OR OTHERWISE AT THE MASTER'S DISCRETION. AFTER RECEIVING THIS DOCUMENT FROM BOTH COUNSEL OR A PARTY TO THE ACTION, IF NOT REPRESENTED BY COUNSEL, INDICATING THAT DISCOVERY IS NOT COMPLETE, THE DIRECTIVE FOR FILING OF PRETRIAL STATEMENTS WILL BE ISSUED AT THE MASTER'S DISCRETION. HOWEVER, IF BOTH COUNSEL, OR A PARTY NOT REPRESENTED, CERTIFY THAT DISCOVERY IS COMPLETE, A DIRECTIVE TO FILE PRETRIAL STATEMENTS WILL BE ISSUED IMMEDIATELY. THE CERTIFICATION DOCUMENT SHOULD BE RETURNED TO THE MASTER'S OFFICE WITHIN TWO (2) WEEKS OF THE DATE SHOWN ON THE DOCUMENT. ~, I t " - ~ " L' -- .~, ~.t1.f\'~!t~',>". 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I' II Ii . . p - 'I - --11--- ---. .. ..----- , -- -- j I .......-..........-- l-..-..-.---...-.----...-.--------__~________________._________,__ "----- -,,--_.,-- ---- ~-_.,-----'_.,-'"-..~_.,---~----~--_.~._----~-_._--------'-----_._-'-----'--_.__.~---_.~---,- --~--------------'-'-----_._,---,-----------"-_._---------".._-" --4 ! , ~--_._------"---"---"--------_._-,--~"-_._--,------~_._----- --"---'--_._.._----------------------_._~-----_.- I " ~')'''''"---~'I:....."''-'I?,;>''''~-J'';'',,-'I''''''''''--,;''jH.~',-...l'~''''-r..,'''I1l!1I11.1W"r~,_,...I'}.'lIi'_!'!""""~'_"~:rel.""I' -----------~-------~------------ 1 f<"'\III'I""l!W__......"~_____'""_"":"""'"~~sI~~-~,,~_ '~....~-"'Ij"""~~r''''''''~ i . o Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesquire.com Counsel for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE NOTICE If you wish to deny any of the statements set forth in this affidavit, you must file a counter-affidavit within twenty days after this affidavit has been served on you or the statements will be admitted. AFFIDAVIT UNDER SECTION 3301(d) OF THE DIVORCE CODE 1. The parties to this action separated in or around October 2001 and have continued to live separate and apart for a period of at least two years. ,&,i>\-f51]iil!1!! "",,:~~~ . 2. The marriage is irretrievably broken. 3. 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. 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. S 4904 relating to unsworn falsification to authorities. fl{ ~2L.tr Mary An Shutty Date: November 1\ ,2004 2 . . ~,' ....... ~. ^ - \ ~ ~ ,- rJlf ,~~ Jll , ,"0 r::::.:> c:? .~- -". Z~ .~ o -'l'"I ::;-J r)"i~i -"FT., -bC] S~~) ~f;~ ..-; ~::; :< f') ~~ c;'? ~n (.,.,) . "",,!,-,~'~1i!iN[Nf,'~"~'Fi1?,J4'C~.mW4~1'i-9'U;,[i)tmlj~~_!f~~l~~'iJ!itIil,J;~~~ " o r--> C:::=.':I- c::;.:;> .;:- o c;; ~~rF ~:i ~:l: 2: -. .,~ -< 00 Ul C" o 'T! .-J I-p nlp= -orn ,:)0 Ci 1. ~.::1C) -.r~ "T, ;;~.~, :::] ~() ;>..nl ,,) ~-,-l !::" ~i~ ;;l'.'.: (.:.) -~ N :r.r.' :1:; Theresa Barrell Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesqulre.com Counsel for Plaintiff COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE AFFIDAVIT OF CONSENT 1. A complaint in divorce under S 3301(c) of the Divorce Code was filed on October 31, 2001. 2. The marriage of plaintiff and defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. S 4904, relating to unsworn falsification to authorities. Date: November 1\ ~~4 Mary n Shutty ,2004 . :J!-.,:",-"i,'i':'.W" ~ " ~'''"~ ""I' ~~-- ~, . ,::-; Ii o 0 "-' ~ 0 C <;..;;:0 -n .L- - ,. :rt :;;ill.:: C) rnpg -<: -rlin N :r59 (1~~~ :r.:~ :J:: /..,\nl 9? ~. S;~ CJl ;'E} (...) " Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesqulre.com Counsel for Plaintiff COURT OF COMMON PLEAS OF DAUPHIN COUNlY, PENNSYLVANIA MARY ANN SHUTlY Pia i ntiff v. NO. 01-6237 Civil Term ROBERT M. SHUTlY: Defendant CIVIL ACTION - DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER S 3301(c) OF THE DIVORCE CODE 1. I consent to the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the prothonotary. