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HomeMy WebLinkAbout07-3277DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW MICHAEL V. ROSS, :NO. 07-3077 CIVIL TERM Defendant IN DIVORCE NOTICE TO DEFEND AND CLAIM RIGHTS You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take prompt action. You are warned that if you fail to do so, the case will proceed without you and a decree of divorce or annulment may be entered against you for any claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rights important to you, including custody or visitation of your children. When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. A list of marriage counselors is available in the Office of the Prothonotary at Cumberland County Courthouse, Carlisle, Cumberland County, Pennsylvania, 17013. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 South Bedford Street Carlisle, Pennsylvania 17013 Phone: (717) 249-3166 or (800) 990-9108 DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION -LAW MICHAEL V. ROSS, NO. 0 1- 3 'Z 7 '7 CIVIL TERM Defendant IN DIVORCE COMPLAINT IN DIVORCE NO FAULT 1. Plaintiff is Denise M. Ross, an adult individual currently residing at a confidential location in Cumberland County, Pennsylvania. 2. Defendant is Michael V. Ross, an adult individual currently residing at 44 Oak Park Avenue, Carlisle, Cumberland County, Pennsylvania. 3. Plaintiff is a bonafide resident of the Commonwealth of Pennsylvania and has been so for at least six months immediately previous to the filing of this Complaint. 4. Plaintiff and Defendant were married on August 26, 1989 in Alleghany County, Pennsylvania. 5. There have been no other prior actions for divorce or annulment between the parties. 6. Neither the Plaintiff nor the Defendant are members of the United States Armed Forces or its Allies. 7. Plaintiff has been advised of the availability of counseling and the right to request that the Court require the parties to participate in counseling. Knowing this, Plaintiff does not desire that the Court require the parties to participate in counseling. 8. Plaintiff and Defendant are citizens of the United States of America. 9. The parties' marriage is irretrievably broken. 10. Plaintiff desires a divorce based upon the belief that the Defendant will, ninety (90) days from the date of service of this Complaint, consent to this divorce. WHEREFORE, Plaintiff requests your Honorable Court to enter a divorce pursuant to 23 P.S. Section 3301 (c) of the Domestic Relations Code. COUNTI ALIMONY ALIMONY PENDENTE LITE AND COUNSEL FEES 11. Paragraphs 1 through 10 are incorporated herein by reference as if set forth in their full text. 12. Plaintiff is unable to provide for, or afford her counsel fees, expenses and costs during the pendency of this divorce action, and through its resolution. 13. Plaintiff is without sufficient property and otherwise unable to financially support herself through appropriate employment. 14. Defendant is presently employed and receiving a substantial income and benefits and is able to pay for counsel fees, expenses, and costs, as well as alimony, and alimony pendente lite for the Plaintiff. WHEREFORE, Plaintiff requests your Honorable Court to enter an Order requiring Defendant to pay for Plaintiff's counsel fees, expenses, and costs as well as providing for payment of appropriate alimony and alimony pendente lite to Plaintiff. COUNT II EQUITABLE DISTRIBUTION 15. Paragraphs 1 through 10 are incorporated herein by reference as if set forth in their full text. 16. Plaintiff and Defendant are joint owners of various items of personal property, furniture, and household furnishings acquired during their marriage which are subject to equitable distribution. 17. Plaintiff is the sole owner of real estate located in Cumberland County, which was acquired during the parties, marriage and which is subject to equitable distribution. 18. Plaintiff and Defendant have incurred debts and obligations during their marriage, which are subject to equitable distribution. WHEREFORE, Plaintiff requests your Honorable Court to enter a decree equitably dividing the parties' property and equitable apportioning the debts incurred by the parties. Respectfully submitted, Hannah Herman-Snyder, E uire Attorney for Plaintiff GRIFFIE & ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 (800) 347-5552 VERIFICATION I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsifications to authorities. DATE: ,??- DENISE M. SS 1 IN 0) r` ; ? OTT ? C7 a rj c w 1y r 0 s v J LAJ DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW NO. CIVIL TERM MICHAEL V. ROSS, Defendant IN DIVORCE PETITION FOR ALIMONY PENDENTE LITE, AND NOW comes Petitioner, Denise M. Ross, by and through her counsel of record, Hannah Herman-Snyder, Esquire, and the law firm of Griffie & Associates, and petitions the Court as follows: 1. Your Petitioner is the above-named Plaintiff, Denise M. Ross, an adult individual currently residing at undisclosed location in Cumberland County, Pennsylvania. 2. Your Respondent is the above-named Defendant, Michael V. Ross, and an adult individual currently residing at 44 Oak Park Avenue, Carlisle, Cumberland County, Pennsylvania. 3. Petitioner's date of birth is May 21, 1962, and her social security number is 174-58- 3586. 4. Respondent's date of birth is June 26, 1956, and his social security number is 192-44- 9894. 5. The divorce action filed to the above docketed number in the Court of Common Pleas of Cumberland County requests a divorce based upon §3301 (c) of the Divorce Code of 1980, as amended. 6. Petitioner filed a claim for alimony, alimony pendente lite, and counsel fees and expenses through the Cumberland County Prothonotary's Office contemporaneously with filing the within petition for a hearing on these matters. 7. Petitioner has employed counsel and incurred certain costs and expenses in pursuit of the aforementioned divorce action, but is without sufficient assets or income to support herself, pay for the attorney's fees, and pay for the costs and expenses associated with this action. 8. Respondent has sufficient income or earning capacity, as well as the assets to support the Petitioner and to assist in supporting Petitioner by pay Alimony Pendente Lite. WHEREFORE, Petitioner requests your Honorable Court to enter an Order requiring Respondent to pay Alimony Pendente Lite to Petitioner. Respectfully submitted, r Hannah Herman-Snyder, Esq ire Attorney for Plaintiff/Petitioner GRIFFIE & ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 (800) 347-5552 VERIFICATION I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsifications to authorities. DATE: 0! 0 7 DENISE M. ROSS DENISE M. ROSS, Plaintiff V. MICHAEL V. ROSS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. CIVIL TERM IN DIVORCE CERTIFICATE OF SERVICE s} I, Hannah Herman-Snyder, Esquire, hereby certify that I did, the 1 tk day of June, 2007, cause a true and correct copy of Plaintiff s Petition for Alimony Pendente Lite to be served upon Defendant by first-class mail, postage prepaid at the following address: Michael V. Ross 44 Oak Park Avenue Carlisle, PA 17013 DATE: U - j ? H ?H rman-Snyder, Es ' uire Attorney for Plaintiff GRIFFIE & ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717)243-5551 (800)347-5552 t? C:=3- n C7. rn 17-1 i Y( J =r ? I-n ? -y am DENISE M. ROSS, THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 07-3277 CIVIL TERM MICHAEL V. ROSS, IN DIVORCE Defendant/Respondent PACSES CASE NO: 902109218 ORDER OF COURT AND NOW, this 14th day of June, 2007, upon consideration of the Petition for Alimony Pendente Lite and/or counsel fees, it is hereby directed that the parties and their respective counsel appear before R.J. Shadday on July 26, 2007 at 10:30 A.M. for a conference, at 13 N. Hanover St., Carlisle, PA 17013, after which the conference officer may recommend that an Order for Alimony Pendente Lite be entered. YOU are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by Rule 1910.11© (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you If you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. BY THE COURT, Edgar B. Bayley, President Judge Copies mailed to: Petitioner Respondent Hannah Herman-Snyder, Esq. Date of Order: June 14, 2007 -? A4 R: J. ha e l l , Co erence Officer YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 cc361 C ?i. DENISE M. ROSS, V. IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA MICHAEL V. ROSS, Defendant CIVIL ACTION -LAW NO. 07-3277 CIVIL TERM IN DIVORCE AFFIDAVIT OF SERVICE AND NOW, this 1?' day of J aj\L , 2007, comes Hannah Herman-Snyder, Esquire, and states that she mailed a certified and true copy of a Complaint in Divorce to the Defendant, Michael V. Ross, at his address of 44 Oak Park Avenue, Carlisle, Pennsylvania, by certified mail, restricted delivery, return receipt requested. A copy of said receipt is attached hereto indicating service was made on June 7, 2007. Hannah Herman-Snyder, Es uire Attorney for Plaintiff GRIFFIE AND ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 (800) 347-5552 Sworn and subscribed to before me this ?f- day of &&"- , 2007 N am" PuONo NIrNon ftNas AW 17. 201 -. M1 ent To „? ? i _ 1 ? . (}f?aw f? . . ' MOM 4 rxff ? Aiio?ctt th 1hat? to ylott 00 to* of aft"em, a on tt>e twig 9. A j. #0 tletla Ad MWSd Cto: A fe l?p/ l ,3 2. ' AYtdds Numbw f1ia,?q,Tr 7002 0860 0001 5848 8539 tzomt 381'1, toot p o Postal CO Servicc m RECEIPT CERTIFIED MAIL only: Ln (Dornestic Mail No Insurance Coverage Provided) 0 Postage $ O Certified Fee ? ?? A p Return Receipt Fee ostm.., ? (Endorsement Required) N H? tis ? Restricted Delivery Fee 111 rota, Postage 8 Few $ if 0 Awtt ? AdA!?" 0. oft of Osk*Y 1 4A-1510 9A iih \ DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 07-3277 CIVIL TERM MICHAEL V. ROSS, IN DIVORCE Defendant/Respondent . PACSES Case Number : 902109218 ORDER OF COURT AND NOW, this 26th day of July, 2007, based upon the Court's determination that Petitioner's monthly net income/earning capacity is $N/A and Respondent's monthly net income/earning capacity is $N/A, it is hereby Ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit, $886.67 per month payable as follows: $886.67 per month for alimony pendente lite and $0.00 per month on arrears. First payment due: within five (5) days upon receipt of this Order. The effective date of the order is June 1, 2007. Arrears set at $233.34 as of July 26, 2007. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.§ 3703. Further, if the Court finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and its discretion make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Said money to be turned over by the PA SCDU to: Denise M. Ross. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the Respondent's PACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. cc360 The monthly support obligation includes cash medical support in the amount of $250.00 annually for unreimbursed medical expenses incurred for each spouse. Unreimbursed medical expenses of the oblige that exceeds $250.00 annually shall be allocated between the parties. The party seeking allocation of unreimbursed medical expenses must provide documentation of expenses to the other party no later than March 31St of the year following the calendar year in which the final medical bill to be allocated was received. The unreimbursed medical expenses are to be paid as follows: 76% by Respondent and 24% by Petitioner. (x) Respondent () Petitioner () Neither party to provide medical insurance coverage. Within thirty (30) days after the entry of this Order, the (x) Respondent () Petitioner shall submit written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at minimum, of. 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage contract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms. This Order is based upon an agreement of the parties. The Respondent is given credit in the amount of $1500.00 for direct payments. The remaining retroactive arrearage of $233.34 is to be paid directly to the Petitioner within five (5) days of receipt of this Order. Petitioner is to report to the Domestic Relations Office that said payment has been received. This Order shall become final twenty (20) after the mailing of the notice of the entry of the Order to the parties unless either party files a written demand with the Prothonotary for a hearing de novo before the Court. Consented: Petitioner Respondent Petitioner's Attorney Respondent's Attorney BY THE COURT, Ke ' A. Hess, J. Mailed copies on: Jul 27, 2007 to: Petitioner Respondent Carol J. Lindsay, Esq. Hannah Herman-Snyder, Esq. DRO: R.J. Shadday G, -c7 tom"" ??? erg -; .? r? zQ ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State -Commonwealth of Pennsylvania Co./City/Dist. of CUMBERLAND Date of Order/Notice 07/27/07 Case Number (See Addendum for case summary) E m ploye r/With holder's Federal EIN Number HARLEY-DAVIDSON MOTOR COMPANY 3700 W JUNEAU AVE MILWAUKEE WI 53208-2818 902109218 xQ Original Order/Notice 07-3277 CIVIL O Amended Order/Notice O Terminate Order/Notice RE: ROSS, MICHAEL V. Employee/Obligor's Name (Last, First, MI) 192-44-9894 Employee/Obligor's Social Security Number 3415000024 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, MI) See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 866.67 per month in current support $ o . oo per month in past-due support Arrears 12 weeks or greater? Oyes ® no $ o . 00 per month in current and past-due medical support $ 0.00 per month for genetic test costs $ o, o o per month in other (specify) for a total of $ 866.67 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 200.00per weekly pay period. $ 400,00 per biweekly pay period (every two weeks). $ 433.34 per semimonthly pay period (twice a month). $ 866.67 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). If required by Pennsylvania law (23 PA C.S. § 4374(b)) to remit by electronic payment method, please call Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. Date of Order: J U L 3 0 2007 DRO: R.J. Shadday Service Type M BY THE COURT: ;5?,- .4 A/, vin A. Hess, Judge Form EN-028 Rev. 1 OMB No.: 0970-0154 Worker ID $ IATT J ? V ? L r i C n ; .,w ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS ? If hecke? you are required to provide a opy of this form to your mployee. If yo r employee works ina state that is di4erent from the state that issued this or?er, a copy must be provi?ed to your employee even if the box is not checed. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Reporting the Paydate/Date of Withholding. You must report the paydate/date of withholding vd-en sending the payment. The You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: 3918054790 EMPLOYEE'S/OBLIGOR'S NAME: ROSS MICHAEL V. EMPLOYEE'S CASE IDENTIFIER: 3415000024 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. §1673 01; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. 10. Additional Info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11.Submitted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 Service Type m If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 OMB No.: 0970-0154 Form EN-028 Rev. 1 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ROSS, MICHAEL V. PACSES Case Number 902109218 Plaintiff Name DENISE M. ROSS Docket Attachment Amount 07-3277 CIVIL$ 866.67 Child(ren)'s Name(s): DOB ® If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. Addendum Form EN-028 Rev. 1 Service Type M Worker ID $IATT OMB No.: 0970-0154 (, 3 Lo> In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Defendant Name: MICHAEL V. ROSS Member ID Number: 3415000024 Please note: All correspondence must include the Member ED Number. ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSATION BENEFITS Financial Break Down of Multiple Cases on Attachment Plaintiff Name DENISE M. ROSS PACSES Docket Case Number Number 902109218 07-3277 CIVIL Attachment Amount/Freouenc $ 866.67 MONTH / / TOTAL ATTACHMENT AMOUNT: $ 866.67 Now, by Order of this Court, the Department of Labor and Industry, Bureau of Unemployment Compensation Benefits and Allowances (BUCBA), is hereby directed to attach the lesser of $199.45 per week, or 5 0 %, of the Unemployment Compensation benefits otherwise payable to the Defendant, MICHAEL V. ROSS Social Security Number 192-44-9894 , Member ID Number 3415000024 . BUCBA is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from BUCBA to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearages, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673 (b)(2) and 23 Pa. C.S.A. § 4348 (g). This Order shall be effective upon receipt of the notice of the Order by the BUCBA and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated FEBRUARY 4, 2 0 0 7 is exhausted, expired or deferred. BUCBA shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. BY THE COURT Date of Order: JUL 3 Q 2007 /0 A4 KEVIN SS, JUDGE DRO: R.J. SHADDAY Form EN-530 Service Type M Worker ID $ IATT d -t?? ?? ? c ? ??? ? ?..., DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 07-3277 CIVIL TERM MICHAEL V. ROSS, IN DIVORCE Defendant/Respondent PACSES Case Number : 902109218 ORDER OF COURT AND NOW, this 26th day of July, 2007, based upon the Court's determination that Petitioner's monthly net income/earning capacity is $ N/A and Respondent's monthly net income/earning capacity is $ N/A, it is hereby Ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit, $866.67 per month payable as follows: $866.67 per month for alimony pendente lite and $0.00 per month on arrears. First payment due within five (5) days upon receipt of this Order. The effective date of the order is June 1, 2007. Arrears set at $233.34 as of July 26, 2007. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.§ 3703. Further, if the Court finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and, at its discretion, make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Said money to be turned over by the PA SCDU to: Denise M. Ross. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the Respondent's PACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. cc360 The monthly support obligation includes cash medical support in the amount of $250.00 annually for unreimbursed medical expenses incurred for the spouse. Unreimbursed medical expenses of the obligee that exceeds $250.00 annually shall be allocated between the parties. The parry seeking allocation of unreimbursed medical expenses must provide documentation of expenses to the other parry no later than March 31St of the year following the calendar year in which the final medical bill to be allocated was received. The unreimbursed medical expenses are to be paid as follows: 76% by Respondent and 24% by Petitioner. (x) Respondent () Petitioner () Neither parry to provide medical insurance coverage. Within thirty (30) days after the entry of this Order, the (z) Respondent ( ) Petitioner shall submit written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at minimum, of 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage contract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms. This Order is based upon an agreement of the parties. The Respondent is given credit in the amount of $1500.00 for direct payments. The remaining retroactive arrearage of $233.34 is to be paid directly to the Petitioner within five (5) days of receipt of this Order. Petitioner is to report to the Domestic Relations Office that said payment has been received. This Order shall become final twenty (20) after the mailing of the notice of the entry of the Order to the parties unless either party files a written demand with the Prothonotary for a hearing de novo before the Court. Consented: Petitioner Respondent Petitioner's Attorney Respondent's Attorney BY THE COURT, K n A. Hess, J. Mailed copies on: August 1, 2007 to: Petitioner Respondent Carol J. Lindsay, Esq. Hannah Herman-Snyder, Esq. DRO: R.J. Shadday O DENISE M. ROSS, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION - DIVORCE NO. 07-3277 CIVIL TERM MICHAEL V. ROSS, ; Defendant IN DIVORCE MOTION FOR APPOINTMENT OF MASTER SAIDIS, FLOWER &t LINDSAY RMUM-UN 26 West High Street Carlisle, PA Petitioner, Michael V. Ross, moves the court to appoint a master with respect to the following claims: ( X) Divorce ( X ) Distribution of Property (Equitable Distribution) ( ) Annulment ( ) Support ( ) Alimony ( ) Counsel Fees ( X) Alimony Pendente Lite ( ) Costs and Expenses and in support of the motion states: (1) Discovery is not complete as to the claim(s) for which the appointment of a master is requested. (2) The Defendant, appeared in the action and is represented by counsel, (3) The statutory grounds for divorce are §3301 (c) and/or (d) (4) Delete the inapplicable paragraph(s). (a) The action is contested. (b) An agreement has been reached with respect to the following claims: NONE. (c) The action is contested with respect to the following claims: ALL. (5) The action does not complex issues of law or fact. (6) The hearing is expected to take: one day (7) Additional information, if any, relevant to the motion: Defendant needs the following information from Plaintiff to proceed: 1. Plaintiff' s 2006 Income Tax Return 2. Plaintiff' s most recent pay stub SAIDIS, FLOWER & LLNOSAY I (I 1 9 Date: Carol J. Lind c 26 West treet Carlisle, PA 17013 717-243-6222 e-a 4_.. r DENISE M. ROSS, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - DIVORCE NO. 07-3277 CIVIL TERM MICHAEL V. ROSS, Defendant IN DIVORCE ORDER APPOINTING MASTER SAMIS, FLOWER & LINDSAY ATFOViMAT-LAW 26 West High Street Carlisle, PA AND NOW, this day of OU44 2007, &464 Esquire, is appointed master with respect to the following claims: Divorce, alimony pendente lite and equitable distribution. S : I I H'V 91 SfIIV LODZ -1 1::!:'0-0T'lIJ In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Defendant Name: MICHAEL V. ROSS Member ID Number: 3415000024 Please note: All correspondence must include the Member ID Number. ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSATION BENEFITS Financial Break Down of Multiple Cases on Attachment Plaintiff Name DENISE M. ROSS PACSES Docket Case Number Number 902109218 07-3277 CIVIL TOTAL ATTACHMENT ANIOUNT: $ 866.67 Attachment Amount/Frequency $ 866.67 MONTH / / Now, by Order of this Court, the Department of Labor and Industry, Bureau of Unemployment Compensation Benefits and Allowances (BUCBA), is hereby directed to attach the lesser of $199.45 per week, or 50 %, of the Unemployment Compensation benefits otherwise payable to the Defendant, MICHAEL V. ROSS Social Security Number 192-44-9894 , Member ID Number 3415000024 . BUCBA is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from BUCBA to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearages, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673 (b)(2) and 23 Pa. C.S.A. § 4348 (g). This Order shall be effective upon receipt of the notice of the Order by the BUCBA and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated NOVEMBER 2 5, 2 0 0 7 is exhausted, expired', or deferred. BUCBA shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be O rected to the Domestic Relations Section of this Court. BY THE C'OLlRT Date of Order: FEB 12 2008 * A.-054 HESS, JUDGE DRO: R. J. SHADDAY Form EN-530 Service Type M Worker ID $ IATT C ;- - "'.? - 4 r-0 r TI ; rr:. DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA VS. NO. 07 - 3277 CIVIL MICHAEL V. ROSS, Defendant IN DIVORCE ORDER OF COURT AND NOW, this / day of 2008, both counsel having failed to return the certification document to the Master's office which was dated August 21, 2007, certifying the status of discovery, the appointment of the Master is vacated. QBE 0 VT, . 1!" dgar B. Bayley, P.J. E Cc: '/Hannah Herman-Snyder Attorney for Plaintiff ",/Carol J. Lindsay Attorney for Defendant rliNVStAq( N3d 91 .Z lid ' I M BOOZ AdViQ i fHLLQl?d 3HI ?0 ',)- C?31U In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Defendant Name: MICHAEL V. ROSS Member ID Number: 3415000024 Please note: Ali correspondence must include the Member ID Number. ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSATION BENEFITS Financial Break Down of Multiple Cases on Attachment Plaintiff Name DENISE M. ROSS PACSES Docket Case Number Number 902109218 07-3277 CIVIL TOTAL ATTACHMENT AMOUNT: $ 866.67 Attachment Amount/Freguencv $ 866.67 MONTH / / Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), is hereby directed to attach the lesser of $ 199.45 per week, or 50 %, of the Unemployment Compensation benefits otherwise payable to the Defendant, MICHAEL V. ROSS Social Security Number XXX-XX- 9894 , Member ID Number 3415000024 . OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearages, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673 (b)(2) and 23 Pa. C.S.A. § 4348 (g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated AUGUST 9, 2009 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. BY THE COURT Date of Order: AUG 2 5 2009 ;! r, - /* /,/ JUDGE Form EN-530 Rev.2 Service Type M Worker ID $IATT RLED-CIFIFICE OF THE ?`(-"NOTAPY 2009 AG 25 PM 2: 2 7 Cl}mbl :, ! till fi lf'i if, ;, f? PEA ? I ? ?Ve?t In the Court of Common Pleas of `? CUMBERLAND County, Pennsyltnia` :,o .? DOMESTIC RELATIONS SECTION rn . i ! 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 r c? Defendant Name: MICHAEL V. ROSS Member ID Number: 3415000024 C: 11-?N Please note: All correspondence must include the Member ID Number. ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSATION BENEFITS Financial Break Down of Multiple Cases on Attachment Plaintiff Name DENISE M. ROSS PACSES Docket Case Number Number 902109218 07-3277 CIVIL Attachment Amount/Freauenc $ 866 . 67 /MONTH 1 / $ $ / TOTAL ATTACHMENT AMOUNT: $ 866.67 Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment Compensation Benefits (0UCB), is hereby directed to attach the lesser of $ 199.45 per week, or 50 %, of the Unemployment Compensation benefits otherwise payable to the Defendant, MICHAEL V. ROSS Social Security Number XXX-XX- 9894 Member ID Number 3415000024 . OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearages, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673 (b)(2) and 23 Pa. C.S.A. § 4348 (g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits., under the Application for Benefits dated AUGUST 29, 2010 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. BY THE COURT Date of Order: S E P 14 2010 DRO: R.J. SHADDAY Service Type M EDWARD E. GUI DO , JUDGE Form EN-530 Rev.2 Worker ID $IATT -` fr ?. 1 -: s..'_G Eli` iji-! 7! c B ,E 12 P11 E` D DENISE M. ROSS, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. MICHAEL V. ROSS, Defendant CIVIL ACTION -LAW NO. 07-3277 CIVIL TERM IN DIVORCE PETITION FOR SPECIAL RELIEF PURSUANT TO PA. R.C.P. 1920.43: HARLEY-DAVIDSON MOTOR COMPANY RETIREMENT SAVINGS PLAN AND NOW comes Petitioner, Denise M. Ross, the above named Plaintiff, by and through her attorney, Hannah Herman-Snyder, Esquire, and the law firm of Griffie and Associates and avers as follows: 1. Your Petitioner is the above named Plaintiff, hereinafter "Wife," an adult individual currently residing at 44 Oak Park Lane, Carlisle, Cumberland County, Pennsylvania. 2. Your Respondent is the above named Defendant, hereinafter "Husband," an adult currently residing at 198 Birch Lane, Carlisle, Cumberland County, Pennsylvania. 3. The parties have been separated since 2007, and although they agreed for a period of time to put the divorce proceedings on hold, Wife served Husband with discovery requests on or about October 20, 2010. 4. A response to Wife's discovery request was provided on or about December 20, 2010. 5. A primary asset in the parties' marital estate is Husband's retirement plan, with his employer, Harley-Davidson Company, where he has been employed for the entire length of the parties' marriage, with the parties having been married on August 26, 1989. 6. Based on information provided by Husband, from his Harley-Davidson Motor Company Retirement Savings Plan, with a statement from January 1, 2007 to October 31, 2008, he withdrew funds in the amount of $50,129.76 since the parties' separation, a copy of said statement is attached hereto and incorporated herein by reference as Exhibit "A." 7. While it is not clear exactly when Husband withdrew said funds, he provided a statement from on or about the parties' date of separation, with the statement being from March 2007 and March 31, 2007, and at that point the balance in the account was $53,530.14 such that the withdrawal had to have been after the date of separation, a copy of aid statement is attached hereto and incorporated herein by reference as Exhibit "B." 8. Wife can only assume, as she has not seen these proceeds being accounted for in any way, that they are being held in a bank account by Husband, with Husband also not providing information on all bank accounts he has, most specifically, he has provided information for only two (2) bank accounts in discovery when pursuant to his paycheck, which was also provided pursuant to discovery, monies from his paycheck are going into two (2) different accounts than those for which he provided information. 9. No prior Judge has been involved in these proceedings. 10. Marylou Matas, Esquire, attorney for Michael V. Ross, is being provided with notice of the filing of these proceedings via first class mail, postage prepaid at her address of 26 West High Street, Carlisle, Pennsylvania, 17013. WHEREFORE, Plaintiff requests this Honorable Court to Order that Husband turn over the funds that he withdrew from his Harley-Davidson Motor Company Retirement Savings Plan to his counsel, to be placed into an interest bearing account, held by both counsel, until such time as equitable distribution takes place, and if all funds are not turned over that Husband, within ten (10) days of the date of this Order, provide an accounting for said funds including interest earned; and award attorney's fees for Husband's behaviors in these matters. Respectfully Submitted, Hannah Herman-Snyder, Es uire Attorney for Plaintiff/Petitioner GRIFFIE & ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 (800) 347-5552 VERIFICATION I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsifications to authorities. DATE: Denise M. Ross, Plaintiff/P Toner 1 ?• Harley-Davidson Motor Company Retirement Savings Plan Retirement Savings Statement January 1, 2007 - October 31, 2010 ENV#OP000134 OP 35444 S MICHAEL V ROSS 198 BIRCH LN CARLISLE, PA 17015 T Customer Service Number: 1-800-835-5091 Internet Address: www.401k.com For information regarding your account, call between 8:30 and 8:00 PM in the time zone from which you are calling. Your Account Summary Beginning Balance $49,251.63 Your Contributions 3016.87 Employer Contributions 2,173.02 Exchange In 110;206.42 Exchange Out -110,206.42 Withdrawals -50,129.76 Loan Repayments 18,839.27 Fees -.60.00 Change In Market Value 78,722.37 Ending Balance $14,368.66 Additional Information ? Vested Balance $14,368.66 ? Dividend & Interest $4,581.02 ? Outstanding Loan Balance $0.00 Loans are an asset of your account but are not included in your asset allocation. Your Personal Rate of Return This Period -15.9% Year to Date 22.8% Your Personal Rate of Return is calculated with a time-weighted formula, widely used by financial analysts to calculate investment earnings. It reflects the results of your investment selections as well as any activity in the plan account(s) shown. There are other Personal Rate of Return formulas used that may yield different results. Remember that past performance is no guarantee of future results. Your Asset Allocation c? a y J 0 Stocks 100% Your account is currently allocated among the asset classes specified above. Percentages and totals may not be exact due to rounding. Please read this statement carefully. Any error must be reported to Fidelity Investments within 90 days. 0134 OP000134 0001 20101108 ONK Fidelity Investments, PO Box 5424, Cincinnati, OH 45250-5424 Page 1 of 6 . - `Harley=Davidson UotortCompany RetirementSavings `Statement Retirement' Savings-Plan March 1, 2007 - March 31, 2007 MICHAEL V ROSS 198 .`BIRCH LN CARLISLE, PA 17015 ENV#OP000068 OP 35444 A T Customer Service Number: 1-800-835-5091 Internet Address: www.401 k.com For information regarding your account, call between 8:30 and 8:00 PM in the time zone from which you are calling. ''Your..Account Summary Your Asset Allocation Beginning `Balance $51,661.98 Your Contributions 801.26 Stocks 100% Loan Repayments 394.60 , ,Change In''Market,Value 472.30 EndingVBalance _ 153,330.14 Additional, Information 4 -Vested Balance $53,330:14 *..DividencI4 Interest $2.90 .Outstanding Loan' Balance - $15;768149 .Loans are anasset of your, account but are not included in your. . asset allocation.' Your account is currently allocated among the asset classes Your Personal Rate of Return specified above. Percentages and totals may not be exact due This.Period 0.9% to rounding. 'Year -toDate 0.4% Your Personal Rate of Return is calculated with a time-weighted formula widely. used by financial analysts to calculate investment earnings. It reflects the results of your investment selections as well_asany activity:inthe. Plan account(s) shown. There.are other Personal Rate of Return formulas used that may,yield:different results.'` Remember' that past performance is7nq-guarantee of future results. Market'Value of Your Account Displayed in!this section is the value of your account for the statement period, in both shares/units and dollars Shares/Units Shares/Units -Price on Price on Market Value Market Value 5fack ICt'Vtiil?titS ,; - $51 y664 :98 $53330:14 _ Harley=Davidson 8.454 8.483 $109.17 $97.46 922.92 826.75 Spartam500. Index 11010.397 1,034.364 $49.94 $50.49 50,459.23 52,225.04 Clipper'Fund 3.101 3.101 $90.24 $89.76 279.83 278.35 AccaLnt: focal. X5.1::661..98 Iss_ Rn 1d Please read.this-statement carefully. Any error 0068 •OP000068 0001 20100729 ONK Fidelityinvestments, PO Box 5424, Cincinnati, OH 45250-5424 J ? R a within 90 days. Page 1 of 6 DENISE M. ROSS, V. : CIVIL ACTION -LAW MICHAEL V. ROSS, NO. 07-3277 CIVIL TERM Defendant IN DIVORCE CERTIFICATE OF SERVICE I, Hannah Herman-Snyder, Esquire, hereby certify that I did, the 1141- day of January, 2011, cause a copy of Plaintiff's Petition for Special Relief Pursuant to P.A. R. C. P. 1920.43: Harley-Davidson Motor Company Retirement Savings Plan to be served upon Defendant by serving his attorney of record, Marylou Matas, Esquire, by first-class mail, postage prepaid at the following address: DATE: - t hZ -11 Marylou Matas, Esquire 26 East High Street Carlisle, PA 17013 Hannah Herman-Snyder, Hquire Attorney for Plaintiff/Petitioner GRIFFIE & ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717)243-5551 (800) 347-5552 IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA DENISE M. ROSS, Plaintiff V. MICHAEL V. ROSS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-3277 CIVIL TERM IN RE: PETITION FOR SPECIAL RELIEF PURSUANT TO PA. R.C.P. 1920: HARLEY-DAVIDSON MOTOR COMPANY RETIREMENT SAVINGS PLAN ORDER OF COURT c? C rnw ?rrt En .<D r- X ?C:7 v? p --+ N Q C_ N 3 .:o O 'T{ __4 M i= -urn ?;° =° c:)-n o? V rn AND NOW, this 21s` day of January, 2011, upon consideration of the above-captioned motion, a hearing is scheduled for Thursday, February 24, 2011, at 10:30 a.m., in Courtroom No. 1, Cumberland County Courthouse, Carlisle, Pennsylvania. BY THE COURT, J. Psley 01;i, Jr., J. ?Hannah Herman-Snyder, Esq. 200 North Hanover Street Carlisle, PA 17013 Attorney for Plaintiff Marylou Matas, Esq. 26 West High Street Carlisle, PA 17013 Attorney for Defendant Hooted Copies a? f rc Fr) L F PR'T,?i'(? `'M Fr --9 AN s. DENISE M. ROSS, Plaintiff . ce` F• i 4„r •,. i f . x i i . ?y IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. MICHAEL V. ROSS, Defendant PACSES Case No. 902109218 NO. 07-3277 CIVIL TERM IN DIVORCE PETITION FOR MODIFICATION OF ALIMONY PENDENTE LITE AND NOW comes Denise M. Ross, by and through her attorney of record, Hannah Herman-Snyder, Esquire and the law firm of Griffie & Associates and avers as follows: I. Petitioner is the above named Plaintiff, Densie M. Ross, an adult individual currently residing at 44 Oak Park Lane, Carlisle, PA, 17013. 2. Respondent is the above Defendant, Michael V. Ross, an adult individual currently residing at 198 Birch Lane, Carlisle, PA, 17015. 3. An Order for Alimony Pendente Lite was entered on July 26, 2007 on behalf of Petitioner. 4. Due to a change in circumstances, including a change in income for both parties, as well as Petitioner now being responsible for the mortgage, taxes, and insurance on the marital debt, Petitioner is requesting a modification of the current Alimony Pendente Lite Order. 5. Counsel for Respondent, Marylou Matas, Esquire is being provided with notice of the filing of this Petition by first class mail, postage prepaid. 6. Prior involvement by the Court consists only of Judge Hess signing the Alimony Pendente Lite Order of July 26, 2007, as well as Judge Oler being involved in a current divorce related matter. WHEREFORE, Petitioner requests this Honorable Court schedule a conference with the Cumberland County Domestic Relations Office to modify the current Alimony Pendente Lite Order. Respectfully Submitted, Hannah Herman-Snyder, Esquire Attorney for Plaintiff/Petitioner Supreme Court ID #91537 GRIFFIE AND ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 VERIFICATION I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsifications to authorities. DATE: Q DENISE M. R SS, Plaint' /Petitioner XL 44 DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. : PACSES Case No. 902109218 MICHAEL V. ROSS, NO. 07-3277 CIVIL TERM Defendant IN DIVORCE CERTIFICATE OF SERVICE I, Hannah Herman-Snyder, Esquire, hereby certify that I did, the r day of February, 2011, cause a copy of the Petition for Modification of Alimony Pendente Lite of Plaintiff, Denise M. Ross, to be served upon the Defendant, Michael V. Ross, by his attorney of record via first class mail, postage prepaid at the following address: Marylou Matas, Esquire 26 West High Street Carlisle, PA 17013 DATE: -) - q - i Hannah Herman-Snyder, Esoire Attorney for Plaintiff/Petitioner Supreme Court ID #91537 GRIFFIE & ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717)243-5551 (800) 347-5552 DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA.., VS. CIVIL ACTION - DIVORCE S 'Co -"' - -n =;;u rat CV i r -0m NO. 07-3277 CIVIL TERM r c MICHAEL V. ROSS, IN DIVORCE ` - `° Defendant/Respondent PACSES CASE: 902109218 -, r; . -.yam ') l^'' ORDER OF COURT ? . =' AND NOW to wit, this 9th day of February, 2011, it is hereby Ordered that the Respondent is to make a direct payment in the amount of $375.22 to the Petitioner for his portion (76%) of the unreimbursed medical expenses that exceed $250.00 from the summary dated December 17, 2010. The payment of $375.22 is to be paid on or before February 28, 2011. BY THE C Edward E. Guido, J. DRO: R.J. Shadday xc: Petitioner Respondent Form OE-001 Service Type: M Worker: 21005 DENISE M. ROSS, IN THE COURT OF COMMON PLEJ? (W Plaintiff CUMBERLAND COUNTY, PENNS*AR A -," 3 ca w7rI VS. CIVIL ACTION - DIVORCE r-? ?-rc NO. 07-3277 CIVIL TERM v© ? C-. MICHAEL V. ROSS, IN DIVORCE c -°-s'-" Defendant PACSES CASE: 902109218 4 C p -t ORDER OF COURT AND NOW, this 11th day of February 2011, a petition has been filed against you, Michael V. Ross, to modify an existing Alimony Pendente Lite Order. You are ordered to appear in person at the Domestic Relations Section, 13 North Hanover Street, Carlisle, Pennsylvania, on March 16, 2011, 2011 at 9:00 A.M. for a conference and to remain until dismissed by the Court. If you fail to appear as provided in this Order, an Order of Court may be entered against you. You are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by the Rule 1910.11. (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. Copies mailed to: Petitioner Respondent Hannah Herman Snyder, Esq. Marylou Matas, Esq. Date of Order: February 11, 2011 BY THE COURT, Edward E W o, Judge YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 cc361 DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSY ANIA ;gym V. :CIVIL ACTION -LAW -"n M;?