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Home My WebLink About03-4324 Andrew C. Sheely, Esquire 127 S. Market Street P.O. Box 95 Mechanicsburg, PA 17055 PA ID NO. 62469 717-697-7050 (Phone) 717-697-7065 (FaX) PATRICIA L. BLOSSER, plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - lf3J'I CIVIL TERM 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 may proceed against you and a decree in divorce or annulment may be entered against you by the Court. A judgment may also be entered against you for any other claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rights important to you, including custody or visitation with your children. When the grounds for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. A list of marriage counselors is available in the Office of the prothonotary at the Cumberland County Courthouse, Carlisle, pennsylvania. IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER'S FEES OR EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM ANY OF THEM. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 '-800-990-::0~ c6Q Andrew C. Sheely, Esquire PA. LD. No. 62469 127 S. Market Street P.O. Box 95 Mechanicsburg, PA 17055 717 697-7050 Attorney for Plaintiff Andrew C. Sheely, Esquire 127 S. Market street P.O. Box 95 .Mechanicsburg, PA 17055 PA 10 NO. 62469 717-697-7050 (Phone) 717-697-7065 (Fax) PATRICIA L. BLOSSER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - '1$P+ CIVIL TERM IN DIVORCE COMPLAINT 1. Plaintiff is PATRICIA L. BLOSSER, an adult individual who currently resides at 2858 Morningside Drive, Camp Hill, Cumberland County, pennsylvania. 2. Defendant is THOMAS E. BLOSSER, an adult individual who resides at 4834 East Trindle Road, Apt. 2, Mechanicsburg, Cumberland county, Pennsylvania. 3. Plaintiff and Defendant have been bona fida residents of the Commonwealth of Pennsylvania for at least six (6) months immediately previous to the filing of this Complaint. 4. Plaintiff and Defendant were married on December 30, 1972, in Mechanicsburg, Pennsylvania. 5. There have been no prior actions of divorce or annulment between the parties. 6. Neither party is a member of the armed forces of the United States of America. 7. Plaintiff has been advised of the availability of marriage counseling and understands that she may have the right to request that the court require the parties hereto to participate in counseling. 8. The marriage between the parties is irretrievably broken. 9. This action is not collusive. 10. The parties separated on or about July 9, 2001. WHEREFORE, Plaintiff requests your Honorable Court to enter a decree in divorce divorcing Plaintiff and Defendant absolutely. COUNT II. CLAIM FOR ALIMONY UNDER SECTION 3701 OF THE DIVORCE CODE 11. The allegations in paragraphs 1 through and 10 are incorporated herein and made a part hereof. 12. Defendant is employed by the Federal Emergency Management Department earning in excess of $3,901.75 net income per month and Plaintiff is retired and employed as a librarian aide earning an amount of approximately $1,050.00 per month. 13. Defendant earns substantially more income than Plaintiff. 14. Defendant earns substantially more retirement benefits than Plaintiff. 15. Plaintiff lacks sufficient property and income to provide for her reasonable needs. 16. Defendant is in a far more superior economic position than Plaintiff. 2 WHEREFORE, plaintiff requests your Honorable Court award Plaintiff a reasonable amount of alimony from Defendant, including any such further relief as the Court may determine equitable and just. Date: September 51 ' 2003 /tAllY ( Andrew C. Sheel, uire Attorney for Plaintiff PA ID No. 62469 P.o. Box 95 127 S. Market Street Mechanicsburg, PA 17055 697-7050 3 VERIFICATION I verify that the statements made in this Complaint are true and correct. I understand that false statements herein are made subject to penalties of 18 Pa.C.S.A. Section 4904, relating to unsworn falsification to authorities. Date: September -3 , 2003 yq~~CPR V! /!~q/ PATRICIA L. B{6S~Y . Andrew C. Sheely, Esquire 127 S. Market street P.O. Box: 95 Mechanicsburg, PA 17055 PA ID NO. 62469 717-697-7050 (Phone) 717-697-7065 (FaX) PATRICIA L. BLOSSER, plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - CIVIL TERM IN DIVORCE AFFIDAVIT patricia L. Blosser, being duly sworn according to law, deposes and says: (1) I have been advised of the availability of marriage counseling and understand that I may request that the Court require that my spouse and I participate in counseling. (2) I understand that the Court maintains a list of marriage counselors in the Domestic Relations Office, which list is available to me upon request. (3) Being so advised, I do not request that the Court require that my spouse and I participate in counseling prior to a Divorce Decree being handed down by the Court. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn falsification to authorities. 4~o;a... (j) /~€/\..J ~~icia L. B~~e!), 0 -. ~~: ~ ~ ~) -r_~ f:f" ~ fT,: -1L - " ~ ~ /:' (/.i , ""- c. -t ~ ~- SL) ,1:>-' .,:- "' ~ >~ '.. "'" -~ ~: '. ~ c-' ~ -" -c V) S-- .- ,. -..r,- ~ , -, ., ""' (-::1 \~ , '. ..-----/ ,..---... ,','") .... ,-J Andrew C. Sheely, Esquire 127 s. Market Street P.O. Box 95 Mechanicsburg, PA 17055 PA ID NO. 62469 717-697-7050 (Phone) 717-697-7065 (Fax) PATRICIA L. BLOSSER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - 4324 CIVIL TERM IN DIVORCE ACCEPTANCE OF SERVICE I, Philip H. Spare, Esquire, of the firm Snelbaker, Brenneman & Spare P.C., hereby accept service of the divorce complaint on behalf of Thomas E. Blosser, Defendant, and further certify that I am authorized to do so in accordance with PA. R.C.P No. 402 (b). Date: September ~, 2003 P~~~qUire Snelbaker, B:Lenneman & Spare P. C. P.O. Box 318 44 West Main Street Mechanicsburg, PA 17055 717-697-8528 (') C ? u(i ~~~~; 0~) c". -,.::;- r _~ \ ~(- ...~-,- j:;'C :c: --i -< f:'J ( " cO,,' cn ,"11 '--a r",~, ."U u .. :-:J \0 POST-NUPTIAL AGREEMENT Q7H THIS AGREEMENT made and entered into this / t day of December, 2003 by and between: THOMAS E, BLOSSER of 4834 East Trindle Road, Mechanicsburg, Cumberland County, Pennsylvania, party of the first part, hereinafter called "Husband", AND PATRICIA L. BLOSSER of2858 Morningside Drive, Camp Hill, Cumberland County, Pennsylvania, party of the second part, hereinafter called "Wife"; WITNESSETH: WHEREAS, Husband and Wife were married to each other on December 30, 1972; and WHEREAS, during their marriage the parties accumulated various assets and property; and WHEREAS, certain differences have arisen between the parties, as a consequence of which they have separated and now live separate and apart from each other; and WHEREAS, the parties anticipate that a divorce action will be filed by one of them in the near future (hereinafter called "Divorce Action"); and WHEREAS, Husband is represented by Philip H, Spare, Esquire of the firm of Snelbaker, Brenneman & Spare, p, C, and Wife is represented by Andrew C. Sheely, Esquire; and WHEREAS, the parties having a full opportunity to be advised of their respective rights, duties and obligations arising out of the marriage and each having a full opportunity to investigate and evaluate the assets, liabilities and all other aspects of each other's property and their jointly owned assets and liabilities, have come to an agreement for the final settlement of their property and affairs, NOW THEREFORE, in consideration of these presents and the mutual covenants, promises, terms and conditions hereinafter set forth and to be kept and performed by each party hereto, and intending to be legally bound hereby, the parties mutually agree as follows: I. INCORPORATION OF PREAMBLE, The foregoing preamble and paragraphs are incorporated by reference herein in their entirety, 2. DECLARATION AS TO ASSETS AND WAIVER OF EV ALUA TION. , The parties agree that each of them are aware of the assets which they acquired during their marriage and which would be the subject of equitable distribution if submitted to a court for division under the provisions of the Pennsylvania Divorce Code. The parties declare and agree that they are familiar with said assets and hereby waive the evaluation thereof, although each party declares that shelhe has had full opportunity obtain such evaluation, 3, DIVISION OF ASSETS, Upon execution of this Agreement, or as otherwise set forth hereinbelow, the parties agree to divide, allocate, retain and/or transfer their assets as follows: A. ASSETS TO HUSBAND I. Balance of net proceeds from the sale of the marital residence known and numbered as 422 West Keller Street, Mechanicsburg, Pennsylvania after payment to Wife set forth below; 2, Furniture, household goods, and any other tangible personal property currently in Husband's possession; -2- 3. Husband's interests acquired during the marriage and increase in value, if any, in pension, retirement, savings plans and like benefits