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. !3 4904 relating to unsworn falsification to authorities. Date: November~, 2004 JJ B.;-?Iif; Mary n Shutty """W:~~~li1!" "",_ ~ *~,"'" <W'l - 'lr ~......, .. MARY ANN SHUTTY, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 01 - 6237 CIVIL ROBERT M. SHUTTY, Defendant IN DIVORCE ORDER OF COURT AND NOW, this / 0 'fPl. 1(2 day of 5~ 2004, the parties and counsel having entered into an agreement and stipulation resolving the economic issues on November 18, 2004, the date set for a Master's hearing, the agreement and stipulation having been transcribed, and subsequently signed by the parties and counsel, the appointment of the Master is vacated and counsel can conclude the proceedings by the filing of a praecipe to transmit the record with the affidavits of consent of the parties so that a final decree in divorce can be entered. BY THE COURT, ~J cc: ~eresa Barrett Male Attorney for Plaintiff > tf&: ~,o~ \\,\V ~obert M. Shutty Defendant ";-..,JCJ -,;f, ,: " ""'''':',::'','',C:f:zf-'', ',', "" jpc--, . ,<:I'~" ,1-'"',, '1 .,- ,j-~U'l"":lL..ilK.~~;~;ii~~i~tIi~'~:~"'i'ilW4.~~I-,,,'I ,~,o~ ,~. '~lff' "illbfl":':'" " '",''' '~""" ,; ., " ","" "."'~";:ii<';>;>>";~""" ii";""';;";';' N' Ul FILED-OfFiCE THE P?.oT~~():\r}r?.RY ZOOL) r-rJV 18 P;-'l 2: 29 ifiji'''.'''.' "'=~i'h ~J :: ".. ~ ~;!Sl'!"'r~1 MARY ANN SHUTTY, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 01 - 6237 CIVIL ROBERT M. SHUTTY, Defendant IN DIVORCE THE MASTER: Today is Thursday, November 18, 2004. This is the date set for a hearing in the above captioned divorce proceedings. Present in the hearing room are the Plaintiff, Mary Ann Shutty, and her counsel Theresa Barrett Male, and the Defendant, Robert M. Shutty. Mr. Shutty is not represented by counsel. This action was commenced by the filing of a divorce complaint on October 31, 2001, raising grounds for divorce of irretrievable breakdown of the marriage. Mrs. Shutty filed her affidavit and waiver with the Prothonotary on November 12, 2004; Mr. Shutty has given the Master a signed affidavit of consent and waiver of notice of intention to request entry of divorce decree dated today which will be filed with the Prothonotary by the Master's office. Therefore, the divorce can be concluded under Section 3301(c) of the Domestic Relations Code. The complaint also raised economic claims of equitable distribution, alimony, and counsel fees and expenses. The parties were married on July 23, 1977, 1 -, "-,--",. ." -I' . :'"1:,' .~ I' ','" ,.. , and separated on October 3, 2001. They are the natural parents of one child who is emancipated. After discussion this morning, the parties have reached an agreement with respect to the outstanding economic issues. The agreement is going to be placed on the record in the presence of the parties. The agreement as placed on the record will be considered the substantive agreement of the parties, not subject to any changes or modifications except for correction of typographical errors which may be made during the transcription. The parties will return later today to review the agreement, make any typographical corrections as required and then affix their signatures affirming the terms of settlement as stated on the record. Upon receipt by the Master of a completed agreement, the Master will prepare an order vacating his appointment and counsel for wife can then file a praecipe with the Court requesting a final decree in divorce. Mr. Shutty, would you give us your address? MR. SHUTTY: 608 Plaza Apartments, Lebanon, pennsylvania 17042. THE MASTER: Mrs. Shutty, do you have an address for the record? MS. MALE: We prefer not to disclose her address at this point. 2 "" - /'~ , ,.,<. .': "'L .'. "",' ^'~f'." - , -~"-",~ -' -- THE MASTER: That is fine. Ms. Male, do you want to proceed with the statement of the agreement on the record? MS. MALE: Yes. Thank you, Mr. Elicker. 1. The parties have agreed that the National Vision Administrator's 401(k) plan, which has an account balance as of today's date of $20,342.83 will be awarded in its entirety to wife. We anticipate doing this by a Domestic Relations Order which wife will be responsible for preparing and submitting to the plan administrator. Mr. Shutty will cooperate in signing any documents necessary to effectuate the transfer. It is further understood that the transfer will be free of any tax consequences unless Mrs. Shutty decides to withdraw the funds which will then be her responsibility for penalty and taxes. 