-;a = mp 4?1 as r- ? F _.? r.-? MICHAEL V. ROSS, NO. 07-3277 CIVIL TERM -' - ° Defendant IN DIVORCE ° - MOTION FOR APPOINTMENT OF MASTER DENISE M. ROSS, Plaintiff, moves the court to appoint a master with respect to the following claims: (X) Divorce (X) Distribution of Property O Annulment ( ) Support (X) Alimony (X) Counsel Fees (X) Alimony Pendente Lite ( ) Costs and Expenses and in support of the motion states: (1) Discovery is not complete as to the claims for which the appointment of a master is requested. (2) The Defendant has appeared in the action, and is represented by counsel, Marylou Matas, Esquire. (3) The Statutory ground(s) for divorce are §3301(c) and/or (d). (4) Delete the inapplicable paragraph(s): a. The action is contested. b. An agreement has been reached with respect to the following claims: NONE. C. The action is contested with respect to the following claims: ALL (5) The action does not involve complex issues of law or fact. (6) The hearing is expected to take one day. (7) Additional information, if any, relevant to the motion: NONE Date: ?? 1 - 11 Hannah Herman-Snyder, Esqui Attorney for Plaintiff Supreme Court ID #91537 GRIFFIE & ASSOCIATES 200 North Hanover Street Carlisle, PA 17013 (717)243-5551 (800) 347-5552 DENISE M. ROSS, v. IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA MICHAEL V. ROSS, Defendant V CIVIL ACTION -LAW NO. 07-3277 CIVIL TERM IN DIVORCE ORDER APPOINTING MASTER AND NOW, Ak , 20// , upon consideration of the attached Motion for Appointment of Master, C' Esquire is appointed master with respect to the following claims: Divorce, Alimony, Alimony endente Lite, Equitable Distribution, and Counsel Fees. By the Court: J. Cc: &/Hannah Herman-Snyder, Esquire Attorney for Plaintiff Marylou Matas, Esquire Attorney for Defendant COp,e,5 m,, Jeer t, r 7:rC... ?' t?-r1 , F . ?: , Asa RL DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. . CIVIL ACTION - LAW MICHAEL V. ROSS, Defendant 07-3277 CIVIL TERM IN RE: PETITION FOR SPECIAL RELIEF PURSUANT TO PA.R.C.P. 1920: HARLEY-DAVIDSON MOTOR COMPANY RETIREMENT SAVINGS PLAN ORDER OF COURT AND NOW, this 24th day of February, 2011, upon consideration of Plaintiff's Petition for Special Relief Pursuant to PA.R.C.P. 1920: Harley-Davidson Motor Company Retirement Savings Plan, and pursuant to an agreement reached in open court between the parties which resolves most of the issues raised in the Petition, a hearing will be held on the issue of attorney's fees to be awarded, if any, in connection with the Petition, and it is further ordered and directed as follows pursuant to the agreement: 1. The parties have agreed that neither party shall do anything to further dissipate any marital assets including but not limited to any further withdrawal from or loans against the remaining balance of husband's Harley-Davidson Motor Company Retirement Saving Plan. 2. Husband shall not take any action to sell the real estate located at 507 Alexander Street, Hunker, Pennsylvania, 15639, until all equitable distribution matters are resolved; furthermore, husband shall prepare mortgage and note paperwork such that wife shall hold a mortgage and a note on the real estate located at 507 Alexander Street, Hunker, Pennsylvania, 15639, in the amount of $50,000. Husband shall be responsible for all costs associated with the preparing of and recording of the mortgage and note. 2. Husband shall prepare said mortgage and note paperwork and provide the same to wife within 14 days of today's order. 3. Wife shall not assign or otherwise sell the mortgage that she may receive in her favor for husband's property. By the Court, J. re s ley 0 , Jr., J. Hannah Herman-Snyder, Esquire 200 North Hanover Street Carlisle, PA 17013 For the Plaintiff t/ Marylou Matas, Esquire 26 West High Street Carlisle, PA 17013 For the Defendant pcb c- -_' ry gyp; es xia, ecl 311111 i -6 ?6 DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF. Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW MICHAEL V. ROSS, Defendant 07-3277 CIVIL TERM IN RE: PETITION FOR SPECIAL RELIEF PURSUANT TO PA.R.C.P. 1920: HARLEY-DAVIDSON MOTOR COMPANY RETIREMENT SAVINGS PLAN ORDER OF COURT AND NOW, this 24th day of February, 2011, upon consideration of Plaintiff's Petition for Special Relief Pursuant to PA.R.C.P. 1920: Harley-Davidson Motor Company Retirement Savings Plan, as the Petition relates to an award of attorney's fees to the Plaintiff and following a hearing, the Petition in that respect is granted, and Defendant is directed to pay to Plaintiff attorney's fees in the amount of $595 within 30 days of today's date. Hannah Herman-Snyder, Esquir 200 North Hanover Street Carlisle, PA 17013 For the Plaintiff Marylou Matas, Esquire 26 West High Street Carlisle, PA 17013 For the Defendant pcb L. ? Y ?r7 f. o =- rn 6 cl -a By the Court, DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 07-3277 CIVIL TERM MICHAEL V. ROSS, IN DIVORCE Defendant/Respondent PACSES CASE: 902109218 ". ORDER OF COURT °+-- Cn r AND NOW, this 16th day of March, 2011, based upon the Court's determinate at_ie 5-' Petitioner's monthly net income/earning capacity is $ 1,485.12 and the Respondent's rpnthlX,Ret income/earning capacity is $ 1,721.89, it is hereby ordered that the Respondent pay to th47 Pennsylvania State Collection and Disbursement Unit Four Hundred Forty-eight and 00/1b0 D'ollax ($ 448.00) per month payable weekly as follows: $ 448.00 per month for Alimony Pendente Lite and $ 0.00 per month on arrears. First payment due in accordance with the Respondent's pay schedule. The effective date of the order is February 14, 2011. Arrears set at $ 376.47 as of March 16, 2011. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.§ 3703. Further, if the Court finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and, at its discretion, make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Said money to be turned over by the PA SCDU to: Denise M. Ross. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the Respondent's name with their PACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. cc360 The monthly support obligation includes cash medical support in the amount of $250 annually for unreimbursed medical expenses incurred for the spouse. Unreimbursed medical expenses of the spouse that exceed $250 annually shall be allocated between the parties. The party seeking allocation of unreimbursed medical expenses must provide documentation of expenses to the other party no later than March 31 st of the year following the calendar year in which the final medical bill to be allocated was received. The unreimbursed medical expenses are to be paid as follows: 54 % by Respondent and 46 % by Petitioner. [X] Respondent [] Petitioner [] Neither party to provide medical insurance coverage. Within thirty (30) days after the entry of this order, the [] Petitioner [X] Respondent shall submit written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at a minimum, of. 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage contract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms. Other conditions: This Order consisders that the Petitioner is making payments on the first mortgage and home equity line of credit on the marital home. This Order is based upon the fact that the Respondent is currently on a short term disability leave since February 14, 2011. The Respondent is to update the Domestic Relations Section of his ability to return to work after his March 25, 2011 doctor's evaluation and when he is released to return to work. This Order shall become final twenty (20) after the mailing of the notice of the entry of the Order to the parties unless either parry files a written demand with the Office of the Prothonotary for a hearing de novo before the Court. Mailed copies on: March 17, 2011 Petitioner Respondent Hannah Herman Snyder, Esq. Marylou Matas, Esq. BY THE COU Edward E. Guido, J. DRO: R.J. Shadday ORDERMOTICE TO WITHHOLD INCOME FOR SUPPORT 07-3277 CIVIL State: Commonwealth of Pennsylvania Co./City/Dist. of: CUMBERLAND Date of Order/Notice: 03/16/11 Case Number (See A en um for case summary) EmployerWthholder's Federal EIN Number STANDARD INSURANCE COMPANY C/O AMY HEATH 900 SW FIFTH AVE PORTLAND OR 97204-1235 CLAIM # OOCR8376-002 Original Order/Notice Q Amended Omer/Notice 0 Terminate Order/Notice 0 One-Time Lump Sum/Notice RE: ROSS, MICHAEL V. Employee/Obligor's Name (Last, First, MI) 192-44-9894 Employee/Obligor's Social Security Number 3415000024 mp oy igo s Case Identifier (See Addendum for plaintiff names associated with cases on attachmeno Custodial Parent's Name (Last, First, MI) See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State- $ 0.00 per month in current child support $ 0.00 per month in past-due child support $ 0.00 per month in current medical support $ 0.00 per month in past-due medical support $ 448.00 per month in current spousal support $ 0.00 per month in past-due spousal support $ 0.00 per month for genetic test costs $ 0.00 per month in other (specify) $ one-time lump sum payment for a total of $ Arrears 12 weeks or greater? 448.00 per month to be forwarded to payee below. a Ads _-?D rw...-. . .. r You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 103.39 per weekly pay period. $ 224.00 per semimonthly pay period (twice a month) $ 206 - 77 per biweekly pay period (every two weeks) $ 448.00 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER /D (shown above as the Employeel0bl' ase entiFer) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND C BY M BY THE COURT: :?;°?udge DRO: R. J. Shadday OMB No.: 0970-0154 Form EN-028 Service Type M Worker ID $OINC ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS if checked you are required to provide a copy of this form to your employee. if your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which amount was withheld from the employee's wages. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. 2427100146 THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER: O THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: Q EMPLOYEE'S/OBLIGOR'S NAME: ROSS, MICHAEL V. EMPLOYEE'S CASE IDENTIFIER: 3415000024 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: LAST KNOWN PHONE NUMBER: NEW EMPLOYER'S NAME/ADDRESS: FINAL PAYMENT AMOUNT: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.* Withholding Limits: You may not withhold more than the lesser of. 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673 (b)); or 2) the amounts allowed by the State or Tribe of the employee's/obligor's principal place of employment. Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, that 50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section. Arrears greater than 12 weeks: If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers who receive a State order, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. 10. Additional info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Send Termination Notice and other correspondence to: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 Service Type M If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsul2l2ort.state.pa.us OMB No.: 0970-0154 Page 2 of 2 Form EN-028 Worker ID $OINC ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ROSS, MICHAEL V. PACSES Case Number 902109218 Plaintiff Name DENISE M. ROSS Docket Attachment Amount 07-3277 CIVIL $ 448.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACKS Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum Form EN-028 Service Type M OMB No.: 0970-0154 Worker ID $OINC ORDERMOTICE TO WITHHOLD INCOME FOR SUPPORT State: Commonwealth of Pennsylvania Co./City/Dist. of: CUMBERLAND Date of Order/Notice: 03/16/11 Case Number (See A etTc?for case summary) Employer/Withholder's Federal EIN Number HARLEY-DAVIDSON MOTOR COMPANY 3700 W JUNEAU AVE MILWAUKEE WI 53208-2818 RE: ROSS. MICHAEL V. 07-3277 CIVIL Q Original Order/Notice Q Amended Order/Notice Q Terminate Order/Notice O One-Time Lump Sum/Notice Employee/Obligor's Name (Last, First, MI) 192-44-9894 mp oy igo s Social ecunty um er 3415000024 Employee/Obligor's Case en er (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, MI) See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 0.00 per month in current child support $ 0.00 per month in past-due child support $ 0.00 per month in current medical support $ 0.00 per month in past-due medical support $ 448.00 per month in current spousal support $ 0.00 per month in past-due spousal support $ 0.00 per month for genetic test costs $ 0.00 per month in other (specify) $ one-time lump sum payment for a total of $ 448.00 per month to be forwarded to payee below. Q es' no ra You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 1 n,3_ -39 per weekly pay period. $ 224.00 per semimonthly pay period (twice $ 2069- 77 per biweekly pay period (every two weeks) $ per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE TH NT'S NAME AND THE PACSES MEMBER /D (shown above as the Employeel0bligor's a Identifi R SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH B AIL BY THE COURT: Edward E. Guido, Judge Arrears 12 weeks or greater? DRO: R. J . Shadday OMB No.: 0970-0154 Form EN-028 Service Type M Worker ID $IATT ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS M If checked you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which amount was withheld from the employee's wages. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. 3918054790 THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER: Q THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: O EMPLOYEE'S/OBLIGOR'S NAME: ROSS, MICHAEL V. EMPLOYEE'S CASE IDENTIFIER: 3415000024 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: LAST KNOWN PHONE NUMBER: NEW EMPLOYER'S NAME/ADDRESS: FINAL PAYMENT AMOUNT: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673 (b)); or 2) the amounts allowed by the State or Tribe of the employee's/obligor's principal place of employment. Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, that 50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section. Arrears greater than 12 weeks: If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers who receive a State order, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. 10. Additional info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Send Termination Notice and other correspondence to: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 Service Type M If you or your employee/obligor have any questions contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us OMB No.: 0970-0154 Page 2 of 2 Form EN-028 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ROSS, MICHAEL V. PACSES Case Number 902109218 Plaintiff Name DENISE M. ROSS Docket Attachment Amount 07-3277 CIVIL $ 448.00 Child(ren)'s Name(s): DOB PACKS Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACKS Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum Form EN-028 Service Type M OMB No.: 0970-0154 Worker ID $IATT In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Phone: (717) 240-6225 Fax: (717) 240-6248 Defendant Name: MICHAEL V. ROSS Member ID Number: 3415000024 Please note: All correspondence must include the Member ID Number. MODIFIED ORDER_ OF ATTACHMENT OF UNEMPLOYMENT BENEBTS% Financial Break Down of Multiple Cases on Attachment -- r PACKS Docket Attachment Amountl?Fieq Plaintiff Name Case Number Number . r ?y DENISE M. ROSS 902109218 07-3277 CIVIL 448.0(ri-MON I /;_. N / } TOTAL ATTACHMENT AMOUNT: $ 448.00 Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), is hereby directed to attach the lesser of $103.10 per week, or 50.0%, of the Unemployment Compensation benefits otherwise payable to the Defendant, MICHAEL V. ROSS Social Security Number XXX-XX-9894, Member ID Number 3415000024. OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearage, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673(b)(2) and 23 Pa. C.S. § 4348(g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated AUGUST 29, 2010 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. Date of Order: MAR 17 2011 DRO: R.J. Shadday Service Type M BY THE COURT EDWARD E. GUIDO, JUDGE Form EN-034 Worker ID $IATT DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 07-3277 CIVIL TERM C-) C_- ` MICHAEL V. ROSS, IN DIVORCE ? = --? Defendant/Respondent PACSES Case No: 902109218 z rn r r X x r- C _')° `'c ORDER OF COURT = c? be w c, C-0 AND NOW to wit, this 14th day of September 2011, it is hereby Ordered that the Respondent will pay an additional sum of $52.00 per month on the accumulated arrears. This Order shall become final twenty (20) days after the mailing of the notices of the entry of the Order to the parties unless either party files a written demand with the Office of the Prothonotary for a hearing de novo before the Court. BY THE COURT: Edward E. o, 4--i J. DRO: R.J. Shadday xc: Petitioner Respondent Marylou Matas, Esq. Hannah Herman-Snyder, Esq. Form OE-001 Service Type: M Worker: 21005 In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Phone: (717) 240-6225 Fax: (717) 240-6248 Defendant Name: MICHAEL V. ROSS Member ID Number: 3415000024 Please note: All correspondence must include the Member ID Number. MODIFIED ORDER OF ATTACHMENT OF UNEMPLOYMENT BENEFITS c Financial Break Down of Multiple Cases on Attachment -OZ Plaintiff Name DENISE M. ROSS PACSES Docket Case Number Number 902109218 07-3277 CIVIL TOTAL ATTACHMENT AMOUNT: 500.00 Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), is hereby directed to attach the lesser of $115.07 per week, or 55.0%, of the Unemployment Compensation benefits otherwise payable to the Defendant, MICHAEL V. ROSS Social Security Number XXX-XX-9894, Member ID Number 3415000024. OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearage, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673(b)(2) and 23 Pa. C.S. § 4348(g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated AUGUST 29, 2010 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. BY THE COU I Date of Order: SEP 15 2011'--?a Edward E. Guido JUDGE rrI aM rn F71 Attachment A=0WFr0Cpency-0 50 M?fH LD G ' 4 C / -I a' C-/ W CD $ Form EN-034 Service Type M Worker ID $IATT ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT D-7 - 3-a-7-7 C) v l L_ State: Commonwealth of Pennsylvania Co./City/Dist. of .CUMBERLAND Date of Order/Notice: 09714/11 Case Number (See A en um for case summary) Employer/Withholder's Federal EIN Number STANDARD INSURANCE COMPANY C/O AMY HEATH 900 SW FIFTH AVE PORTLAND OR 97204-1235 0 Original Order/Notice (. Amended Order/Notice 0 Terminate Order/Notice 0 One-Time Lump Sum/Notice RE: ROSS, MICHAEL V. Employee/Obligor's Name (Last, First, MI) 192-44-9894 mp oyee Igor s Social Sec-un1T9u-m_5_er 3415000024 Employee /Obligor's ase enti ier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, MI) See Addendum for dependent names and birth dates associated with cases on attachment ORDER INFORMATION: This is an Order/Notice to Withhold from CUMBERLAND Count C . Income for Support based upon an order for support y, ommonwealth of Pennsylvania from the above-named employee's/obligor's income ntil f th . By law, you are required to d94uct these-amounts ' " u ur er notice even if the Order/No R A iss6ied by your ti im is m State . $ 0.00 per month in current child support ti Ce) rTi m M $ 0.00 per month in past-due child su pport $ x -a ? Arrears 12 weeks or greagl??- (i)..yes-Ta? no 0.00 per month in current medical support -< cn , $ 0.00 per month in past-due medical support r --?-,- $ 448.00 per month in current spousal support , D? °-! ? $ 52.00 per month in past-due spousal support =CD CZ Fri $ 0.00 per month for genetic test costs n $ 0.00 per month in other (specify) - t $-_ _ one-time lump sum payment for a total of $ 500.00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 115.39 per weekly pay period. $ 250.00 per semimonthly pa P y period $ 230.11 Per biweekly pay period (every (twice a month) two weeks) $ 500.00 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. IN ADDITION, PAYMENTS MUST INCLUDE THE D? (shown above as the Employee/Obligor's Case /di PROCESSED. DO NOT SEND CASH BY MAIL. , BY THE COURT: Box 69112, Harrisburg, Pa 17106-9112 FEND E AND THE PACSES MEMBER /D 5OWT7 OR N *L SECURITY NUMBER IN ORDER TO BE OMB No.: 0970-0154 Form EN-028 Service Type M Worker ID $OINC ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS If checked you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.' Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which amount was withheld from the employee's wages. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.' Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. 2427100146 THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER: O THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: O EMPLOYEE'S/OBLIGOR'S NAME: ROSS MICHAEL V. EMPLOYEE'S CASE IDENTIFIER: 3415000024 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: LAST KNOWN PHONE NUMBER: FINAL PAYMENT AMOUNT: - NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.' Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673 (b)); or 2) the amounts allowed by the State or Tribe of the employee's/obligor's principal place of employment. Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, that 50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section. Arrears greater than 12 weeks: If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers who receive a State order, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. 10. Additional info: 'NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Send Termination Notice and other correspondence to: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www childsupport state. pa.us OMB No.'. 0970-0154 Form EN-028 ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ROSS, MICHAEL V. PACSES Case Number 902109218 Plaintiff Name DENISE M. ROSS Docket Attachment Amount 07-3277 CIVIL $ 500.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Namg Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Casa Number Plaintiff Name Docke Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACKS Cace Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum Form EN-028 Service Type M OMB No.: 0970-0154 Worker ID $OINC ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT 0- 3;?17 L' 1 U 1 L. State: Commonwealth of Pennsylvania O Original Order/Notice Co./City/Dist. of: CUMBERLAND Q Amended Order/Notice Date of Order/Notice: 09/14/11 Case Number (See A en um for case summary) O Terminate Order/Notice 0 One-Time Lump Sum/Notice tmployer/Withholder's Federal EIN Number HARLEY-DAVIDSON MOTOR COMPANY 3700 W JUNEAU AVE MILWAUKEE WI 53208-2818 RE: ROSS, MICHAEL V Employee/Obligor's Name (Last, First, MI) 192-44-9894 Employee/Obligor's Social Security N`um`6e-r 3415000024 mp oyee igor s ase enti ier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, MI) See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 0.00 per month in current child support $ $_ 0.00 per month in past-due child support Arrears 12 weeks or 0.00 per month in current medical sup ort greater? 2 YE?g ??o $ p 0.00 per month in past-due medical support c .i a $ 448.00 per month in current spousal support =z n -mo - $_ 52.00 per month in past-due spousal support ter- o $ 0.00 per month for genetic test costs -<? u? ZD ` ' $ 0.00 per month in other (specify) c $ _ one-time lump sum payment C; ? for a total of $ 500.00 per month to be forwarded to payee below cz? w ?D . You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 115.3q per weekly pay period. $ 250.00 per semimonthly pa P y period $ 230.E per biweekly pa (twice a month) y period (every two weeks) $ 500.00 per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT' (shown above as the Employee/Obligor's Case /dentifieryC SOC/A CUR/TY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. l? BY THE COURT: Edw&ird C Guido OMB No.: 0970-0154 Form EN-028 Service Type M Worker ID $IATT ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS E] If checked you are required to provide a copy of this form to your employee, if your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment. to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which amount was withheld from the employee's wages. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. 3918054790 THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER: O THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: O EMPLOYEE'S/OBLIGOR'S NAME: ROSS MICHAEL V. EMPLOYEE'S CASE IDENTIFIER: 3415000024 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: LAST KNOWN PHONE NUMBER: FINAL PAYMENT AMOUNT: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673 (b)); or 2) the amounts allowed by the State or Tribe of the employee's/obligor's principal place of employment. Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, that 50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section. Arrears greater than 12 weeks: If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers who receive a State order, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. 10. Additional info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Send Termination Notice and other correspondence to: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.statg.pa.us Form EN-028 TOMB No.: 0970-0154 ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ROSS, MICHAEL V. PACSES Case Number 902109218 Plaintiff Name DENISE M. ROSS Docke Attachment Amount 07-3277 CIVIL $ 500.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PAQSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PAQSES as Number Plaintiff Name Docket Attachment Amo int $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Names Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum Form EN-028 Service Type M OMB No.: 0970-0154 Worker ID $IATT DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE `== NO. 07-3277 CIVIL TERM MICHAEL V. ROSS, IN DIVORCE Defendant/Respondent PACSES Case No: 902109218 .. ?.. ORDER OF COURT AND NOW to wit, this 26th day of October 2011, it is hereby Ordered that the Respondent will pay his proportionate share (54%) of the Petitioner's unreimbursed medical expenses of $601.75, minus the first $250.00. The sum of $189.50 will be added to the current arrears balance. This Order shall become final twenty (20) days after the mailing of the notices of the entry of the Order to the parties unless either party files a written demand with the Office of the Prothonotary for a hearing de novo before the Court. BY THE CO r Edward E. Guido, J. DRO: R.J. Shadday xc: Petitioner Respondent Marylou Matas, Esq. Hannah Herman-Snyder, Esq. Form OE-001 Service Type: M Worker: 21005 INCOME WITHHOLDING FOR SUPPORT 90? U9tJg, ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) O AMENDED IWO 07- _3,277 C/ ?! / O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT O TERMINATION OF IWO nftfe. ncr.c- ? Child Support Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One)L NOTE: This IW mintb? r Iqr its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions ht i iJtryov 14- !j-ograms/cse/newhire/employer/publication/publication htm forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. ..- _ _..__., memiliance ioenimer (inciuae w/payment): 3415000024 City/County/Dist.rTribe CUMBERLAND Order Identifier: (See Addendum for orderldocket /nforma/ton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case SUMMAM D-A AUTO SALES, INC. DBA PITT INDEP AUTO AUC PO BOX 431 NEW STANTON PA 15672-0431 Employer/Income Withholder's FEIN 251192344 Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) RE: ROSS, MICHAEL V. Employee/Obligor's Name (Last, First, Middle) 192-44-9894 Employee/Obligor's Social Security Number (See Addendum for plaintiff names associated with cases on attachment) Custodial Party/Obligee's Name (Last, First Middle) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions hUD;1/www.ac;f_hh s gov Dr grams/csernewhire/ employer/publication/publication htm - forma. If you receive this document from someone other than a State or Tribal CSE agency or a Court , a copy of the underlying order must be attached. 2511923440 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the employee/ obligor's income until further notice. $ 0.00 per month in current child support $ 0.00 per month in past-due child support - Arrears 12 weeks or greater? Q yes O no $ 0.00 permonth in current cash medical support $ 0.00 per month in past-due cash medical support $ 448.00 per month in current spousal support - - $ 0.00 per month in past-due spousal support mr??` `?t = r?' -c; $ 0.00 per month in other (must specify) U) for a Total Amount to Withhold of $ 448,00 per month. %C -a C-5 - AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with rdW lnfi ration. If your pay cycle does not match the ordered payment cycle, withhold one of the following amot;tc? $ 103.3 per weekly pay period. $ 224.00 per semimonthly pay perioa wlC8?9 month) $ 206.77Per biweekly pay period (every two weeks) $ 448.00 per month) y pay period'- $ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs ten (10) working days after the date of this Order/Notice. Send payment within y n 7 working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to 55% of disposable income for all orders. If the employee/obligor's principal place of employment is not CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe), obtain withholding limitations, time requirements, and any allowable employer fees at http://www acf hhs govv/,{2rograms/cse/ngwhire/employer/contacts/ contact map htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.: 0970-0154 Form EN-028 01112 Service Type M Worker ID $IATT ? Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. , Signature of Judge/Issuing Official (if required by State or Tribal law): Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. ? If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufFcient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877.676.9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the EmployeWObligor's Case /dentlrier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. State-specific contact and withholding information can be found on the Federal Employer Services website located at: http 1/? . ^ acf hhs go {?rogra setng)ybire/=Woyeric2n_tacts/contact man htm Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42 §6,66(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/ obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SOU or to a Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency, you must follow the "Remit payment to" instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all iWOs due to Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should havewithheld and any penalties set by State or Tribal law/procedure. Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an emptoyee/obligor because of this IWO. OMB Expiration Date - 05131/2014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. Form EN-028 01/12 Service Tvne M Page 2 of 3 Worker ID $IATT Employer's Name: D-A AUTO SALES, INC. Employer FEIN: 251192344 Employee/Obligor's Name: ROSS MICHAEL V. 3415000024 CSE Agency Case identifier: (See Addendum for case summarvl Order Identifier: (See Addendum for order/docket information) Withholding Limits: You may not withhold more than the lesser of. 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor's principal place of employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitted by the State or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the Employer should calculate the CCPA limit using the lower percentage. Additional Information: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you a no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by returning this form to the address listed in the Contact Information below: 2511923440 Q This person has never worked for this employer nor received periodic income. O This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known address: Last known phone number: Final Payment Date To SDU/Tribal Payee: New Employer's Name: New Employer's Address: Final Payment Amount: CONTACT INFORMATION: To Em foyer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT (Issuer name) by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at: www.childsupportstate a us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST P.O. BOX 320 -ARLISLE PA 17013 (Issuer address). To Employeg(Qbligor• If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT (Issuer name) by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at www childsuRQOrt state us. IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. Service Type M OMB No.: 0970-0154 Page 3 of 3 Form EN-028 01/12 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ROSS, MICHAEL V. PACSES Case Number 902109218 Plaintiff Name DENISE M. ROSS Docket Attachment Amount 07-3277 CIVIL $ 448.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name t Docket Attachment Arnpun $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Service Tvoe M PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Doc AUaM t Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum OMB No.: 0970-0154 Form EN-028 01/12 Worker ID $IATT 1 Date: 06/01/12 ? Child Support Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions http•//www acf hhs aov/programs/oetnewhire/eMigygripublicatign/publication htm forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. Staterrribe/Territory Commonwealth of Pennsylvania Remittance Identifier (include w/payment): 3415000024 City/County/Dist.rrdbe CUMBERLAND Order Identifier: (See Addendum for orderldocket lnforma/ton) Private Individual/Entity CSE Aqencv Case Identifier: (Son Addendum fnr -- ---k BUREAU OF COMMONWEALTH* Sent Electronically DO NOT MAIL . _._..- __------ _... INCOME WITHHOLDING FOR SUPPORT Cl 0 ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) O AMENDED IWO ci v I I? 0 ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT l? O TERMINATION OF IWO Employer/Income Withholder's FEIN 232172299 Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) RE: ROSS, MICHAEL V Employee/Obligor's Name (Last, First, Middle) 192-44-9894 Employee/Obligor's Social Security Number (See Addendum for plaintiff names associated with cases on attachment) Custodial Party/Obligee's Name (Last, First Middle) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions httD://www acf hhs qvlp grams/cse/newhire/ emDloyerlDublication/publication htm - form . If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. 2321722990 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe), You are required by law to deduct these amounts from th"mpioyee/ r-D obligor's income until further notice. $ 0.00 per month in current child support $ 0.00 per month in past-due child support - Arrears 12 weeks or greater? O y° O $ 0.00 per month in current cash medical support - $ 0.00 per month in past-due cash medical support $ 0.00 per month in current spousal support -o $ 0.00 per month in past-due spousal support "c $ 0.00 per month in other (must specify) for a Total Amount to Withhold of $ 0.00 per month. _-_AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information. If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: $ 0.00 per weekly pay period. $ 0.00 per semimonthly pay period (twice a month) $ 0.00 per biweekly pay period (every two weeks) $ 0.00 per monthly pay period. $ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is within the Commonwealth of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs n 10 working days after the date of this Order/Notice. Send payment within seven 7 working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to 55% of disposable income for all orders. If the employee/obligor's principal place of employment is not within the Commonwealth of Pennsylvania (State/Tribe), the employer can obtain withholding limitations, time requirements, and any allowable employer fees at httl2://www acf hhs aov/1roarams/cse/newhire/employer/contacts/contact man htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.: 0970-0154 Form EN-428 06/12 Service Type M Worker ID $IATT ? Return to Sender [Completed by Employer/income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: JUNE 1 2012 _ _j If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. ? If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERVINCOME WITHHOLDERS Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an glect_ronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA RIPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case /dentifter) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. State-specific contact and withholding information can be found on the Federal Employer Services website located at: http llww^•r acf hhs qovltLr_ograms/cse/r ewhirelemployer/cOntaCts/contact mal2htm Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42 §666(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/ obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SOU (e.g., payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: if this IWO was sent by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency, you must follow the "Remit payment to instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all 1WOs due to Federal, State, or Tribal withholding limits, you must honor all IW©s to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by State or Tribal law/procedure. Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO. OMB Expiration Date - 05/31/2014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. KEVIN A HESS Form EN-428 06/12 Service Type M Page 2 of 3 Worker ID $IATT Employer's Name: BUREAU OF COMMONWEALTH` Employer FEIN: 232172299 Employee/Obligor's Name: ROSS MICHAEL V. 3415000024 CSE Agency Case Identifier: (See Addendum for case cum aryl Order Identifier: (See Addendum for order/doc,trot „_, information) Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor's principal place of employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitted by the State or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the Employer should calculate the CCPA limit using the lower percentage. Additional Information: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by returning this form to the address listed in the Contact Information below: 2321722990 O This person has never worked for this employer nor received periodic income. O This person no longer works for this employer nor receives periodic income Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU/Tribal Payee: New Employer's Name: Final Payment Amount: New Employer's Address: CONTACT INFORMATION: To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT (Issuer name) by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at: www childsuRportstate I2a us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST P.O. BOX 32Q-CARLISLE, PA 17013 (Issuer address). To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT (Issuer name) by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at www.childsugportstate. pa us. IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. OMB No.: 0970-0154 Form EN-428 06/12 Service Type M Page 3 of 3 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ROSS, MICHAEL V. PACSES Case Number 902109218 Plaintiff Name DENISE M. ROSS 07-3277 CIVIL $ 0.00 Child(ren)'s Name(s): DOB ?p[sF? Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name pocket Attaent Amount $ 0.00 Child(ren)'s Name(s): DOB Service Tvoe M PACSES Case Number Plaintiff Name Docket Attchment Amount $ 0.00 Child(ren)'s Name(s): DOB PACKS Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Numbs Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum OMB No.: 0970-0154 Form EN-42806/12 Worker ID $IATT C, DENISE M. ROSS, V. Plaintiff MICHAEL V. ROSS, Defendant ' y21 A, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -LAW NO. 07-3277 CIVIL TERM IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under §3301 (c) of the Divorce Code was filed on June 1, 2007, and served on June 7, 2007, by certified mail, restricted delivery. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety (90) 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 THE FOREGOING AFFIDAVIT ARE TRUE AND CORRECT. I UNDERSTAND THAT FALSE STATEMENTS HEREIN ARE MADE SUBJECT TO THE PENALTIES OF 18 Pa.C.S. §4904 RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES. DATE: DENISE M. RO , Plaintiff DENISE M. ROSS, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. MICHAEL V. ROSS, Defendant CIVIL ACTION -LAW NO. 07-3277 CIVIL TERM IN DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST THE ENTRY OF A DIVORCE DECREE UNDER 0301(c) OF THE DIVORCE CODE I . I consent to the entry of a final decree in 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 THE FOREGOING AFFIDAVIT ARE TRUE AND CORRECT. I UNDERSTAND THAT FALSE STATEMENTS HEREIN ARE MADE SUBJECT TO THE PENALTIES OF 18 Pa.C.S. §4904 RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES. DATE: DENISE M. ROSS, Plain9K DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW .a> MICHAEL V. ROSS, NO. 07-3277 CIVIL TERM Defendant IN DIVORCE= u _ DEFENDANT'S AFFIDAVIT OF CONSENT _?? mom:: - 1. A Complaint in Divorce under § 3301(c) of the Divorce Code was;i t Jur i 1, 2007. 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. 1 consent to the entry of a final Decree in Divorce after service of notice of intention to request entry of the Decree. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. Date: ` k7- f;' Michael V. Ross DEFENDANT'S WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVI DECREE UNDER4 3301 WOF THEWIVORCE CODE Q 1. 1 consent to the entry of a final Decree of Divorce without notice. 2. 1 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. 1 understand that I will not be divorced until a Divorce Decree is entered by the Court Law Offices of Saidis Sullivan & Rogers 26 West High Street Carlisle, PA 17013 and that a copy of the Decree will be sent to me immediately after it is filed with the Prothonotary. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. Date: 4 oy- /-A _ 7&,U V Michael V. Ross DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. MICHAEL V. ROSS, Defendant CIVIL ACTION - LAW NO. 07-3277 CIVIL TERM IN DIVORCE PROPERTY AND SEPARATION AGREEMENT BETWEEN DENISE M. ROSS AND MICHAEL V. ROSS GRIFFIE AND ASSOCIATES 200 NORTH HANOVER STREET CARLISLE, PA 17013 I Pare THIS AGREEMENT, made this s? day of 2012, by and between DENISE M. ROSS, of 44 Oak Park Avenue, Carlisle, Cumberland County, Pennsylvania, party of the first part, hereinafter referred to as "Wife, " AND MICHAEL V ROSS, of 507 Alexander Street, Hunker, Westmoreland County, Pennsylvania, party of the second part, hereinafter referred to as "Husband," WITNESSETH: WHEREAS, the parties hereto are Husband and Wife, having been married on August 26, 1989, in Allegheny County, Pennsylvania. They are the parents of one child, now an adult. WHEREAS, diverse unhappy differences, disputes and difficulties have arisen between the parties and it is the intention of Wife and Husband to live separate and apart, and the parties hereto are desirous of settling their respective financial rights and obligations as between each other including the settling of matters between them relating to the past, present and future support and/or maintenance of Wife by Husband and Husband by Wife. WHEREAS, the parties hereto wish finally and for all time to settle and determine their respective property and other rights growing out of their marital relation; wish to live separate and apart; and, wish to enter into this property and separation Agreement; WHEREAS, both and each of the parties hereto have been advised of their legal rights and the implications of this Agreement and the legal consequences which may and will ensue from the execution hereof; 21Page WHEREAS, Wife acknowledges that she is thoroughly conversant with and knows accurately the size, degree, and extent of the estate and income of Husband, and Husband acknowledges that he is thoroughly conversant with and knows accurately the size, degree and extent of the estate and income of Wife; NOW, THEREFORE, in consideration of the mutual promises, covenants and undertakings hereinafter set forth which are hereby acknowledged by each of the parties hereto, Wife and Husband, each intending to be legally bound hereby, covenant and agree as follows: 1. ADVICE OF COUNSEL: The provisions of this Agreement and their legal effect have been fully explained to the parties by their respective counsel, Hannah Herman-Snyder, Esquire for Wife and Marylou Matas, Esquire for Husband. The parties acknowledge that they have received independent legal advice from counsel of their selection and that they fully understand the facts and have been fully informed as to their legal rights and obligations and they acknowledge and accept that this Agreement is, in the circumstances, fair and equitable and that it is being entered into freely and voluntarily after having received such advice and with such knowledge and that execution of this Agreement is not the result of any duress or undue influence and that it is not the result of any collusion or improper or illegal agreement or agreements and the parties hereto state that he or she in the procurement and execution of this Agreement, has not been subjected to any fraud, concealment, overreaching, imposition, coercion, or other unfair dealing on the part of the other, or on the part of the other's counsel. 3 ?Page 2. WARRANTY OF DISCLOSURE: The parties warrant and represent that they have made a full disclosure of all assets and their valuation prior to the execution of this Agreement. This disclosure was in the form of both formal and informal exchanges of information by the parties' attorneys and/or parties and this Agreement between the parties is based upon this disclosure. Husband and Wife represent and warrant that they have disclosed to each other in full their respective assets (including the basis and holding period of such assets, where applicable), liabilities and income, valued as of February 28, 2007, the date of separation of the parties, that they have been given ample opportunity to identify, analyze and value the assets titled in the name of or held for the benefit of the other party and that this Agreement was negotiated and entered into on the basis of those disclosures and their substantial accuracy. The parties acknowledge that: (a) some formal real estate appraisals have been conducted and that the values assigned to other assets merely are the good faith estimates of current fair market value/book value by the parties themselves and that the values ascribed to the assets might be very different if other methods of valuation were utilized; (b) the parties assign very different values to many of the assets; and (c) they are aware that, but for this Agreement,, they might be entitled to additional formal discovery, including by review of documents, inspections, interrogatories, depositions or otherwise. Notwithstanding the foregoing, any further disclosure, and any further statement in this Agreement regarding disclosure, is specifically waived. 3. MUTUAL RELEASE: Husband and Wife each do hereby mutually remise, release, quitclaim, and forever discharge the other and the estate of such other, for all times to come and for all purposes whatsoever, of and from any and all right, title and interest, or claims in or against the property 41 Page (including income and gain from property hereafter accruing) of the other or against the estate of such other, of whatever nature and wheresoever situate, which he or she now has or at any time hereafter may have against such other, the estate of such other, or any part thereof, whether arising out of any former acts, contracts, engagements, or liabilities of such other as by way of dower or curtesy, or claims in the nature of dower or curtesy or widow's or widower's rights, family exemption, or similar allowance, or under the intestate laws, or the right to take against the spouse's Will; or the right to treat a lifetime conveyance by the other as testamentary, or all other rights of a surviving spouse to participate in a deceased spouse's estate, whether arising under the laws of (a) Pennsylvania, (b) any state, commonwealth or territory of the United States, or (c) any other country, or any rights which either party may have or at any time hereafter have for past, present, or future support or maintenance, alimony, alimony pendente lite, counsel fees, costs or expenses, whether arising as a result of the marital relation or otherwise, except and only except, all rights and agreements and obligations of whatsoever nature arising or which may arise under this Agreement or for the breach of any thereof. It is the intention of Husband and Wife to give to each other by execution of this Agreement a full, complete, and general release with respect to any and all property of any kind or nature, real or personal, not mixed, which the other now owns or may hereafter acquire, except and only except, all rights and agreements and obligations of whatsoever nature arising or which may arise under this Agreement or for the breach of any thereof. 4. PERSONAL RIGHTS AND SEPARATION: Wife and Husband may and shall, at all times hereafter, live separate and apart. They shall be free from any control, restraint, interference or authority, direct or indirect, by the other in all respects as if they were unmarried. They may reside at such place or places as they may 51 Page select. Each may, for his or her separate use or benefit, conduct, carry on and engage in any business, occupation, profession or employment which to him or her may seem advisable. Wife and Husband shall not molest, harass, disturb or malign each other or the respective families of each other nor compel or attempt to compel the other to cohabit or dwell by any means or in any manner whatsoever with him or her. 5. AGREEMENT NOT A BAR TO DIVORCE PROCEEDINGS. This Agreement shall not be considered to affect or bar the right of Wife or Husband to a limited or absolute divorce on lawful grounds if such grounds now exist or shall hereafter exist or to such defense as may be available to either party. This Agreement is not intended to condone and shall not be deemed to be a condonation on the part of either party hereto of any act or acts on the part of the other party which have occasioned the disputes or unhappy differences which have occurred prior to or which may occur subsequent to the date hereof. The parties intend to secure a mutual consent, no-fault divorce pursuant to the terms of Section 3301 (c) or (d) of the Divorce Code of 1980. 6. AGREEMENT TO BE INCORPORATED IN DIVORCE DECREE: The parties agree that the terms of this Agreement may be incorporated into any divorce decree which may be entered with respect to them. Notwithstanding such incorporation, this Agreement shall not be merged in the decree, but shall survive the same and shall be binding and conclusive on the parties for all times. 7. DATE OF EXECUTION: The "date of execution" or "execution date" of this Agreement shall be defined as the date upon which it is executed by the parties if they have each executed the Agreement on the 6 1 P a g e same date. Otherwise, the "date of execution" or "execution date" of this Agreement shall be defined as the date of execution by the party last executing this Agreement. 8. PERSONAL PROPERTY: Husband and Wife do hereby acknowledge that they have previously divided their tangible personal property, including, but without limitation, jewelry, clothes, furniture, furnishings, rugs, carpets, household equipment and appliances, pictures, books, works of art and other personal property and hereafter Wife agrees that all of the property in the possession of Husband shall be the sole and separate property of Husband; and Husband agrees that all of the property in the possession of Wife shall be the sole and separate property of Wife. The parties do hereby specifically waive, release, renounce and forever abandon whatever claims, if any, he or she may have with respect to the above items which shall become the sole and separate property of the other, with full power to him or her to dispose of the same as fully and effectually, as though he or she were unmarried. 9. BANK ACCOUNTS: For the mutual promises and covenants contained in this Agreement, Husband and Wife hereby waive all right, title, claim or interest they may have to equitable distribution in their respective bank accounts, checking or savings, if any, and each party waives against the other any duty of accounting for disposition of any jointly held funds. Wife shall retain all of the funds held at her Commerce, Metro, and M&T accounts, whether held individually or jointly with her daughter. Husband waives all right, title and interest he may have to those funds. Husband shall retain all of the funds held at his M&T and PNC accounts. Wife waives all right, title and interest she may have to those funds. 7JPage 10. AFTER-ACQUIRED PERSONAL PROPERTY: Each of the parties shall hereafter own and enjoy, independently of any claim or right of the other, all items of personal property, tangible or intangible, hereafter acquired by him or her after the parties' date of separation, with full power, in him or her to dispose of the same as fully and effectively, in all respects and for all purposes, as though he or she were unmarried. 11. MOTOR VEHICLES The parties agree to the division of their motor vehicles, acquired during their marriage, as follows: A. The 2000 Ford Taurus currently titled in Wife's name alone shall remain the sole and exclusive property of Wife. Husband hereby waives any right, title, claim and/or interest he has or may have in said vehicle. B. The 1999 Ford pickup currently titled in Husband's name alone shall remain the sole and exclusive property of Husband. Wife hereby waives any right, title, claim and/or interest she has or may have in said vehicle. 12. PENSION, RETIREMENT, PROFIT SHARING: A. Husband has a 401(k) as a result of his employment with Harley Davidson Motor Company with said 401(k) being the Harley Davidson Motor Company Retirement Savings Plan. The parties recognize that Husband had NINETEEN THOUSAND NINE HUNDRED FIFTY-SEVEN DOLLARS AND 57/100 ($19,957.57) in said account as of March 31, 2011. The parties agree that this account shall be divided equally so that Wife receives 50% of the balance as of 8 1Page March 31, 2011, plus or minus any market gains or losses from March 31, 2011 to the date of distribution. A Qualified Domestic Relations Order shall be prepared on behalf of Wife by her counsel to implement the terms of this Agreement, with the Qualified Domestic Relations Order being signed by the parties at execution of this Agreement. As the QDRO has not yet been pre-approved, if there are any changes necessary after the pre-approval of the same, Husband shall cooperate in signing a new copy within ten (10) days of being requested to do so. The QDRO shall be processed by counsel for Husband to implement the terms of this Agreement. Wife waives all right, title, claim and/or interest in the remaining balance of Husband's Harley Davidson Motor Company Retirement Savings Plan. B. Husband has a pension plan pursuant to his employment at Harley Davidson Motor Company, that being a Retirement Annuity Plan for York Hourly Employees of Harley Davidson. For her interest in the marital estate, Wife shall receive the sum of EIGHTY SIX THOUSAND FOUR HUNDRED DOLLARS and 00/100 ($86,400.00), to be paid to her at the rate of EIGHT HUNDRED DOLLARS and 00/100 ($800.00) per month for nine (9) years from Husband's Harley Davidson pension benefit. Wife shall receive the payment as a wage attachment through the Cumberland County Domestic Relations Office, which shall be considered alimony payments only for the purpose of effectuating said wage attachment. The payment is equitable reimbursement to Wife and is not alimony. The payment is not taxable income to Wife and is not tax deductible to Husband. Effective the date of entry of the divorce decree, the wage attachment shall be in effect for a payment of FOUR HUNDRED FORTY-EIGHT 9 1Page DOLLARS and 00/100 ($448.00) per month through August 31, 2012. Effective September 1, 2012, the wage attachment shall be in effect for a payment of EIGHT HUNDRED DOLLARS and 00/100 ($800.00) per month. Husband's counsel shall prepare an Order and Stipulation for the parties' signature to incorporate the terms of this Agreement, to be submitted to DRO, to implement the wage attachment. C. In the event the Court or DRO does not accept the parties' stipulation and implement a wage attachment, then the parties agree that Wife's payment shall be paid as a split payment of $800 per month for 9 years from Husband's Harley Davidson pension benefit. In that event, Husband's counsel shall prepare a QDRO to effectuate the terms of this subparagraph. In the event a QDRO is necessary, Husband shall continue the payments to Wife of $448.00 per month until Wife receives her payments from a QDRO. Husband shall not be under a wage attachment or DRO order to make such payments; rather, Husband shall make such payment to Wife directly at her address of 44 Oak Park Avenue, Carlisle, PA 17013, by the last day of each month. Such payments shall be an advance on Wife's equitable distribution due and owing to her herein and shall be credited to Husband. If Wife receives more than what she is owed under this paragraph, she shall reimburse Husband the overpayment(s). D. At Wife's request, Wife shall not be entitled to guaranteed benefits and she shall not be named as the survivor beneficiary of the account. Therefore, when Husband elects a form of payment to begin his payment for the pension, he is not required to elect a form of payment with a guarantee period. Wife hereby waives 101Page all other right, title, claim and/or and interest she has or may have in said pension plan or 401(k) other than what is specifically listed herein as she is receiving due consideration for the same as set forth in this Agreement. E. Husband shall maintain a life insurance policy, naming Wife and her estate as the beneficiary, in the amount of the unpaid pension payments for the remainder of the term of the pension payments, to cover the remaining payments in the event of his death before the expiration or termination of the pension payments. Proof of said insurance shall be provided to Wife within 90 days of the execution of this Agreement and every December 31 thereafter, upon Wife's request. F. If at the time of Husband's death, Wife collects an amount from Husband's life insurance and/or mortgage payments which combined with the payments she has received during his lifetime from the pension exceeds the total she is to receive pursuant to the terms of this Agreement ($86,400), she shall pay back all excess amounts to Husband's estate. Furthermore, upon payment in full to Wife of the amounts due to her herein, Wife shall satisfy the mortgage she holds pursuant to paragraph16 herein. If Wife fails and refuses to satisfy the mortgage within 30 days of payment in full, Wife shall be considered in breach of this Agreement and Husband or Husband's estate shall be entitled to the remedies due pursuant to paragraph 21 of this Agreement at and law. G. The parties recognize that Wife has no pension, retirement or profit sharing plan. 13. REAL ESTATE: 11 Page A. Wife is the sole owner of real estate located at 44 Oak Park Avenue, Carlisle, Cumberland County, Pennsylvania. Said property is owned solely by Wife as it was gifted to her during the parties' marriage. However, the parties acknowledge that there was an increase in value during their marriage such that that increase in value is marital. From the time of execution of this Agreement forward, Husband waives any right, title, claim and/or interest he has or may have in said real estate. At the time of execution of the Agreement, Husband shall sign a spousal waiver and deed to permit Wife to sell or transfer the property. Said waiver or deed shall be prepared by Wife's counsel and provided to Husband for execution. Said documents shall be held by Wife's counsel in escrow to be recorded upon Wife's sale or refinance of the mortgage, thereby releasing Husband from liability from the mortgages. From the date of separation forward, Wife shall be responsible for all household expenses associated with this property, including but not limited to, all mortgages and liens of record, insurance, real estate taxes, utilities, maintenance and repairs. At the time of execution of this Agreement, there are two liens encumbering this real estate, due and owing to PNC bank, requiring monthly payments. Wife shall be responsible for paying both liens on a timely and consistent basis to the creditor as they are due. Wife shall hold Husband harmless and indemnify him from liability in the event of any collection activity with regard to the liens due to PNC bank, or to any mortgage holder should these liens be transferred. All proceeds from the sale of this home shall be distributed to Wife or her estate. 