from his current and/or former employers; 4, Bank accounts or deposits in other financial institutions in the name of Husband, 5. Jeep Cherokee titled in his name only; B. ASSETS TO WIFE I. Forty-five Thousand Dollars ($45,000.00) of net proceeds from the sale of the marital residence known and numbered as 422 West Keller Street, Mechanicsburg, Pennsylvania; 2, Furniture, household goods, any other tangible personal property currently in Wife's possession; 3. Wife's automobile lease interest in her name only; 4, Wife's interests acquired during the marriage and increase in value, if any, in pension, retirement, savings plans and like benefits from her current and/or former employers, including, but not limited to the Mechanicsburg Area School District; 5, Bank accounts or deposits in other financial institutions in the name of Wife; 6, Life insurance policy with Wife as the insured, 4, MARITAL DEBT, Parties acknowledge and agree that Husband will be solely responsible for the following marital debts: a. First Card Visa Platinum Statement (Account No: 4366 163032244747) with a July 200 I balance of $3, I 82.46; b, Home Depot Credit Line Account No: 51 92000077492 with a balance of$2,382,74 as ofJune 16,2001; c, Gateway (Account No: 6011 7672 0128 6356) with a balance of $1,120,36 as of June 2001; -3- d, Wal-Mart (Account No: 6032 2075 4017 8514) with a balance of $619,06 as of July 2001; e, American Express Optima (Account No: 3730-208008-92009) with a balance of $9,641.5 I as of June 2001; f, First Union (Account No: 74972173 042 228) with a balance of $683.31 as of June 2001; and g. AM Financial Services Credit Card (Account No: 4264 2960 2405 9237) with a balance of $11 ,928,72 as of July 200 I. 5, MARITAL HOME, The parties have sold the marital residence and divided the net proceeds of the sale to their mutual satisfaction, 6. SPOUSAL SUPPORT AND ALIMONY. a, Effective January I, 2004, the current spousal support order and amount shall cease and Husband shall pay Wife alimony in the amount of$300.00 bi-weekly. The alimony shall continue until Wife reaches age 62 on February 2, 2008, at which time alimony shall terminate, The alimony described in this paragraph shall terminate prior to February 2, 2008 in the event of Wife's remarriage or cohabitation or in the event of the death of either Husband or Wife. Except for possible termination for the reasons set forth above, the alimony is not subject to modification, Wife shall reimburse Husband for any overpayments she may receive during the period of transition between spousal support and alimony. b, Husband and Wife hereby acknowledge that the current rate of inflation may change, that Husband or Wife's income and assets may substantially increase in value, that he or she may be employed at various times in the future, and that notwithstanding these or other economic circumstances which may be changes in circumstances of a substantial and -4- continuing nature, the alimony payments to Wife required under this Paragraph 6 are fair, just and reasonable, Therefore, except as set forth in this Agreement, Husband and Wife do hereby expressly waive, discharge and release any and all rights and claims which he or she may have now or hereafter by reason of the parties' marriage, to alimony, alimony pendent elite, support and/or maintenance or any other benefits resulting from the parties' status as wife and husband, and further waive, discharge and release any and all rights which he or she may now or hereafter have to seek modification of the terms of this Paragraph in a court oflaw or equity, it being understood that the foregoing constitutes a final determination for all time of Husband's obligation to pay alimony to Wife or for Wife's obligation to pay alimony to Husband, c, This Agreement has been negotiated on the agreement that the alimony payments described in this Paragraph 6 will be deductible by Husband and taxable to Wife. Therefore, it is the intention, understanding and agreement of the parties that the payments described in this Paragraph 6, to the extent permitted by law, shall constitute "periodic" payments payable by reason of the "marital or family relationship" of the parties, as those terms are defined in Section 71 of the Internal Revenue Code of 1954, as amended, and accordingly that all such payments shall be included in Wife's gross income and deductible by Husband for federal income tax purposes pursuant to Sections 71 and 