2. Mr. Shutty has agreed to pay as alimony to Mrs. Shutty the sum of $750.00 per month for a period of 36 months. This alimony obligation will begin 60 days after the date on which Mr. Shutty secures employment as a pharmacist earning $30.00 an hour or more. These payments will be treated as alimony for federal income tax purposes. Mr. Shutty will make the payments directly to Mrs. Shutty through her counsel. The payments are nonmodifiable. The alimony obligation will terminate upon the death of either party. It will not terminate on wife's cohabitation or remarriage. 3. Mr. Shutty has agreed to pay the sum of $2,000.00 as counsel fees towards Mrs. Shutty's attorney fees incurred during this divorce proceeding. He agrees to make that payment within 6 months of his securing employment as a pharmacist earning $30.00 an hour or more. He will make the payment or payments directly to wife's counsel. In order to implement the award of counsel fees and the alimony award, Mr. Shutty has agreed to contact wife's attorney when he secures the employment that we have just discussed. Concurrently with entry of the divorce decree, Mrs. Shutty will withdraw with prejudice the support action currently pending in the Domestic Relations section. The arrears to stand subject to any further settlement between the parties either privately or through the Domestic Relations section. 4. Prior to today's proceedings, Mr. Shutty sold a 1990 Hyundai. He will retain the $500.00 proceeds which he received from that. Mrs. Shutty traded in a 1994 Suzuki. 3 :":<~i,J"..., _., - - ~ . - 'iJ~ ,-,;~rr'_ ,..- - ' , .---- ,I' , -,','i - ~ ~~ ~. '~'.' She received $1,000.00 as a trade-in value. She will retain that. Mrs. Shutty will retain without any claim by Mr. Shutty the proceeds she received from the sale of the former marital residence which had been deeded from Mr. Shutty to Mrs. Shutty prior to the appointment of the Master. Mr. Shutty will retain without claim by Mrs. Shutty the proceeds he previously had received from the 40l(k) plan through National Vision Administrators. 5. Prior to today's proceedings, the parties divided the personal property within the home to their mutual satisfaction and neither party will make any claim with respect to any of those items of personal property. (An off the record discussion was held.) The parties had an agreement off the record regarding some personal property items that Mr. Shutty has an interest in securing. Mrs. Shutty has acknowledged that some items may be in storage from after the house was sold. She will use her best efforts to investigate the contents of storage unit and any and all items that belong to Mr. Shutty, such as books or CDs, CD player, musical instruments or their cases and accessories, Mrs. Shutty will make available to her counsel for delivery to Mr. Shutty. 6. Except as herein otherwise provided, each party may dispose of his or her property in any way and each party hereby waives and relinquishes any and all rights he or she may now have or hereafter acquire under the present or future laws of any jurisdiction to share in the property or the estate of the other as a result of the marital relationship including without limitation, statutory allowance, widow's allowance, right of intestacy, right to take against the will of the other, and right to act as administrator or executor in the other's estate. Each will at the request of the other execute, acknowledge, and deliver any and all instruments which may be necessary or advisable to carry into effect this mutual waiver and relinquishment of all such interest, rights, and claims. 