121Page B. Wife is the sole owner of a mobile home located at 39937 West Oliver Circle, Fenwick Island, Delaware. Said mobile home was purchased during the marriage. From the time of execution of this Agreement forward, Husband waives any right, title, claim and/or interest he has or may have in said mobile home. C. Husband is the co-owner of real estate located at 507 Alexander Street, Hunker PA. Husband purchased this real estate after separation with marital funds. Except to the extent that Wife shall hold a mortgage and Note on this property as referenced in paragraph 16, Wife waives all right, title and interest she may have to this property. Husband is responsible for maintaining the payments for the mortgages, liens of record, utility bills, insurance and taxes, maintenance and repairs from the date of purchase of this property forward. 14. LIFE INSURANCE: Except for the insurance referenced in paragraph 12E herein, each party agrees that the other party shall have sole ownership and possession of any life insurance policies owned by the other, with the right to designate a beneficiary as each of the party sees fit for his/her respective policy, except as set forth herein. Each party agrees to sign any documents necessary to waive, relinquish, or transfer any rights on such policies to the respective party who presently owns such policies. 15. MARITAL DEBT: The parties acknowledge that during their marriage, and shortly thereafter, they incurred debt through PNC Bank in. the form of a home equity loan and a home equity credit line, 131Page currently totaling approximately ONE HUNDRED SIX THOUSAND DOLLARS AND 00/100 ($106,000.00) total as of the date of this Agreement, which they agree shall remain in joint names pursuant to the restrictions as set forth in paragraph sixteen (16a). Neither party will take any action to incur additional debt of any nature whatsoever in the other parties' name from the date of execution of this Agreement forward. Neither party shall access either home equity loan or home equity line of credit from the date of execution of this Agreement forward, so that neither party shall further encumber the real estate with those liens and neither party shall increase the balances due on those liens due to cash advances, withdrawals, transfer of balances or consolidations. 16. MORTGAGE AND NOTE: To offer additional protection and guaranty for Wife's interest in the pension payments she is to receive pursuant to paragraph 1213, Husband shall provide to Wife the Mortgage and Note for the property located at 507 Alexander Street, Hunker PA he prepared pursuant to Wife's Petition for Special Relief, in the amount of FIFTY THOUSAND DOLLARS AND 00/100 ($50,000.00), with all the same requirements as set forth in the Order resulting from said Petition, dated February 24., 2011, such that Husband is responsible for the filing fees of the same. In addition, as Husband purchased the property located at 507 Alexander Street, Hunker, PA with Deborah Ross as joint tenants with the right of survivorship, Husband shall ensure that Deborah Ross also signs the mortgage and note. Within thirty (30) days of execution of this Agreement, the Mortgage and Note shall be executed by Michael V. Ross and Deborah L. Ross, and shall be appropriately recorded by Husband, who shall be responsible for all filing fees for the same. Wife intends to record the mortgage but will cooperate in the event of Husband's 141Page refinance to satisfy the payments to Wife in 12B herein, so that if her recorded mortgage is prohibiting Husband's refinance in any way, Wife will subordinate her mortgage of record though it shall still be a secondary lien on the property if necessary to protect her payments herein. In the event Husband dies prior to making payment in full to Wife pursuant to the terms of paragraph 12B herein, and if at the time of Husband's death, Wife collects an amount from Husband's life insurance and/or mortgage payments which combined with the payments she has received during his lifetime from the pension exceeds the total she is to receive pursuant to the terms of this Agreement ($86,400), she shall pay back all excess amounts to Husband's estate. Furthermore, upon payment in full to Wife of the amounts due to her herein, Wife shall satisfy the mortgage she holds pursuant to paragraph. If Wife fails and refuses to satisfy the mortgage within 30 days of payment in full, Wife shall be considered in breach of this Agreement, and Husband shall be entitled to the remedies due to him pursuant to paragraph 21 herein and at law. 17. WARRANTY AS TO FUTURE OBLIGATIONS: Wife and Husband each covenant, warrant, represent and agree that each will now and at all times hereafter save harmless and keep the other indemnified from all debts, charges and liabilities incurred by the other after the execution date of this Agreement, except as may be otherwise specifically provided for by the terms of this Agreement and that neither of them shall hereafter incur any liability whatsoever for which the estate of the other may be liable. 18. ALIMONY, ALIMONY PENDENTE LITE, SPOUSAL SUPPORT AND MAINTENANCE: 151Page A. Husband hereby waives any right or claims of any nature whatsoever relative to alimony, alimony pendente lite, spousal support, spousal maintenance, counsel fees and expenses against Wife. Wife hereby waives any right or claims of any nature whatsoever relative to alimony, alimony pendente lite, spousal support, spousal maintenance, counsel fees and expenses against Husband. B. The support obligation currently paid to Wife through the Cumberland County Domestic Relations Office at PACSES Case No. 902109218 shall terminate upon entry of the parties' decree in divorce. On that date, Wife shall notify DRO of the entry of the divorce decree and shall provide them a copy of the same. 19. DIVORCE: Wife has commenced an action for divorce from Husband pursuant to Section 3301 (c) of the Pennsylvania Divorce Code by the filing of a Divorce Complaint. Each of the parties shall sign an Affidavit of Consent and Waiver of Notice of Intention to Request the Entry of a Divorce Decree at the same time of execution of this Agreement and shall provide the same to counsel for Wife. It is further agreed and understood that any Decree of Divorce issuing in this matter shall reflect the fact that Wife shall bear the cost of same in her individual capacity. A. Each of the parties agree that this Agreement represents a complete and final agreement as to their respective property rights which arose from the marital relation and therefore mutually waive any and all rights they may have under Section 3501 (Equitable Distribution) of the Pennsylvania Code, Act No. 1990- 206. 161Page B. This Agreement may be offered in evidence in the action for divorce and may be incorporated by reference in the decree to be granted therein. Notwithstanding such incorporation, this Agreement shall not be merged in the decree, but shall survive the same and shall be binding and conclusive on the parties for all time. 20. LEGAL FEES: In the review and preparation of this Agreement, each party shall bear his/her own legal fees. 21. REMEDY FOR BREACH: In addition to the above, if either party breaches any provision of this Agreement, the other party shall have the right, at his or her election, either to sue for damages for such breach, in which event the breaching party shall be responsible for payment for reasonable legal fees and costs incurred by the other in enforcing their rights hereunder, or to seek such other remedies or relief as may be available to him or her. 22. EQUITABLE DISTRIBUTION: It is specifically understood and agreed that this Agreement constitutes an equitable distribution of property, both real and personal, which was legally and beneficially acquired by Husband and Wife or either of them during the marriage as contemplated by The Act of December 19, 1990 (P.L. No. 1240, No. 206) known as "The Divorce Code," 23 P.S. 3501 et seq. of the Commonwealth of Pennsylvania, and as amended. 23. SUMMARY OF EFFECT OF AGREEMENT: It is specifically understood and agreed by and between the parties hereto, and each party accepts the provisions herein made in lieu of and in full settlement and satisfaction of any and all 171 Page of said parties' rights against the other for any past, present and future claims on account of support, maintenance, alimony, alimony pendente lite, counsel fees, costs and expenses, equitable distribution of marital property and any other claims of each party, including all claims raised by them in the divorce action pending between the parties. 24. TAX CONSEQUENCES: By this agreement, the parties have intended to effectuate and have equitably divided their marital property. The parties have determined that such equitable division conforms to a right and just standard with regard to the rights of each party. The division of existing marital property is not, except as may be otherwise expressly provided herein, intended by the parties to constitute in any way a sale or exchange of assets and the division is being effected without the introduction of outside funds of other property not constituting a part of the marital estate. 25. MUTUAL COOPERATION/DUTY TO EFFECTUATE AGREEMENT: Each party shall, at any time and from time to time hereafter, take any and all steps and execute, acknowledge, and deliver to the other party any and all further instruments and/or documents that the other party may reasonably require for the purpose of giving full force and effect to the provisions of this Agreement. 26. RECONCILIATION: The parties shall only effect a legal reconciliation which supersedes this agreement by their signed agreement containing a specific statement that they have reconciled and that this agreement shall be null and void; otherwise, this agreement shall remain in full force and effect. Further, the parties may attempt a reconciliation, which action, if not consummated by the 181Page aforesaid agreement, shall not affect in any way the legal effect or this agreement or cause any new marital rights or obligations to accrue. 27. SEVERABILITY: The parties agree that the separate obligations contained in this Agreement shall be deemed to be interdependent. If any term, clause, or provision of this Agreement shall be determined by a court of competent jurisdiction to be invalid or unenforceable, then the parties agree that the Agreement may be reviewed and renegotiated in order to fulfill as closely as possible the purpose of the invalid provision. Notwithstanding any release contained herein, the parties intend that they may reinstate any and all economic claims to the extent available under the Divorce Code of 1980. Further, any court of competent jurisdiction may, under the equitable provisions and purposes of the Divorce Code, reinstate any economic claim which was available at the time of the parties' separation or avoid any waiver herein contained to renegotiate or effectuate as nearly as possible the purpose of the unenforceable provision. 28. NO WAIVER OF DEFAULT: This Agreement shall remain in full force and effect unless and until terminated under and pursuant to the terms of this Agreement. The failure of either party to insist upon strict performance of any of the provisions of this Agreement shall in no way affect the right of such party hereafter to enforce the same, nor shall the waiver of any breach of any provision hereof be construed as a waiver of any subsequent default of the same or similar nature, nor shall it be construed as a waiver of strict performance of any other obligations herein. 29. INTEGRATION : 191 Page This Agreement constitutes the entire understanding of the parties and supersedes any and all prior agreements and negotiations between them. There are no representations or warranties other than those expressly set forth herein. This Agreement shall survive integration by any court into any judgment for divorce and shall continue to have independent legal significance as written contract separate from such judgment for divorce and may be enforced as an independent contract. 30. EFFECT OF DIVORCE DECREE: The parties agree that unless otherwise specifically provided herein, this Agreement shall continue in full force and effect after such time as a final decree in divorce may be entered with respect to the parties. 31. NOTICES: Any and all notices given hereunder shall be in writing and shall be sent registered mail, return receipt requested: A. To the Wife, at 44 Oak Park Avenue, Carlisle, Pennsylvania, 17013. B. To the Husband, at 507 Alexander Street, Hunker, Pennsylvania, 15672. 32. WAIVER OR MODIFICATION TO BE IN WRITING: No modification or waiver of any of the terms hereof shall be valid unless in writing and signed by both parties and no waiver of any breach hereof or default hereunder shall be deemed a waiver of any subsequent default of the same or similar nature. 33. CAPTIONS: 20JPage The captions of this Agreement are inserted only as a matter of convenience and for reference and in no way define, limit or describe the scope and intent of this Agreement, nor in any way effect this Agreement. 34. AGREEMENT BINDING ON HEIRS: The Agreement shall be binding and shall inure to the benefit of the parties hereto and their respective heirs, executors, administrators, successors and assigns. 35. LAW OF PENNSYLVANIA APPLICABLE: This Agreement shall be construed in accordance with the laws of the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, the parties have set their hands and seals to two counterparts of this Agreement, each of which shall constitute an original, the day and year first above written. Witness: 1t1 A n e k 0 i' (Seal) Denise M oss 1. AZI4 (Seal) Michael V. Ross 21 JPage COMMONWEALTH OF PENNSYLVANIA ) ) SS. COUNTY OF CUMBERLAND ) On this, the ? ( 51- day of .' t?A C_ , 2012, before me, a notary public, the undersigned officer, personally appeared Denise M. Ross, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. In Witness Whereof, I hereunto set my hand and notarial seal. Commonwealth of PennsyWartla NOTARIAL SEAL KELLY L PEREZ Notary Public C8fte Borough, CumberiarM County Nly Commission Expires January 25, 2oia COMMONWEALTH OF PENNSYLVANIA COUNTY OF &Je-5 7MOk,4"G AN'-b P?2.V Notary ublic SS. On this, the / j:1 day of J0,0j C- , 2012, before me, a notary public, the undersigned officer, personally appeared Michael V. Ross, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. In Witness Whereof, I hereunto set my hand and notarial seal. 221 Page DENISE M. ROSS, - Plaintiff VS. MICHAEL V. ROSS, - Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 07 - 3277 CIVIL IN DIVORCE ORDER OF COURT AND NOW, this a 1-4-t' day of 01 2012, the economic claims raised in the proceedings having been resolved in accordance with a property and separation agreement dated June 21, 2012, the appointment of the Master is vacated and counsel can file a praecipe transmitting the record to the Court requesting a final decree in divorce. BY THE COURT, Kevi . Hess, P.J. cc: ?l Hannah Herman-Snyder Attorney for Plaintiff Marylou Matas - Attorney for Defendant N) -?.. CD, - ;es Aka, v :._ 4'F THE Ra x11p t 4, 1912 JU 30 PM 1. 18 E ERtAyj) CO NT !/ PEjjkSYCV,?NrA DENISE M. ROSS, V. Plaintiff MICHAEL V. ROSS, Defendant TO THE PROTHONOTARY: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENN YLVAI CIVIL ACTION -LAW NO. 07-3277 CIVIL TERM IN DIVORCE Transmit the record, together with the following information to the court for entry divorce decree: 1. Ground for divorce: 3301(c) of the Divorce Code 2. Date and manner of service of the Complaint: Complaint was served by c mail, restricted delivery on June 7, 2007, as evidenced in the Acceptance of Service, on June 11, 2007, filed on June 25, 2007. 3. Date of execution of the Affidavit of Consent required by §3301 (c) of the Code: by Plaintiff: June 21, 2012, by Defendant: June 20, 2012. 4. Related claims pending: none. 5. Date plaintiff's Waiver of Notice in §3301 (c) Divorce was filed with Prothonotary: June 21, 2012. Date defendant's Waiver of Notice in §3301 (c) Divorce was filed with Prothonotary: June 21, 2012. Hannah Herman-Snyder, Esq Attorney for Plaintiff`' Attorney ID No. 91537 GRIFFIE & ASSOCIATES, P.C. 200 North Hanover Street Carlisle, PA 17013 (717) 243-5551 a IN THE COURT OF COMMON PLEAS OIL CUMBERLAND COUNTY, PENNSYLVANIA DENISE M. ROSS V. MICHAEL V. ROSS : NO. 07-3277 DIVORCE DECREE Ato-?l - C2.1- .41. , ??l,) , it is ordered and decreed AND NOW, DENISE M. ROSS , plaintiff, and MICHAEL V. ROSS , defendant, are divorced from the bonds of matrimony. Any existing spousal support order shall hereafter be deemed an order for alimony pendente lite if any economic claims remain pending. The court retains jurisdiction of any claims raised by the parties to this action for which a final order has not yet been entered. Those claims are as follows: (If no claims remain indicate "None.") None. The parties' Separation and Property Settlement Agreement, entered into June 21, 2012, is incorporated herein, but not merged. By th ourt, Attest: J. P thonotary g? 3 .4, - Co(z . Po9p 1W 'zec/ /-,:, c +ba' DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OFc_, _ Plaintiff CUMBERLAND COUNTY, PENNSYLVA a- rn 4-0 r _ v. CIVIL ACTION -LAW r e r MICHAEL V. ROSS, NO. 07-3277 CIVIL TERM v Defendant IN DIVORCE :c < STIPULATION AND AGREEMENT REGARDING ALIMONY This Agreement, made this s;t 5 " day of J Uj\ _ , 2012 by and between Denise M. Ross, party of the first part, hereinafter referred to as "Wife," AND Michael V. Ross, party of the second part, hereinafter referred to as "Husband." WITNESSETH: WHEREAS, the parties are divorced from the bonds of matrimony, with a copy of the Divorce Decree being attached hereto and incorporated herein by reference as "Exhibit A." WHEREAS, the parties entered into a Separation and Property Settlement Agreement. WHEREAS, pursuant to the Separation and Property Settlement Agreement, Law Offices of Saidis Sullivan & Rogers 26 West High Street Carlisle, PA 17013 Husband owes to Wife an alimony obligation in the total amount of EIGHTY SIX THOUSAND FOUR HUNDRED DOLLARS and 00/100 ($86,400.00), payable on a monthly basis such that Husband pays to Wife FOUR HUNDRED FORTY EIGHT DOLLARS and 00/100 ($448.00) a month, beginning the date the Divorce Decree is entered, through August 31, 2012, and, effective September 1, 2012, EIGHT HUNDRED DOLLARS and 00/100 ($800.00) a month. WHEREAS, the parties agree the alimony obligation shall be collected from Husband by Cumberland County Domestic Relations Office via wage attachment. WHEREAS, Husband and Wife have agreed to the following Stipulation: 1. Husband shall pay to Wife alimony in the total amount of EIGHTY SIX THOUSAND FOUR HUNDRED DOLLARS and 00/100 ($86,400.00), payable on a monthly basis such that Husband pays to Wife FOUR HUNDRED FORTY EIGHT DOLLARS and 00/100 ($448.00) a month, beginning the date the Divorce Decree is entered, through August 31, 2012, and, effective September 1, 2012, EIGHT HUNDRED DOLLARS and 00/100 ($800.00) a month. 