215 of the Internal Revenue Code of 1954, as amended, respectively, Wife agrees to report payments received under this Paragraph 6 in her gross income for federal, and, if applicable, for local and state income tax purposes. Wife shall be solely responsible for any and all income taxes with respect to any payments received by her as alimony as required by this Paragraph 6, -5- 7, FUTURE OBLIGATIONS AND OBLIGATIONS SINCE SEPARATION, The parties agree that any and all obligations incurred subsequent to the date separation, July 9, 200 I, shall be the sole and separate liability and responsibility of the party incurring the obligation, Each party agrees that he/she will not incur or attempt to incur any obligations for or on behalf of the other party and will indemnify and hold harmless the other party of and from any and all liability arising from such past or future obligation. 8. RELEASE OF RIGHTS UNDER DIVORCE CODE. Except only as specifically provided to the contrary hereinabove in this Agreement, each party hereby waives and forever releases the other party of and from any and all claims which either may have against the other by reason of and pursuant to the Pennsylvania Divorce Code (and the divorce law of any other jurisdiction) including, but not limited to, alimony, alimony pendente lite, spousal support, equitable distribution of marital property, counsel fees, costs and expenses, except that the performance of any obligations created hereunder may be enforced by any remedies under the Pennsylvania Divorce Code, 9, INDIVIDUAL PROPERTY. Except only as may be provided specifically to the contrary hereinabove, each party shall retain all property, real, personal and otherwise, which is presently titled in his or her name and ownership, whether or not said property is or would be deemed to be marital property under the Pennsylvania Divorce Code and each party hereby expressly releases the other of and from any and all right of equitable distribution in and to said individually owned property of such other party, 10. GENERAL RELEASE, Husband relinquishes his inchoate intestate right in the estate of Wife, and Wife relinquishes her inchoate intestate right in the estate of Husband, and -6- each of the parties hereto by these presents, for himself or herself, his or her heirs, executors, administrators or assigns, does hereby remise, release, quit-claim and forever discharge the other party hereto, his or her heirs, executors, administrators or assigns, or any of them, of any and all claims, demands, damages, actions, causes of action or suits at law or in equity of whatsoever kind or nature, for or because of any matter or thing done, omitted or suffered to be done by such other party prior to the date hereof, except that this release shall in no way exonerate or discharge either party from the obligations and promises made or imposed by reason of this Agreement. This Agreement shall not be construed to affect or bar the right of either party to an action for the enforcement or performance of this Agreement which may be instituted pursuant to the remedies available under the Pennsylvania Divorce Code. I I, SURVIVAL OF AGREEMENT, It is the intention of the parties that this Post- Nuptial Agreement shall survive any action in divorce which may be instituted or prosecuted by either party, and no order, judgment or decree of divorce, temporary, interlocutory, final or permanent, shall affect or modify the terms of this Agreement, but said Agreement may be enforced by any remedy at law or in equity, including enforcement proceedings under the Pennsylvania Divorce Code, The parties agree to incorporate this Agreement into a separate order of court to be entered in the Divorce Action, but this Agreement shall not be merged into said order or decree in divorce. 