7. If there are any documents which need to be signed to implement the equitable distribution award or the counsel fee or alimony award, both parties will do so within ten days of the request. Specifically if there are any documents that Mr. Shutty may need to execute he will do so within ten days of my requesting him do so. 4 . ~I' 1~ ~, v ~;~Z:~~"'. ,,,,"",:~,,"S\""'-t:1~,, :C,."f"., ,'~ ,C'",.'. THE MASTER: Mr. Shutty, have you present during the statements on the record? MR. SHUTTY: Yes. THE MASTER: Do you understand the agreement as stated on the record? MR. SHUTTY: Yes. THE MASTER: Do you have any questions about it? MR. SHUTTY: No, except for what we have to talk about, my personal property. THE MASTER: Right. We will do that after we complete the statement on the record. You and Ms. Male can talk about some of those items. Are you satisfied to have this agreement entered as an agreement to resolve all of the economic claims in the divorce action? MR. SHUTTY: Yes. MS. MALE: Mrs. Shutty, have you been present during the recitation of the agreement that we just placed on the record? MRS. SHUTTY: Yes. MS. MALE: Do you understand the agreement as I have stated it? MRS. SHUTTY: Yes. MS. MALE: Do you agree with its terms? 5 , I ,.,...... -"~I . " ,I :\,WF~'lll!ll_ ... ,. , ~. MRS. SHUTTY: Yes. MS. MALE: Are you willing to be bound by the agreement that we have reached here today? MRS. SHUTTY: Yes. MS. MALE: Do you understand that once we have this agreement on the record neither one of you will be able to litigate this matter any further - the divorce action, I mean? MRS. SHUTTY: I have one question (An off the record discussion was held.) MRS. SHUTTY: Yes. I acknowledge that I have read the above stipulation and agreement, that I understand the terms of settlement as set forth herein, and that by signing below I ratify and affirm the agreement previously made and intend to bind myself to the settlement as a contract obligating myself to the terms of settlement and subjecting myself to the methods and procedures of enforcement which may be imposed by law and in particular Section 3105 of the Domestic Relations Code. WITNESS: DATE: ;Lb~~~ Theresa Barrett Male Attorney for Plaintiff 1f/If/tJf f f I fLop<- 6~A~ ///IY(O"f . ~o~ Robert M. Shut 6 I ,. ~-". -, '.""~ " ~ -. ^ '-' ?I~,,- ! ,) .it""",~""o~ ,e, " ,~, """,?w,."",.,.,,,,,,",'c" .. ..",- - ~" ,. '~,~9ilJF-'~,,_, ~:;'J"im.~~j;, ',' - ~~,lJ@\W,_-, !"r-' , ., "'~~h~~r~u,-~"i',:";0';'"'r,w"i17S~' -. ~, ~ " ... " "" UJj!.!I,.~~T)J!f,~L m~ J~,Jm~~l"",'~:" ',_ " , -- ~" , .c' , ,., ',", , _, . ' '} Fc[;~~::'S7~~:l DEe 1 :Y 2005 I I ___J R~~r- ~----;---'.-=---=-:~: Theresa Barrett Male Supreme Court # 46439 513 North Second Street Harrisburg, PA 17101 (717) 233-3220 tbm@tbmesquire.com Counsel for Plaintiff COURT OF COMMON PLEASOFCUMBERLAND COUNTY, PENNSYLVANIA MARY ANN SHUTTY Plaintiff v. NO. 01-6237 Civil Term ROBERT M. SHUTTY Defendant CIVIL ACTION - DIVORCE QUALIFIED DOMESTIC RELATIONS ORDER AND NOW, December -z..o, 2005, it appearing to the Courtthat: 1. Plaintiff and Defendant were married on July 23,. 1977 and were divorced decree of this Court on November 30, 2004. A copy of the decree, which incorporates by reference the parties' settlement agreement placed on the record before this Court's divorce master on November 18, 2004, is attached as Exhibit.1. 2. This is a Court of competent jurisdiction exercised in accordance with the laws ofthe Commonwealth of Pennsylvania. ';W~~"~k~, ~ " , ~ ~- - "<,' ,", '. I' - _11 ",~~~' 3. At all times incident to this proceeding, the Court had jurisdiction over the parties. 4. Defendant ("Participant") is Robert M. Shutty, 608 Plaza Apartments, Lebanon, PA 17042 DOB: 03/29/52, 55 #189-42-0639. The Participant shall be responsible for keeping the Plan Administrator apprised of his current address. 5. Plaintiff ("Alternate Payee") is Mary Ann Shutty, 73R Winter Lane, Enola, PA 17025, DOB: 08/20/56, SS #176-52-6717. The Alternate Payee shall be responsible for keeping the Plan Administrator apprised of.her current address. 