2. Husband shall be wage attached through the Cumberland County Domestic Relations Office. IN WITNESS WHEREOF, the parties hereto have set their hands and seals Law Offices of Saidis Sullivan & Rogers 26 West High Street Carlisle, PA 17013 the day and year first above written. WITNESSED BY: %A)S&Ak -A - 4 tb\ - 1A ' 4D lal Aev 050??'O? W7 Hannah Herman-Snyder, Esq ire ate DENISE . 1609S Attorney for Denise M. Ross (a - '?AAJ / o/-&VW M tas, Es ire Date MI HAEL V. ROSS Attorney or Michael V. Ross DENISE M. ROSS V. MICHAEL V. ROSS IN THE COURT OF COMMON PLEAS O? CUMBERLAND COUNTY, PENNSYLVANIA NO. 07-3277 DIVORCE DECREE at 12:10 P.M. AND NOW, August 1 2012 , it is ordered and decreed that DENISE M. ROSS , plaintiff, and MICHAEL V. ROSS bonds of matrimony. defendant, are divorced from the Any existing spousal support order shall hereafter be deemed an order for alimony pendente lite if any economic claims remain pending. The court retains jurisdiction of any claims raised by the parties to this action for which a final order has not yet been entered. Those claims are as follows: (If no claims remain indicate "None.") None. The parties' Separation and Property Settlement Agreement, entered into June 21, 2012, is incorporated herein, but not merged. By the Court, Certified Copy Issued: August 3rd, 2012 Date ry Edward E. Guido .w DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA r VS. CIVIL ACTION - DIVORCE y -71 . , °' . NO. 07-3277 CIVIL TERM vr? . : MICHAEL V. ROSS, IN DIVORCE _ Defendant/Respondent PACSES Case No: 902109218 ; v _ - ORDER OF COURT AND NOW to wit, this 8th day of August, 2012, it is hereby Ordered that the Aalimony Pendente Lite obligation is terminated, effective August 1, 2012 pursuant to the parties' stipulation and agreement order of August 8, 2012 and the divorce decree of August 1, 2012. The credit balance of $401.36 from the Alimony Pendente Lite account will be directed to the alimony account. This Order shall become final twenty (20) days after the mailing of the notices of the entry of the Order to the parties unless either party files a written demand with the Office of the Prothonotary for a hearing de novo before the Court. BY THE CO Edward E. Guido, J. DRO: R.J. Shadday xc: Petitioner Respondent Hannah Herman Snyder, Esq. Marylou Matas, Esq. Service Type: M Form OE-001 Worker 21005 S EE 17711.. . Financial Obligation Entry RYAtJA? 06/09/12 06'58 1 >>E Type N Case Status 0 Date Entered (7 2707 r V l Orde r Type S Docket Num 07-327 7 CIV L ` CIO Ir.; 7 ROSS, MICHAEL V. %Ic& Frror ? 111 1 000?J' ROSS, DENISE M, Wor-:Er 11) 21005 i r l t t~ = 3arE" ,i?' Ordered On Amt this page only 448.00 D. Date Due i P lemher Periodic Amt Normal Arrs ID i Name Ordered On Amt Eff Date End Date Retro Arrs `? ..OU ? ?? 99110Q0958 O.QO 1? 08/02/12 Q8iQ2t12 86,4Q0.00 AI lr.nr NY;S;1 DENISE 44g,Op P? 08101112 08131+12 0.00 iSPO ? ? 9911000958 0.:00 !11 QS#01112 08101112 -00136 Ai=;_IS0 DENISE 0.00 M 06108112 8112 08;0 O.QO X - D ? D C1? ? D O ? D O D D D D r BACK I: REV NEXT ! ADD PACSES Case No.: 902109218 DENISE M. ROSS, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVAN - V. CIVIL ACTION - LAW = 5 J MICHAEL V. ROSS, `-?`' NO. 07-3277 CIVIL TERM Defendant : IN DIVORCE M - r' 4'p ORDER OF COURT ?.i AND NOW this 8th day of Auger 2012, upon consideration of the attached Stipulation and Agreement, it is hereby ORDERED as follows: 1. Husband shall pay to Wife alimony in the total amount of EIGHTY SIX THOUSAND FOUR HUNDRED DOLLARS and 00/100 ($86,400.00), payable on a monthly basis such that Husband pays to Wife FOUR HUNDRED FORTY EIGHT DOLLARS and 00/100 ($448.00) a month, beginning the date the Divorce Decree is entered, through August 31, 2012, and, effective September 1, 2012, EIGHT HUNDRED DOLLARS and 00/100 ($800.00) a month. 2. Husband shall be wage attached through the Cumberland County Domestic Relations Office. Law Offices of Saidis Sullivan & Rogers 26 West High Street Carlisle, PA 17013 By the Court, DRO: R.J. Shadday Denise M. Ross Michael V. Ross Hannah Herman-Snyder, Esquire Marylou Matas, Esquire Edward E. Q. 3 DENISE M. ROSS, Plaintiff V. MICHAEL V. ROSS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVA? CIVIL ACTION -LAW NO. 07-3277 CIVIL TERM IN DIVORCE QUALIFIED DOMESTIC RELATIONS ORDER AND NOW, this day of AiookA? , 20 it is appearing to the V1 Court that: 14 1. The p arties to the Divorce Action. The parties to this action are Michael V. R ("Participant") and Denise M. Ross ("Alternate Payee"). 1.1 Participant's name, address, social security number and date of birth are follows: Name: Michael V. Ross Address: 507 Alexander Street Hunker, PA 15672 Soc. Sec. No.: xxx-xx-9894 Date of Birth: June 26, 1956 1.2 Alternate Payee's name, address, social security number and date of birth are follows: Name: Denise M. Ross Address: 44 Oak Park Avenue Carlisle, PA 17013 Soc. Sec. No.: xxx-xx-3586 Date of Birth: May 21, 1962 The parties were divorced by Order of this Court (a copy attached hereto). Decree has not been amended. 2. Plan. This Order applies to Harley Davidson Motor Company Retirement Savings Plan of Michael V. Ross, Plan Number OP000068. Plan information shall be handled through Fidelity Workplace Services, LLC, P.O. Box 770003 Cincinnati, Ohio, 45277-0070. The administrator responsible for determine g whether the Order constitutes a Qualified Domestic Relations Order as describ d below is Fidelity Workplace Services, LLC, P.O. Box 770003 Cincinnati, Ohi , 45277-0070. 3. Interpretation and Construction of Order. 3.1 The parties intend this Order (the "Order") to constitute a "Qualified Domes Relations Order," within the meaning of Section 414(p) of the Internal Revenue Code of 1986, amended (the "Code") and Section 206(d)(3)(B) of the Employee Retirement Income Secur Act of 1974, as amended, ("ERISA"). The provisions of this Order shall be administered a interpreted in conformity with Section 414(p) of the Code and Section 206(d)(3)(B) of ERISA. 3.2 Nothing in this order shall be construed to require the Plan to provide: 3.2.1 Any type or form of benefit, or any option, not otherwise provided the Plan. 3.2.2 Benefits to Alternate Payee (as defined in Paragraph 4) in an amount exceeds the amount of benefits that the Plan would be required to pay respect to the Participant. 3.2.3 Benefits to Alternate Payee which are required to be paid to anotl alternate payee under another order previously determined to be qualified domestic relations order. IT IS ORDERED, ADJUDGED, AND DECREED as follows: 4. Alternate Payee. This Order creates or recognizes the existence of the right f Alternate Payee (as hereinafter defined) to receive all or a portion of the benefi s payable with respect to Participant under the Plan. For purposes of this Orde , Alternate Payee is: X 4.1 Former Spouse Amount of Distribution and Form of Distribution to the Alternate Payee. distribution to Alternate Payee contemplated by this Order shall be made such Alternate Payee receives 50% of the balance as of March 31, 2011, plus or in any market gains or losses from March 31, 2011 to the date of distribution. 6. Distribution Date. The distribution to Alternate Payee contemplated by this Order shall be made as soon as administratively practicable following the Company's determination that this Order is a Qualified Domestic Relations Order. 7. Death of Participant or Alternate Pam The death of Participant before benefits to which Alternate Payee is entitled under this Order have been paid sh not affect the right of Alternate Payee to benefits from the Plan as described this Order. Should Alternate Payee die before benefits have been distributed her, Alternate Payee's designated beneficiary shall receive any and all benel remaining to be paid, with her estate receiving any portion not designal specifically by her. 8. Continuing Jurisdiction. The Court shall retain jurisdiction to amend this for the purpose of carrying out the intent of the Parties as reflected in this and to establish or maintain the status of the Order as a Qualified Dor. Relations Order. Either party to this Order may apply to the court for amendment. IT IS INTENDED that this Order shall qualify as a Qualified Domestic Relations Order ur the Retirement Equity Act of 1984. The Court retains jurisdiction to amend this Order as mi be necessary to establish or maintain its status as a Qualified Domestic Relations Order under Retirement Equity Act of 1984. By th urt, J. a N 7.M c = G7 Zn r- _ -,U "< "? "2`7 I ' I . CONSENTED TO: Date: ?4' Date: G -26 r'? Date: 1j . 1- I a Date: ZP' ?_ I - ?b I2 Denise M. Rosh Plai r_"CrwwA- v - w -L Michael V. Ross, Defendant ? Hannah Herman-Snyder, Esquire Attorney for Plaintiff Mari s, Esquire Attorney r Defendant eD?e5 ya.Q,;/.? )e_)e c I verify that the statements made in this Stipulation and Agreement are true and correct. understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Date: 420 Denise M. Ro I verify that the statements made in this Stipulation and Agreement are true and correct understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Date: Co ) 6 ? 1 ;k Michael V. Ross, Defendant __ _ _ _ _ ,_ . -- In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Phone: (717) 240-6225 Fax: (717) 240-6248 Defendant Name: MICHAEL V. ROSS Member ID Number: 3415000024 Please note: All correspondence must include the Member ID Number. MODIFIED ORDER OF ATTACHMENT OF UNEMPLOYMENT BENEFITS Financial Break Down of Multiple Cases on Attachment PACSES Docket AttachmentAmou Frequencyt Plaintiff Name Case Number Number DENISE M. ROSS 902109218 07-3277 CIVIL 800.0 OII'~I "~ ..a - ~ ~,,,L. ~~ ~" ~'t $ ~ ~t .~~ ~ TOTAL ATTACHMENT AMOUNT: $ 80 t~ ~~. --i ~„ _~,. w ~~ Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment-`~ Compensation Benefits (OUCB), is hereby directed to attach the lesser of $184.11 per week, or 55.0%, of the Unemployment Compensation benefits otherwise payable to the Defendant, MICHAEL V. ROSS Social Security Number XXX-XX-9894, Member ID Number 3415000024. OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearage, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant tc 15 U.S.C. § 1673(b)(2) and 23 Pa. C.S. § 4348(g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated AUGUST 9, 2009 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. BY THE C T ~~~ ~. SEP 0 4 212 Date of Order: Edward E. Guido JUDGE Form EN-034 Service Type M Worker ID $IATT ` INCOME WITHHOLDING FOR SUPPORT ~~G~_-~ l D 1 ~ O ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) O AMENDED IWO ~7 _ ~ ~ ~ ~ VI L O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT O TERMINATION OF IWO Date: !03112 ^ Child Support Enforcement (CSE) Agency ® Court ^ Attorney ^ Private IndividualfEntity (Chet One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (s a IWO instructions ~D'//www acf hhs goy/~qr grams/cse/newhire/e lover/DUblicatl~nin~,hli~.ation htm forms). If you receive this docu ent from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier (include w/payment): 3415000024 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket lnltmrrr-alton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) D-A AUTO SALES, INC. RE: ROSS, MICHAEL V. DBA PITT INDEP AUTO AUC Employee/Obligor's Name (Last, F rst, Middle) PO BOX 431 192-44-9894 NEW STANTON PA 15672-0431 Employee/Obligor's Social Securi Number (See Addendum for plaintlft na s associated with cases on attach ent) Custodial Party/Obligee's Name (L st, First, Middle) Employer/Income Withholder's FEIN 251192344 Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) NOTE: This IWO must be regular on 'ts face. Under certain circumstances you mu •t reject this IWO and return it to the sender ( ee IWO instructions ./ i .If you receive this document from som one other than a State or Tribal CSE agency o a Court, a copy of the underlying order must be attached. 2511923440 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from M RAND t Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the em ' ogee/ obligor s income until further notice. ~ ~ , $ 0.00 perm n h in current child support -m3 rv -+ $ 0.00 perm n h in past-due child support -Arrears 12 weeks or greater? O ye n~ fi = "" $ 0.00 perm n h in current cash medical support ~ r "'dam $ 0.00 per month in past-due cash medical support -<~' .~- ~~' $ 0.00 perm n h in current spousal support ~~ "`t z ~, ~ $ 800.00 perm n h in past-due spousal support ~~ 3 ~ ' '*1 " $ 0.00 per month in other (must specify) ~;,~ t,~, ~,. for a Total Amount to Withhold of $ 800.00 per month. -'-~ --- ~ _c t.,a AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Infor ation If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: . $ 184.1~z per weekly pay period. $ 400.00 per semimonthly pay period (twice month) $ 36°1_L~ per biweekly pay period (every two weeks) $ 800.00 per monthly pay period. $ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is within the m of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs t 1 workina days after the date of this Order/Notice. Send payment within v n 7 working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to of disposable income for all orders. If the employee/obligor's principal place of employment is not within the Commonwealth of Pennsylvania (State/Tribe), the employer can obtain withholding limitations, time requiremen s, and any allowable employer fees at h ://www. f.hh v/ r m / whir / m I r/ n nta htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.: 0970-0154 Form EN-028 06/1 Service Type M Worker ID $IATT ^ Return to &ender [Completed by Erya~tlt~me 11'it~hlaatd~r]. Payment must be directed to an SDU in accordance with 42 USC §666{b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SC?U(Tribai Payee or this IWO is not regular on its face, you must check t ' rn the IWO to the sender. Signature of Judge/issuing Official (if required by State Qr Tribal law}; Print-Name. of Judge/Issuing Officiate Title of Judge!lssuing Official; Date of Signature: Sf P A ~. 2 2 If the employeelobfigorwerks in a State°or for a Trios that is diff®rent from the State or Tribe that issued this order, a copy of this IWO must be provided tv the employee/obligor. ^ If checked, the employer/income wtkhhoidar must provide a copy of this form to the employeelobligor. ADMIT#ONAl.1~1fC}Pr#tlf~iA'f#ON F(=I~~PLOYERSJ#NCOME WITMHOLt3ERS Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an ~ac.,~~r+ic Ferment metes if an employer is ordered to entithhold irtcorete from more than ens emptoyee and employs 15 or more persons, or if an employer has a his#ory of two or more returr~d checks due to nonsufflaient funds. Please Galt the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Custom®r Service at 1-$77.676-9560 for instructions. PA F#PS CODE 42 OQO U0 Make l~t~e Payable to: PA SC~U S~artd tom: Pennsylvania S~CDU, PO. . X112, l~rr~s~urg, Pa 171 Q6-9112. IN ADDfT1QN, P~14Yit~NTS MUST INGLl1DE THE L>~fEN~b~MT'S tMAialE AND TML~ RAGS€S ~1~? !D (sl~or+l'n above as the ErttPfoY'e'P~+`s Case kibr+l~ar) QR St~CIAL S€CUiPAIT"V A~ililR fN DER 'i'~J- tSE 'J'r~. D#~ Nt'~T SEND CASH 8Y Mi41L. State-specific Contact and withholding information can be found on the Federal EmployerServices website located at h~o lla.w.>i a.,f hhs goo/ni4m~ar.. rC.~-~^ew ~relemRiS~yFit/_contacts/c~ntact man 1~trn Priority: Withholding far support has priority over any other legal process under State law. against the same income (USC 42 §666{bx7)). If a i=ederat tax levy Is in effect, pkeas~!'no~fy'tha sier-der. Combining Pa#rmonts: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from more than one ernployaelobligor's income in a single payment. You must, how~rer, separaterly 'td~ntify each employee/ obligor's portion of-the payment. Payments To SDU: Yau must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agelncy: If.this IWO irtstructs .you to send a payment to an entity other than an SDU (e.g., payable to the custodial party, court, dr=attomey~, You must Check the box above anti return this noire to the sender. Exception: Ifthis IWO was sent by a Court, Attorney, car Private Individual/Entity and the initial c~rcfer was entered bpefore January 1, 1594 or the order was.. issued 6y a Tribal CSi agency, You must follow the "Remit payment to" instructions on this form.. Reportln~ the. Pay Date:. You must report the pay date when sending the payment. The pay date is the date on which the amount:-wee withheld1 frxem the employee/obligor's wages. You must comply with the law of'the State {or Tribal few if applicable) of'~+e employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments: Multiple tWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to Federal, State, or Tribal withholding limits, you must honor afi ftML9$ to th® greatest extent possible, giving priority to current support. before payment of any past-due support. Foltouv the State or Trfbai I~twJprocedure of the employr$e/cabligor's principal plaEye of elt~plvyment to determine the appra'prfate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE, agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact file sender to determine if you are required to report andlor withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income. as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by State or Tribal law/procedure. Anti-discrimination: You are subject to a fine determined under State or Tribe! I~w for discharging. an employeelobligor from employment, refusing to employ, or taking d'isclplinary action 'against an employeirltabligor because of this IWO. OMB Expiration Date - 05/31!2014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use: Form EN-028 06/12 Service Type M Page 2 of 3 Worker ID $IATT Employer's Name: 0-A AUTO SALES INC. Employee/Obligor's Name: ROSS, MICHAEL V. CSE Agency Case Identifier: {See Addendum for case summary) Order Identifier: Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Cre it Protection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor's principal place f employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory dedu tions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal lim t is 50% of the disposable income if the obligor is supporting another family and 60°l° of the disposable income if the obligor is not su porting another family. However, those limits increase 5% - to 55% and 65°!0 - if the arrears are greater than 12 weeks. If perrrtitte by the State or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit in icated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal empl yers/incon withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdicti n in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C 1673 (b)). Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums n determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, the the Employer should calculate the CCPA limit using the lower percentage. Additional information: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the send returning this form to the address listed in the Contact Information below: 2511 Q This person has never worked for this employer nor received periodic income. Q This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: last known phone number: or you are r by 23aao Last known address: Final Payment Date To SDU/Tribal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To Em Ig! Dyer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT (Issuer name) by phone at L 17) 240-6225, by fax at L17) 240-6248, by email or website at: www.childsupgort.state.pa.us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, P.O. BOX 320. CARLISLE. PA. 17013 (issuer address). To EmnloyeelObliygr: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT (Issuer name) by phone at (717) 240-6225, by fax at X7,.17) 240-6248, by email or website at www.chifds~Qport.state.pa.us. IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. Service Type M OMB No.: 0970-0154 Page 3 of 3 Employer FEIN: 251 Form EN-028 0611 Worker ID $IATT AQ.t,IM D~endalr~ft?btf~r: RQSS, MICHAEL V. PACSES ~mber 90210218 P}1CSES C~~ Number.. plaintiff N~@ PJsn~-.ff_ DENISE M. RQSS QocKeS AID;~~,,t,au~,a-,~ 07-3277: CIVIL $ 800.00 $ 0:00. Child(r~n)'s Nsrne(s): DC?B Chiid(rert)'s llfarrte(s): .