12, VOLUNTARY EXECUTION, Each party has had the opportunity to have the provisions of this Agreement and their legal effect have been fully explained to the parties by an attorney of his or her choice, Each party acknowledges that this Post-Nuptial Agreement is fair and equitable, that it is being entered into voluntarily, with full knowledge of the assets of -7- both parties, and that it is not the result of any duress or undue influence, The parties acknowledge that they have been furnished with all information relating to the financial affairs of the other to the extent same has been requested by each of them, 13. ENTIRE AGREEMENT, This Post-Nuptial Agreement contains the entire understanding of the parties and there are no representations, warranties, covenants or undertakings other than those expressly set forth herein, The parties acknowledge and agree that the provisions of this Agreement with respect to the distribution and division of marital and separate property are fair, equitable and satisfactory to them based on the length of their marriage and other relevant factors which have been taken into consideration by the parties, Both parties hereby accept the provisions of this Agreement with respect to the division of property in lieu of and in full and final settlement and satisfaction of all claims and demands that they may now have or hereafter have against the other for equitable distribution of their property by any court of competent jurisdiction pursuant to the Pennsylvania Divorce Code or any amendments thereto, Each party voluntarily and intelligently waives and relinquishes any right to seek a court ordered determination and distribution of marital property, but nothing herein contained shall constitute a waiver by either party of any rights to seek the relief of any court for the purpose of enforcing the provisions of this Agreement. 14, WAIVER. The waiver of any term, condition, clause or provision of this Agreement shall in no way be deemed or considered a waiver of any other term, condition, clause or provision of this Agreement. 15, APPLICABLE LAW, This Agreement shall be construed, interpreted and enforced according to the laws of the Commonwealth of Pennsylvania, -8- 16, HEADINGS, The headings or titles of the numbered paragraphs of this Agreement have been used only for the purpose of convenience and shall not be resorted to for the purposes ofinterpretation or construction of the text ofthis Agreement. 17, BREACH. It is expressly stipulated that if either party fails in the due performance of any of his or her material obligations under this Agreement, the other party shall have the right, at his or her election, to sue for damages for breach thereof, to sue for specific performance or to seek any other legal remedies as may be available, and the defaulting party shall pay the reasonable legal fees for any services rendered by the non-defaulting party's attorney in any action or proceeding to compel performance hereunder. 18, AFTER-ACQUIRED PROPERTY. Each of the parties shall hereafter own and enjoy independently of any claim or right of the other, all items of property, be they real, personal or mixed, tangible or intangible, which are hereafter acquired by him or her, 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, 19, COUNSEL FEES. COSTS AND EXPENSES. Each party shall be responsible for his or her own legal fees, costs and expenses incurred in connection with their separation and/or the dissolution of their marriage. -9- 20, INDEMNIFICATION, Each party represents and warrants to the other that he or she has not incurred any debt, obligation, or other liability, other than described in this Agreement, on which the other party is or may be liable, Each party covenants and agrees that if any claim, action or proceeding is hereinafter initiated seeking to hold the other party liable for any other debts, obligations, liability, act or omission of such party, such party will at his or her sole expense, defend the other against any such claim or demand, whether or not well- founded, and that he or she will indemnifY and hold harmless the other party in respect of all damages as resulting therefrom. Damages as used herein shall include any claim, action, demand, loss, cost, expense, penalty, and other damage, including without limitation, counsel fees and other costs and expenses reasonably incurred in investigating or attempting to avoid same or in opposing the imposition thereof or enforcing this indemnity, resulting to Husband or Wife from any inaccurate representation made by or on behalf of either Husband or Wife to the other in this Agreement, any breach of any of the warranties made by Husband or Wife in this Agreement, or breach or default in performance by Husband or Wife of any of the obligations to be performed by such party hereunder, The Husband or Wife agrees to give the other prompt written notice of any litigation threatened or instituted against either party which might constitute the basis for a claim for indemnity pursuant to the terms of this Agreement. 