6. In this action, Plaintiff raised claims for, inter alia, equitable distribution of marital property pursuant to the Pennsylvania Divorce Code, 23 Pa. C.SA SS 3101-3707. 7. This Order applies to benefits under the National Vision Administrators, LLC 401 (k) Plan ("Plan"). Changes in Plan Sponsor, Plan Administrator or Plan Name shall not be deemed to affect any order. 8. This Order is intended to be a qualified domestic relations order ("QDRO"), as defined in section 206(d) of the Employee Retirement Income Security Act of 1974 ("ERISA") and section 414(p) of the Internal Revenue Code of 1986 ("Code"). This QDRO is granted in accordance with the Divorce Code, as amended, and applicable caselaw relating to marital property rights between spouses and former spouses in matrimonial actions. 2 . - .' '.... ",_,0 ,,~ " ,,^"'r,'T "", .. . 1- - f"1 t;, 9. The Participant assigns to the Alternate Payee one hundred percent (100%) in U.S. Dollars of the Participant's benefits from the Plan, and any successor or transferee plans will pay benefits to the Alternate Payee as provided in this Order; 10. The Plan will pay to the Alternate Payee one hundred percent (100%) of the Participant's vested accounts, which shall be segregated by the Plan Administrator for the benefit of the Alternate Payee upon receipt ofthis Order. The Alternate Payee shall be entitled to receive from the Plan the value of this segregated amount, as adjusted for all earnings thereon and all investment gains and/or losses thereon through the date of complete distribution. If the Alternate Payee elects, her benefits shall be paid to her as soon as administratively feasible following the date the Plan Administrator approves this Order as a QDRO, or at the earliest date permitted under the terms of the Plan or section 414(p) of the Internal Revenue Code, if later. Benefits will be payable to the Alternate Payee in any form or permissible option available to participants under the terms of the Plan, including but not limited to a single lump-sum cash payment. The Participant shall not be entitled to any portion of his account. 11. Using the segregated amount provided in the preceding paragraph, the Plan will pay to the Alternate Payee benefits in accordance with the benefit distribution provisions of the Plan, with distribution to be made at any time upon the agreement and consent of the Plan Administrator and the Alternate Payee. Such distribution may be made immediately. Notwithstanding the foregoing, the Alternate Payee may elect, within the applicable period specified in section 402(c) of the Code, to make an eligible rollover distribution to an eligible 3 ,<~"'N~I!tI?"l!"Il', . _","~,~ . , ',"", '" --, ,-,"'""1'" ~ ';' '-I Lr retirement plan designated by the Alternate Payee irl writing to the Plan Administrator or may elect to make a direct trustee-to-trustee transfer to an eligible retirement plan so designated, in accordance with the provisions of section 401(a)(31) of the Code. 12. If the Alternate Payee dies before all the benefits to which she is entitled from the Plan are paid to her under this Order, the beneficiary shall be the Alternate Payee's estate. 13. The assignment of benefits to the Alternate Payee shall not be reduced, abated or terminated as a result of the death of the Participant. Upon the Participant's death, the Alternate Payee will be entitled to all survivor benefits attributable to the Participant's share of benefits under the Plan and the benefit set forth in paragraph 9 above. 14. The assignment of benefits under this Order does not require the Plan to provide any type or form of benefit, or any option, not otherwise provided under the Plan, to provide increased benefits determined on the basis of actuarial value, or to provide benefits to the Alternate Payee which are required to be paid to another alternate payee under another order previously determined to be a qualified domestic relations order. 