# $ 0.00 Child(ren)'s Name(s):. DOB $ 0.00 Chiid(ren)'s Name(s): DOB PACSES Cass Number Plaintiff N~r-e AQfl ~ a.~o Chiid(ren)'s Names): Df7B Attachment Amount $ 0.00 Child(ren)'s Name(s): DQB Addendum Form EN-028 06/12 Service Type M oMg No.: os~o-oasa Worker iD $IATT In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION DENISE M. ROSS )Docket Number: Plaintiff ) vs. ) PACSES Case Number: MICHAEL V. ROSS ) Defendant )Other State ID Number: 07-3277 CIVIL 902109218 Order AND NOV1l to wit, this SEPTEMBER 7, 2012 it is hereby Ordered that: Respondent is to make a direct payment to the Petitioner in the amount of $27.11 ~ ~.~,, -~ for his proportionate share of her 2012 unreimbursed medical expenses within twent da s from this' dat d b th ti ~ +"'`z y y , e an o par es are to report to the Domestic ~ Relations Section that the obligation has been paid. ~ --i Failure to make a p yrr~ent will result in a petition for contempt of this order and ~~ ~ ~ =~ -t~ s ~ ~ c, listing before the Coup for hearing. _ ~''~ ~ ~', ~ c7 BY THE COURT: 1 E and E• Guido JUDG Service Type M Form 0E-520 02/1~~ Worker ID 21205 DENISE M. ROSS. Plaintiff v. MICfIAEL V. ROSS. Defendant IN THE COURT OF COMMON PLC O><,~ CUMBERLAND COUNTY, PENN~~~,`'A~IA CIVIL ACTION - I_AW - `"~ NO. 07-3277 CIVIL TERM "= -..~~ P~' DIVORCE - - STIPULATION AND AGREEMENT S~~ and between, ~~enise l~l. Ross. Plainti~-f. and lvlich~e? is .Ross. Defendant, u'INESSFTH: VdHEREAS, the parties, intending to be legally bound and waiving their right to be present when this Agreement and Order are presented and signed b5~ the Court, hereby stipulate and agree that the Court may enter the attached Order of Court. IN WITNESS WHEREOF, the parties, intending to be bound by the terms and conditions of this Agreement, execute this Agreement by signing belo~~: «~ i ~ ~. ~ ~ •.~: ~, Hannah Herman-Snyder. Es ~ ire Attorney for Plaintiff `~"-~~-- Denise M. Ross, laintiff 9~,` ~~ 4 f,i ~i~4 ~l ~4'' 't Marylou Maus, Esquire Atte~rn.~y fer Defendant Michael V. Ross, Defendant I ~~erifo that the statements made in this Stipulation and Agreement are true and correct. I understand that false statements herein are made subject to the penalties of 1 b Pa. C.S. Section 4901 relating to unsworn falsification to authorities. Date: Af"- ;--~ /.~~,~_~. .:,, `.~ Denise M. Ross,~laintiff I verifi that the statements made in this Stipulation and Agreement are true and correct. I Under starlG that .else StatCment herein. 'ure made S~whJeCt tti tliP perlaltleS of ~ ~' pa. ~~.~. SeCt:Qn 4904 relati~~~ to unsworn falsification to authorities. ~- ~) i ~ Date: Michael V. Ross, Defendant ~ A . ter' DENISE M. ROSS, Plaintiff ~. MICHAEL V. ROSS. Defendant IN THE COURT OF COMMON PLE~,AS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -- LAIN' NO. 07-3277 CIVIL TERM IN DIVORCE AMENDED QUALIFIED DOMESTIC' RELATIONS ORDER ~--~ .4ND NOW, this day of e~~`~' " '~ _, 2012. it is appearing tc~ the Court that: 1. The parties to the Divorce Action. The parties to this action are Michael V. Ross ("Participant') and Denise M. Ross ("Alternate Payee"). 1.1 Participant's name, address, social security number and date o:F birth are as follol~s: ?dame: Michael V. Ross Address 507 Alexander Street Hunker, PA 15672 Soc. Sec. No.: xxx-xx-9894 Date of Birth: June 26, 1956 1 ? Alternate Payee's name. address. social security number and date of birth are as follows: Dame: Denise M. Ross Address: 44 Oak Park Avenue Carlisle, PA 17013 SOC. Sec. No.: xxx-xx-386 llate of Birth: May 21, 1962 The parties were divorced by Order of this Court (a copy attached hereto}. The Decree has not been amended. ~. Plan. This Order applies to Harley-Davidson Retirement Savings Plan for York Hourly Bargaining Unit Employees. Plan information shall be handled through Fidelity Workplace Services, LLC, P.O. Box 770003 Cincinnati, Ohio, 45277- 0070. The administrator responsible for determ~~ning whether. the Order constitutes a Qualified Domestic Relations Order as described below is Fidelity Workplace Services, LLC, P.O. Box 770003 Cincinnati, Ohio, 4277-0070. 3. Intemretation and Construction of Order. 3.1 The parties intend this Order (the "Order'") to constitute a "Qualified Domestic Relations Order.'' within the meaning of Section 414(p) of the Internal Revenue Code of 1986, as amended (the "Code"} and Section 206(d)(3)(B) of the Employee Retirement Income Security Act of 1974. as amended, (`BRISA"). The provisions of this Order shall be administered and interpreted in conformity with Section 414(p) of the Code and Section 206(d)(3}(B~ of ERISA. 3.2 Nothing in this order shall be construed to require the Plan to provide: 3?.l Any type or form of benefit, or any option, not otherwise provided under the Plan. 3.22 Benefits to Alternate Payee (as defined in Paragraph 4) in an amount that exceeds the amount of benefits that the Plan would be required to pay with respect to the Participant. 3.2.3 Benefits to Alternate Payee which are requiired to be paid to another alternate payee under another order previously determined to be a qualified domestic relations order. IT IS ORDEF;ED, ADJUDGED, AND DECREED as follows: 4. Alternate Payee. This Order creates or recognizes the existence c,f~ the right of Alternate Payee (as hereinafter defined} to receive all or a portion of the benefits payable with respect to Participant under the Plan. For purposes of this Order, Alternate Payee is: _K __ 4.1 Former Spouse Amount of Distribution and Form of Distribution to the Alternate_Pavee. The distribution to Alternate Payee contemplated by this Order shall be made such that Alternate Payee receives 50% of the balance as of March ~ I, 201 l . plus or minus any market gains or losses from March 31.201 l to the date of distribution. 6. Distribution Date. The distribution to Alternate Payee contemplated by this Order shall be made as soon as administratively practicable following the Company s determination that this Order is a Qualified Domestic Relations Order. i . Death of Participant or Alternate Payee_ The death of Participant before all benefits to which Alternate Payee is entitled under this Order have been paid shall not affect the right of Alternate Payee toy benefits from the Plan as described in this Order. Should Alternate Payee die before benefits have been distributed to her. Alternate Payee's designated beneficiary shall receive any and all benefits remaining to be paid, with her estate receiving any portion nr_~~t designated specifically by her. 8. Continuing~Jurisdiction. The Court shalll retain jurisdiction to amend this Order for the purpose of carrying out the intent of the Parties as reflected in this Order and to establish or maintain the status of the Order as a Qualified Domestic Relations Order. Either party to this Order may apply to the court for such amendment. IT IS INTENDED that this Order shall qualify as a Qualified Domestic Relations Order under the Retirement Equity Act of 1984. The Court retains jurisdiction to amend this Order as might be necessary to establish or maintain its status as a Qualified Domestic Relations Order under the Retirement Equity Act of 1984. By the Court, '~ ..+r~ . ~;_~ J °~ rv1Qr y you y-'lA,~. ~s/" ~ H~ h'lA~ ~Cr~ n -~Snydc~, ~l ~ r~ G ~ ~ ~ '°' ~-+~ rn ~ ~ ~ z ~ -a N ~r *+ ~ -Cp Z ~ p0 s C ~ s~ r» ZO ~ O~ -i -~ ~ `-'~ :tJ -< ,e~G CONSE~ TE;D TO: Date -~ r° -~~..~~:~d._.z._ Date: ~ ~ _ ~ 7 - ~ ~~ Date: ~ f_ '~~ ; ~ /!, ~r, '~~ eft ~ i Denise M. Ross.:. laintiff ~,. Michael V. Ross. Defendant ~~.. Hannah Herman-Snyder, ~squtr~ Attorney for Plaintiff t, { ., ~; Marylou Ma s, l_squire Attorney for Defendant INCOME WITHHOLDING FOR SUPPORT III M 1,09 ,.)S O ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO) 0 AMENDEDIWO n - 3xl-� CJJ I I 0 ONE-TIMEORDERMOTICE FOR LUMP SUM PAYMENT 0 TERMINATION OF IWO Date: 05/17/13 ❑ Child Support Enforcement(CSE)Agency Court ❑ Attorney ❑ Private IndividuallEntity(Check One) NOTE:This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender(see IWO instructions http://www.acf.hhs.gov/procirams/cse/newhire/employer/publication/publication.htm-forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. Statef'rribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 3415000024 City/County/Dist.rTribe CUMBERLAND Order Identifier: (See Addendum for orderldocket informalton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) HARLEY-DAVIDSON MOTOR COMPANY RE: ROSS,MICHAEL V. 1425 EDEN RD Employee/Obligor's Name(Last,First,Middle) YORK PA 17402-1507 192-44-9894 Employee/Obligor's Social Security Number (See Addendum for plaintiff names associated with cases on attachment) Custodial Party/Obligee's Name(Last,First, Middle) Employer/income Withholders FEIN 391972792 NOTE:This IWO must be regular on its face. Under certain circumstances you must reject Child(ren)'s Name(s)(Last,First,Middle) Child(ren)'s Birth Date(s) this IWO and return it to the sender(see IWO instructions http://­lNww.acf.hhs.00v/programs/cse/newhire emolgyer/r)ublication/publication.htm-forms}.If you receive this document from someone other than a State or Tribal CSE agency or a Court,a copy of the underlying order must be attached. 3919727920 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts fr"th�y___*e'm016yee/ obligor's income until further notice. __V Zr r.JCV := =, -J-y =M $ 0.00 per month in current child support .--::o rQ9 $ 0.00 per month in past-due child support-Arrears 12 weeks or greater? yar—0 7,,D err t -<> (=�, CD $ 0.00 per month in current cash medical support $ 0.00 per month in past-due cash medical support C:) $ 0.00 per month in current spousal support $ 800.00 per month in past-due spousal support $ 0.00 per month in other(must specify) ­ for a Total Amount to Withhold of$ 800.00 per month. AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information. If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: $ 184.11 per weekly pay period. $ 400.00 per semimonthly pay period(twice a month) $ 368.22 per biweekly pay period (every two weeks) $ 800.00 per monthly pay period. $ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order, REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is within the Commonwealth of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs ten (10) working days after the date of this Order/Notice. Send payment within seven (7)working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to 55% of disposable income for all orders. If the employee/obligors principal place of employment is not within the Commonwealth of Pennsylvania (State/Tribe), the employer can obtain withholding limitations, time requirements, and any allowable employer fees at http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact map- htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.:0970-0154 Form EN-028 06/12 Service Type M Worker ID $IATT ❑ Return to Sender[Completed by Employer/Income Withholder), Payment must be directed to an SDU in accordance with 42 USC§666(b)(5)and (b)(6)or Tribal Payee(see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this PAX-ATMMrn the IWO to the sender. �V�ft Signature of Judge/Issuing Official (if required by State or Tribal law): Print Name of Judge/Issuing Official: EdwgFBE.9%n-MU i Title of Judge/Issuing Official: Date of Signature: MAY 2 0 1013 If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order,a copy of this IWO must be provided to the employee/obligor. ❑ If checked,the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS Pennsylvania law(23 PA C.S.§4374(b))requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons,or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit(PA SCDU)Employer Customer Service at 1-877-676-9580 for instructions. PA FlPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID(shown above as the Employeel0bligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. State-specific contact and withholding information can be found on the Federal Employer Services website located at: http://www.aef.hhs.aov/programs/"cse/newhire/employer/contacts/contact-map.htm Priority:Withholding for support has priority over any other legal process under State law against the same income(USC 42 §666(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency,you may combine withheld amounts from more than one employee/obligor's income in a single payment.You must, however, separately identify each employee/ obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU(e.g., payable to the custodial party,court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a Court,Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency,you must follow the"Remit payment to"instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment.The pay date is the date on which the amount was withheld from the employee/obligor's wages.You must comply with the law of the State(or Tribal law if applicable)of the employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by State or Tribal law/procedure. Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from employment, refusing to employ,or taking disciplinary action against an employee/obligor because of this IWO. OMB Expiration Date—05/3112014.The OMB Expiration Date has no bearing on the termination date of the IWO;it identifies the version of the form currently in use. Form EN-028 06/12 Service Type M Page 2 of 3 Worker ID$IATT Employees Name: HARLEY-DAVIDSON MOTOR COMPANY Employer FEIN: 391972792 Employee/Obligor's Name: ROSS, MICHAEL V. 3415000024 CSE Agency Case Identifier:(See Addendum for case summary See Order Identifier:IS Addendum for orderj-d-Qcket information) Withholding Limits:You may not withhold more than the lesser of: 1)the amounts allowed by the Federal Consumer Credit Protection Act(CCPA)(15 U.S.C. 1673(b));or 2)the amounts allowed by the State or Tribe of the employee/obligor's principal place of employment(see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such as:State, Federal,local taxes;Social Security taxes;statutory pension contributions;and Medicare taxes.The Federal limit is 50%of the disposable income if the obligor is supporting another family and 60%of the disposable income if the obligor is not supporting another family. However,those limits increase 5%-to 55%and 65%-if the arrears are greater than 12 weeks. If permitted by the State or Tribe,you may deduct a fee for administrative costs.The combined support amount and fee may not exceed the limit indicated in this section. For Tribal orders,you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income withholders who receive a State IWO,you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section 303(d)of the CCPA(15 U.S.C. 1673(b)). Depending upon applicable State or Tribal law,you may need to also consider the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks?If the Order Information does not indicate that the arrears are greater than 12 weeks,then the Employer should calculate the CCPA limit using the lower percentage. Additional Information: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are no longer withholding income for this employee/obligor,an employer must promptly notify the CSE agency and/or the sender by returning this form to the address listed in the Contact Information below: 3919727920 0 This person has never worked for this employer nor received periodic income. 0 This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU[Tribal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To Employer/income Withholder: If you have any questions,contact WAGE ATTACHMENT UNIT(issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at:www.childsupport.state.pa..us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST. P.O. BOX 320. CARLISLE, PA. 17013(Issuer address). To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT(Issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at www.childsupp-ort.state.pa.us. IMPORTANT:The person completing this form is advised that the information may be shared with the employee/obligor. OMB No.:0970-0154 Form EN-028 06/12 Service Type M Page 3 of 3 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ROSS, MICHAEL V. PACSES Case Number 902109218 PACSES Case Number Plaintiff Name Plaintiff Name DENISE M. ROSS Doc et Attachment Amount Docket Attachment Amount 07-3277 CIVIL $ 800.00 $ 0.00 Child(ren)'s Name(s): DOS Child(ren)'s Name(s): DOB PACSES-Case Number PACSES Case Number Plaintiff Name Plaintiff Name Docke t Attachment Amount D9 kkeet A achment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Docket Attachment Amours Docke Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB Addendum Form EN-028 06112 Service Type M OMB No.:0970-0154 Worker ID$IATT In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N.HANOVER ST,P.O.BOX 320,CARLISLE,PA.17013 C'- d T. Defendant Name: MICHAEL V. ROSS .° rn M Xs" ember ID Number: 3415000024 ter- I Please note:All correspondence must include the Member ID Number. —I t= ^p ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSATION BE�:1.ITFI N Financial Break Down of Multiple Cases on Attachment "✓ PACSES Docket Plaintiff Name Case Number Attachment Amount/Freauency DENISE M.ROSS 902109218 800.00 MONTH TOTAL ATTACHMENT AMOUNT: $ 800.00 Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), is hereby directed to attach the lesser of$ 184.11 per week, or 55%, of the Unemployment Compensation benefits otherwise payable to the Defendant, MICHAEL V. ROSS Social Security Number XXX-XX-9894, Member ID Number 3415000024. OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearages, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673(b)(2)and 23 Pa. C.S.A. §4348 (g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated DECEMBER 22, 2013 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. BY THE COURT Date of Order: JAN 0 7 2014 Edward E. Guido JUDGE Form EN-530 Service Type M Worker ID $IATT In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Phone: (717) 240-6225 Fax: (717) 240-6248 Defendant Name: MICHAEL V. ROSS Member ID Number: 3415000024 Please note: All correspondence must include the Member ID Number. ORDER TO VACATE ATTACHMENT OF UNEMPLOYMENT BENEFITS Plaintiff Name DENISE M. ROSS Financial Break Down of Multiple Cases on Attachment PACSES Docket Case Number Number 902109218 07-3277 CIVIL TOTAL ATTACHMENT AMOUNT: Attachment A Frency : , 80r a „MORN -0� ocn $ < —747o ? =75 $ X. -, N . C .3 ...: $ 800.00 The prior Order of this Court directing the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), to attach $184.10 or 50% per week of the Unemployment Compensation benefits of MICHAEL V. ROSS, Social Security Number XXX -XX -9894, Member ID Number 3415000024 is hereby vacated. This Order to Vacate shall be effective upon receipt of the notice of the Order by the Department and shall remain in effect until a further Order of the Court is filed. BY THE COURT Date of Order: CJD E2014 E rd E. Guido , JUDGE Service Type M Form EN -035 Worker ID $IATT In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320,CARLISLE, PA. 17013 Phone: (717) 240-6225 Fax: (717) 240-6248 Defendant Name: MICHAEL V. ROSS -; Member ID Number: 3415000024 . E C= Please note:All correspondence must include the Member ID Number. �ii.0 G-7i"t OD ORDER TO VACATE ATTACHMENT OF UNEMPLOYMENT BE F1 ` — w c4 Financial Break Down of Multiple Cases on Attachment PACSES Docket Attachment Amount/Frequency Plaintiff Name Case Number Number DENISE M. ROSS 90210921ga >07-3277 CIVIL' 800.00 MONTH TOTAL ATTACHMENT AMOUNT: $ 800.00 The prior Order of this Court directing the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), to attach$184.10 or 50% per week of the Unemployment Compensation benefits of MICHAEL V. ROSS, Social Security Number XXX-XX-9894, Member ID Number 3415000024 is hereby vacated. This Order to Vacate shall be effective upon receipt of the notice of the Order by the Department and shall remain in effect until a further Order of the Court is filed. BY THE COURT Date of Order: AUG 2 8 2P1 Edward E. Guido JUDGE Form EN-035 Service Type M Worker ID $IATT C