21. MODIFICATION, No modification, rescission or amendment to this Agreement shall be effective unless in writing signed by each of the parties hereto, 22, SEVERABILITY. If any provision of this Agreement is held by a Court of competent jurisdiction to be void, invalid or unenforceable, the remaining provisions hereof shall nevertheless survive and continue in full force and effect without being impaired or invalidated in any way, 23. COOPERATION, The parties hereto shall from time to time, cooperate with one another and execute, acknowledge and deliver any and all further documents or instruments that may be reasonably required to give full force and effect to the provisions of this Agreement. 24, DIVORCE BY MUTUAL CONSENT, The parties agree and acknowledge that their marriage is irretrievably broken, that they do not desire marital counseling, and that they both consent to the entry of a decree in divorce pursuant to 23 Pa, C. S, Section 3301(c), Accordingly, the parties have executed and will timely file with the Court such consents, affidavits, waivers of notice and/or other documents as may be necessary to promptly proceed to obtain a divorce pursuant to 23 Pa,C.S. Section 3301(c). IN WITNESS WHEREOF, the parties have hereunto set their respective hands and seals the day and year first above written intending to legally bind themselves and their respective heirs, personal representatives and assigns, Tld:tf-, k>?/L. (SEAL) Thomas E, Blosser ~(]~ lfJat<<e;(t ~U~) Patricia L~)j~r~ (") r-> c~-..-> C;,-' ,-~ '" eel ::. ) <', :- f') r--j -'-{, .-. -j--;"l ,,-' l~-J ,.t) ( ~ ) C'i PATRICIA L. BLOSSER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - 4324 CIVIL TERM IN DIVORCE ORDER OF COURT IN RE: ALIMONY AND NOW, this '2.7 day of (r~ 2003, is hereby Ordered and Decreed that Defendant, Thomas E. Blosser, shall pay Plaintiff, patricia L. Blosser, Alimony, in the amount of SIX HUNDRED FIFTY DOLLARS ($650.00) per month payable at THREE HUNDRED DOLLARS ($300.00) BI-WEEKLY, effective January 1, 2004 and continuing through February 2, 2008, whereupon Alimony shall forever cease. All payments of Alimony herein shall be made in accordance with and subject to the provisions of paragraph 6 of the attached Post Nuptial Agreement, which shall be incorporated BY J. but not merged in the Divorce Decree. Andrew C. Sheely, Esquire Attorney for Patricia L. Blosser, Plaintiff Philip H. Spare, Esquire Attorney for Thomas E. Blosser, Defendant \ i f' .'.} ;J "In r!1'H j'J l.tJu" LJQ Andrew C. Sheely, Esquire 127 s. Market street P.O. Box 95 Mechanicsburg, PA 17055 PA ID NO. 62469 717-697-7050 (Phone) 717-697-7065 (Fax) PATRICIA L. BLOSSER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - 4324 CIVIL TERM IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under Section 3301(c) of the Divorce Code was filed on september 5, 2003. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety (90) days have elapsed from the date of filing the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this Affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn falsification to the authorities. DATE: I~ (~ (!O?::> ~ r-(/~~ / paMt" ~Jfosser '>, " i- ~ ...., C..:J c:..:~ ~.> CJ ,.,., ("'..' f",) ('.: '.,) ~ 11 ::::-1 i\"' r--- ~:":-~ 2:;, ~-:':J ~, Andrew C. sheely, Esquire 127 s. Market Street P.O. Box 95 Mechanicsburg, PA 17055 PA ID NO. 62469 717-697-7050 (Phone) 717-697-7065 (Fax) PATRICIA L. BLOSSER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - 4324 CIVIL TERM IN DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER S3301 (C) OF THE DIVORCE CODE 1. I consent to the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce decree is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the prothonotary. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn falsification to the authorities. DATE: I ;J/~ tj;-~ IV / ~// y1Jtj;;q ~y!~" patricia L. Blosser (~') r-' ~~:~ '"-' C':: r; -, coO, ( .~ ;~) r<, <_.J ..-" Andrew c. sheely, Esquire 127 S. Market Street P.O. Box 95 Mechanicsburg, PA 17055 PA ID NO. 62469 717-697-7050 (Phone) 717-697-7065 (FaX) PATRICIA L. BLOSSER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - 4324 CIVIL TERM IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under Section 3301(c) of the Divorce Code was filed on September 5, 2003. I acknowledge that my attorney accepted service of the divorce complaint on my behalf on September 12, 2003. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety (90) days have elapsed from the date of filing the complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this Affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn falsification to the authorities. DATE:I:ljI7/0...J ~~ !?8L Thomas E. Blosser o C' ......, ~:::::) (:.;;::) ~ ~ 1':; C'j i"'.) 1'.:J -") (,,) C' .-.1 ::--1 d~::!=-: , r Ci , ~-"':) ';:.' :-::-~ ,I, Andrew C. Sheely, Esquire 127 s. Market street P.O. Box 95 Mechanicsburg, PA 17055 PA 10 NO. 62469 717-697-7050 (Phone) 717-697-7065 (Fax) PATRICIA L. BLOSSER, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW THOMAS E. BLOSSER, Defendant 03 - 4324 CIVIL TERM IN DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER S3301 (C) OF THE DIVORCE CODE 1. I consent to the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce decree is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the prothonotary. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn DATE: 1;)/17 f 07, falsification to the authorities. Crk-. f?~ Thomas E. Blosser ,,-, = C...::l L'" ,~ !"~:;'l C-; f',) N C, -11 ---' ."'(~ .~ ; .) , vs. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW PATRICIA L. BLOSSER, Plaintiff . . THOMAS E. BLOSSER, Defendant 03 - 4324 CIVIL TERM IN DIVORCE PRAECIPE TO TRANSMIT RECORD TO THE PROTHONOTARY: Kindly transmit the record, together with the following information to the Court for entry of a Divorce Decree: 1. Grounds for Divorce: Irretrievable breakdown under Section 3301 (C) of the pennsylvania Divorce Code. 2. Date and Manner of service of the complaint: Acceptance of service by counsel filed September 12, 2003. 3. Complete either paragraph (a) or (b). (a) Date of execution of affidavit of consent reguired by Section 3301 (C) of the Pennsylvania Divorce Code: by Plaintiff on December 21, 2003 and by Defendant on December 17, 2003. (b) (1) Date of execution of the affidavit required by Section 3301 (d) of the Divorce Code: Not applicable: (2) Date of filing and service of the plaintiff's affidavit upon the respondent: Not applicable. 4. Related claims pending: None. The marital settlement agreement dated December 19, 2003 and Alimony Order are incorporated but not merged in the Decree in Divorce. 5. Complete either (a) or (b). (a) Date and manner of service of the notice of intention to file praecipe to transmit record, a copy of which is attached: Not applicable (b) Date Plaintiff's Waiver of Notice in Section 3301 (C) was filed with the prothonotary. December 21- . 2003. Date Defendant's Waiver of Notice in Section 3301 (C) was filed with the prothonotarr. DeC~mbe~'~?~7T003. l hNtvJ C~)'I{J Andrew C. Sheely, '~quire Attorney for Plainpiff Divorce :....<, c',,',' <;--' <:'.....) (,- =--::J !,'1 --.,., ] , , P,) r,.=, C,) c' .. . ;f.'f;:+':f.:f.:f.:f. .. Of. :f.:f.:f.:f.:f. :f.:f. Of. ;+;:+: :f. :+;:f.:f.:f. :f. .. . . . .. . . IN THE COURT OF COMMON PLEAS . . OFCUMBERLANDCOUNTY . . . PENNA, STATE OF . . . PATRTrIA I. HI nSSFR . . . 03 4324 PLAINTIFF No. . . VERSUS . . . CIVIL ACTION - LAW IN DIVORCE THOMAS E. BLOSSER, . . . . . . DEFENDANT . DECREE IN DIVORCE . . . . . . . . NOW,r--v~ PATRICIA L. BLOSSER 27 ~J , IT IS ORDERED AND AND . . . . . . . . . . . . . . . . . DECREED THAT , PLAINTIFF, THOMAS E. BLOSSER AND , DEFENDANT, ARE DIVORCED FROM THE BONDS OF MATRIMONY. . . . . . . THE COURT RETAINS JURISDICTION OF THE FOLLOWING CLAIMS WHICH HAVE BEEN RAISED OF REC'i'\lD IN THIS ACTION FOR YET BEEN ENTERED; l.J()\.J{. The Marital Settlement Agreement dated December 19,2003 and Order of Court regarding WH ICH A FI NAL ORDER HAS NOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . "':f.:f.:f. Alimony are incorporated but not merged in this Decree in Divorce. 'I' Of. :+;:f.'f. :+::f.'I''+':f.'f. '+' . . . . . . . . . . . . . . . . . . . :f.:f. Of. Of.:f. 'f '+':f.:f. ",'" mm~ PROTHONOTARY . . . .. . . :f.:f.:f.:f.:f.'+':f. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J. ~ P f2 ~~ ~t< (U. '?r. q ~~:z ~.v ~")'~ W7CC '\ . ; ." . ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania Co./City/Dist. of CUMBERLAND Date of Order/Notice 01/02/04 Tribunal/Case Number (See Addendum for case summary) o Original Order/Notice @ Amended Order/Notice o Terminate Order/Notke FEDERAL EMERGENY MANAGEMENT C/O PAYROLL DEPT 615 CHESTNUT ST PHILADELPHIA PA 19106-4404 1J# ~03 ~~</ (l(I//L I~ ?o(lc3to&)- RE: BLOSSER, THOMAS E. Employee/Obligor's Name (Last, First, Ml) 195-32-0332 Employee/Obligor's Social Security Number 5467100814 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, MI) EmpJoyerMtithholder's Federal EIN Number See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania, By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State, $ 650,00 per month in current support $ 22.00 per month in past-due support Arrears 12 weeks or greater? <Xl yes 0 no $ 0,00 per month in medical support $ 0 . 