15. The Participant, the Alternate Payee, and the Court intend this order to be a qualified domestic relations order as defined in section 206 of ERISA and section 414(p) of the Internal Revenue Code of 1986, as amended. The provisions of this Order are to be administered and interpreted in a manner consistent with such provisions. 4 "~*",,10"-If"'1'~~ -'"'-" ';,1' 1'< -~ 16. After submission to the Plan Administrator, if this Order is held not to be a Qualified Domestic Relations Order as defined in section 206 of ERISA and section 414(p) of the Internal Revenue Code of 1986,as amended, this Court reserves jurisdiction to amend this Order to establish or maintain its status as a QDRO under ERISA and the Code. Modified Orders may be entered nunc pro tunc. No amendment or modification of this Order shall require the Plan to provide any type or form of benefit, or any option, not otherwise provided under such Plan. BY THE COURT: ~ J. 5 ;--"W;?"""'''''''~'''''~''. rn __,"~ f' :^~'~,- ~~> ~-- ,~,. . ~11m. ~. N ~ -, a~ ..:r :::>< UJ . Es~ 05 :It: if:!:, Cl.. c-~;2 %0 (:) :~{ ~~ , a: N ':!:to.; .--'L- U :(:7":::' ..---iJUJ u:.~ lJ.J ;_~ID- l- e:> .~ /- en :::> ~ = = () .... L ~,' ~Jl~ i1I11'tIIR,~,O ~ "- - ~"~ w',.- "~'."""""-"~~_. - ..""'''~v.~.' '.~'" '!~""'= ~~ t-Jot ~Jtl'!1~,,,",~,,;~~~~~~'~$;'Io'J:i' ~""">",rn,,,,,"'w;I'''W81'llfll;1'j[j)'il!k><'!.I~~~!4~~~''I~.~ J ~~ ,. :Ii",;!;:Ii . . . . . . . . . . . . . . . . . . . . . . :Ii'" '" :Ii "':Ii "'''':Ii'''''' :Ii :f."':f.:f.~:f.:f.:f. :Ii"'''' :Ii "''''''':Ii "''''''' :Ii:li"''''''''''''''''''' :f.m:f.mm:f.:f.~ . IN THE COURT OF COMMON-PLE . m~ OF CUMBERLAND COUNTY rn~ @ ~ Q \I] ~ ~ ~ DEe 0 6 2004 ~ : STATE OF PENNA. ~ . MARY ANN SHUTTY Plaintiff VERSUS ROBERT M. SHUTTY Defendant . By No. 6237 Civil 2001 DECREE IN DIVORCE 2004 . AND NOW, November30 Mary Ann Shutty , IT IS ORDERED AND . DECREED THAT . . AND . . . . , PLAINTIFF, Robert M. Shutty , DEFENqANT, ARE DIVORCED FROM THE BONDS OF MATRIMONV. THE COURT RETAINS JURISDICTION OF THE FOLLOWING CLAIMS WHICH HAVE BEEN RAISED OF RECORD IN THIS ACTION FOR WHICH A FINAL ORDER HAS NOT VET BEEN ENTERED; A/tA!C All economic claims raised of record are resolved by the agreement reached by the parties at the November 18, 2004 Master's Heanng. A Hue and correct CUfJY uf Lilt: t'dll""dpt of . . . . . . . . . . . . . . . . . . . . . . . )"-'>~AY","'''''"''"' ""'~""Il'!~I>>" <_, , ~~ J :1 Bv THE COURT: Edgar B. Bayley ATTEST: . . . J. . . . . . . . . . . . "'''' :Ii :Ii :Ii"''''''''''''''''''''''''' ~ . Certified Copy Issued: December 3, 2 "':Ii "'''':Ii "''''''''''''''''''''''''' "'''''''''':Ii'''''''''''' "':Ii "\',-U,r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . $~ MARY ANN SHUTTY, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 01.- 6237 CIVIL ROBERT M. SHUTTY, Defendant o ~ 0 C" c::; ." :.;; J::"' :::i . '"tJ~1j X ..L-n n~frl ~ n1- THE MASTER: Today is Thursday, Nov~er~8,~~ This is the date set for a hearing in the a~~k ",. :i~ 2;::0 .::1; Qo ~-::;C} -'"-en >e: \.D ~ 7' .. i.2: =:J w ~ -- <."" IN DIVORCE 2004. captioned divorce proceedings. Present in the hearin~ room are the Plaintiff, Mary Ann Shutty, and her counsel Theresa Barrett Male, and the Defendant, Robert M. Shutty. Mr. Shutty is not represented by counsel. This action was commenced by the filing of a divorce complaint on October 31, 2001, raising grounds for divorce of irretrievable breakdown of the marriage. Mrs. Shutty filed her affidavit and waiver with the Prothonotary on November 12, 2004; Mr. Shutty has given the Master a signed affidavit of consent and waiver of notice of intention to request entry of divorce decree dated today which will be filed with the Prothonotary by the Master's office. Therefore, the divorce can be concluded under Section 3301(c) of the Domestic Relations Code. The complaint also raised economic claims of equitable distribution, alimony, and counsel fees and expenses. The parties were married on July 23, 1977, 1 ;~'ll'.'''!''W'''''-~ , 4 .,""1'" <'t".' ,'~ _0_ '" and separated on October 3, 2001. They are the natural parents of one child who is emancipated. After discussion this morning, the parties have reached an agreement with respect to the outstanding economic issues. The agreement is going to be placed on the record in the presence of the parties. The agreement as placed on the record will be considered the substantive agreement of the parties, not subject to any changes or modifications except for correction of typographical errors which may be made during the transcription. The parties will return later today to review the agreement, make any typographical corrections as.. required and then affix their. signatures affirming the terms of settlement as stated on the record. Upon receipt by the Master of a completed agreement, the Master will prepare an order vacating his appointment and counsel for wife can then file a praecipe with the Court requesting a final decree in divorce. Mr. Shutty, would you give us your address? MR. SHUTTY: 608 Plaza Apartments, Lebanon, Pennsylvania 17042. THE MASTER: Mrs. Shutty, do you have an address for the record? MS. MALE: We prefer not to disclose her address at this point. 2 ';,*,IiW~'\='\"lTJIl~. >"', ._,~, ",'I ,', "" ~,,"':,' , ,,~ . -'^ :~~;'l!11W''''''''4W'''-~ "!lfm'_ THE MASTER: That is fine. Ms. Male, do you want to proceed with the statement of the agreement on the record? MS. MALE: Yes. Thank you, Mr. Elicker. 1. The parties have agreed that the National Vision Administrator's 40l(k) plan, which has an account. balance as of today's date of $20,342.83 will be awarded in .its entirety to wife. We anticipate doing this by a Domestic Relations Order which wife will be responsible for preparing and submitting to the plan administrator. Mr. Shutty will cooperate in signing any documents necessary to effectuate the transfer. It is further understood that the transfer will be free of any tax consequences unless Mrs. Shutty decides to withdraw the funds which will then be her responBibility for penalty and taxes. 2. Mr. Shutty has agreed to pay as alimony to Mrs. Shutty the sum of $750.00 per month for a period of 36 months. This alimony obligation will begin 60 days after the date on which Mr. Shutty secures employment as a pharmacist earning $30.00 an hour or more. These payments will be treated as alimony for federal income tax purposes. Mr. Shutty will make the payments directly to Mrs. Shutty through her counsel. The payments are nonmodifiable. The alimony obligation will terminate upon the death of either party. It will not terminate on wife's cohabitation or remarriage. 3. Mr. Shutty has agreed to pay the sum of $2,000.00 as counsel fees towards Mrs. Shutty's attorney fees incurred during this divorce proceeding. He agrees to make that payment within 6 months of his securing employment as a pharmacist earning $30.00 an hour or more. He will make the payment or payments directly to wife's counsel. In order to implement the award of counsel fees and the alimony award, Mr. Shutty has agreed to contact wife's attorney when he secures the employment that we have just discussed. Concurrently with entry of the divorce decree, Mrs. Shutty will withdraw with prejudice the support action currently pending in the Domestic Relations section. The arrears to stand subject to any further settlement between the parties either privately or through the Domestic Relations section. 4. Prior to today's proceedings, Mr. Shutty sold a 1990 Hyundai. He will retain the $500.00 proceeds which he received from that. Mrs. Shutty traded in a 1994 Suzuki. i ,""' -";'" """I r-f '",-j " '.j',"-" ~ ~.," ~ She received $1,000.00 as a trade-i~ value. She will retain that. Mrs. Shutty will retain without any claim by Mr. Shutty the proceeds she received from the sale of the former marital residence which had been deeded from Mr. Shutty to Mrs. Shutty prior to the appointment of the Master. Mr. Shutty will retain without claim by Mrs. Shutty the proceeds he previously had received from the 401(k) plan through National Vision Administrators. 5. Prior to today's proceedings, the parties divided the personal property within the home to their mutual . satisfaction and neither party will make any claim with respect to any of those items of personal property. (An off the record discussion was held.) The parties had an agreement off the record regarding some personal property items that Mr. Shutty has an interest in securing. Mrs. Shutty has acknowledged that some items may be in storage from after the house was sold. She will use her best efforts to investigate the contents of storage unit and any and all items that belong to Mr. Shutty, such as books or CDs, CD player, musical instruments or their cases and accessories, Mrs. Shutty will make available to her counsel for delivery to Mr. Shutty. 6. Except as herein otherwise provided, each party may dispose of his or her property in any way and each party hereby waives and relinquishes any and all rights he or she may now have or hereafter acquire under the present or future laws of any jurisdiction to share in the property or the estate of the other as a result of the ma,rital .relationship including without limitation, statutory allowance, widow's allowance, right of intestacy, right to take against the will of the otherr and right to act as administrator or executor in the other's estate. Each will at the request of the other execute, acknowledge, and deliver any and all instruments which may be necessary or advisable to carry into effect this mutual waiver and relinquishment of all such interest, rights, and claims. 7. If there are any documents which need to be signed to implement the equitable distribution award or the counsel fee or alimony award, both parties will do so within ten days of the request. . Specifically if there are any documents that Mr. Sr,utty may need to execute he will do so within ten days of my requesting him do so. 4 ','f'\~'m:'!f1:r,,"f)''''~~<~ , -" --""'I','. Ll"" '",- , T~E MASTER: .Mr. Shutty, have you present during the statements on the record? MR.' SHUTTY: Yes. THE MASTER: Do you understand the agreement as stated on the record? MR. SHUTTY: THE MASTER: Yes. Do you have any questions about it? MR. SHUTTY: No, except for what we have to talk about, my personal property. THE MASTER: Right. We will do that after we complete the statement on the record. You and Ms. Male can talk about some of those items. Are you satisfied to have this agreement .entered as an agreement to resolve all of the economic .claims in the divorce action? MR. SHUTTY: Yes. MS. MALE: Mrs. Shutty, have you been present during the recitation of the agreement that we just placed on the record? MRS. SHUTTY: Yes. MS. MALE: Do you understand the agreement as I have' stated it? MRS. SHUTTY: Yes. MS. MALE: Do you agree with its terms? 5 ----~- MRS. SHUTTY: Yes. MS. MALE: Are you willing to be bound by the agreement that we have reached here today? MRS. SHUTTY: Yes. MS. MALE: Do you understand that once we have this agreement on the record neither one oJ you will pe able to litigate this matter any further - the divorce action, I mean? MRS. SHUTTY: I have one question (An off the record discussion was held.) MRS. SHUTTY: Yes. I acknowledge that I have read.the above stipulation and_ftgreement, that r understand the terms of settlement as set forth herein, and that by signing below I ratify and affi~m the agreement previously made and intend to bind myself to the qettlement as a- contract "-Obligating myself to the terms of settlement. and subjecting myself to the methods and procedures of enforcement wh~ch may be imposed by law and in particular section 3105 of the Domestic Relations Code. WITNESS: DATE: ~~ 1;)0(- J t ~i ,c-k.. Theresa Barrett ale Attorney for Plaintiff /LkL-liudt. ~ u' , , /1(;1/ /07 ~~.~ Rober~ M. Shutty 6 ~l <- ~"_,_ ,"","""''W"__~_~,~, """ '-' ~,,,..Jl!IP'n]JlJP,f~~~~~~'f_,';\-':=l.6~!,,,,g""-:~iit*'fi~~~~',,,~j:j!,~~,,if~!~t~llfW::r"_" "-.;J.,[;r.J1~~!jitJ~',,,~?,;'