00 per month for genetic test costs $ per month in other (specify) for a total of $ 672.00 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: $ 155.08 per weekly pay period. $ 310,15 per biweekly pay period (every two weeks), $ 336.00 per semimonthly pay period (twice a month), $ 672.00 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 SS'!. of the employee's/ obligor's aggregate disposable weekly earnings, For the purpose of the limitation on withholding, the following information is needed (See #10 on pg, 2). If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer Service at 1-877-676-9580 for instructions, Make Remittance Payable to: PA SCOU Send check to: Pennsylvania SCOU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. Date of Order: ,\(J,\>\ ~ 4 '2.1\\\~ OMB No.: 097Q.O 's For EN-028 Worker ID $IATT Service Type M ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o I(,hecked you are required. to prpvi(le a (:opy of this form to your. employee. If yo~r employeefworks in.a statehthat is different from the state that ISSUed this order, a copy must be provIded to your employee even I the box IS not c ecked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned businesses located on a reservation that choose to withhold in accordance with this notice. 2. 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, 3, Combining Payments: You can combine withheld amounts from more than one employeeJobligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employeeJobligor. 4.* ~~~~;;! ~'~ r.a:yd~~~D"t:&f';:'ill,I'6Idilo5' Y6u ,,,",t "pM 11,. p'yd.WJ.t~ of ..ill,holdi"5 ..1,eI, ""dilog II,. P'yn.t"t. TI,. p'ydAtdd.l. of ..ilfJ,okh"g is II.~ dOl' &" ..Liel, .,,,6ul1t ..0; ..;!I,kld f,,,,,, !I,~ c",ploy,,', ,,'g~', You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments, 5. * Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employeeJobligor 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 #1 0 below) 6. Termination Notification: You must promptly notify the Requesting Agency when the employeeJobligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S 10: 9653000184 EMPLOYEE'S/OBlIGOR'S NAME: EMPLOYEE'S CASE IDENTIFIER: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: BLOSSER, THOMAS E, 5467100814 DATE OF SEPARATION: 7, Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 8. liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld 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, 9, Antkliscrimination: You are subject to a fine determined under State law for discharging an employeeJobligor from employment, refusing to employ, or taking disciplinary action against any employeeJobligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 10. * Withholding limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S,c. 91673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. 11, 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. Submitted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P,O, 80X 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (71 7) 240-6225 or by FAX at (7171 240-6248 or by internet www.childsupport.state.pa.us Service Type M Page 2 of 2 Form EN-028 Worker ID $IATT OMS No.: 0970-0154 ADDENDUM Summarv of Cases on Attachment Defendant/Obligor: BLOSSER, THOMAS E. PACSES Case Number 804103662 Plaintiff Name PATRICIA L. BLOSSER Docket Attachment Amount 03=4324 CIVIL $ 672.00 Child(ren)'s Name(s): D08 you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s); DaB you are required to enroll the child(ren) in any health insurance coverage available employee'slobligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0,00 Child(ren)'s Name(s); DaB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee'slobligor's employment. Service Type M Addendum OM6No.:097()..()154 PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0,00 Child(ren)'s Name(s): DaB you are required to enroll the child(ren) in any health insurance coverage available employee'slobligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s); DaB you are required to enroll the child(ren) in any health insurance coverage available employee'sfobligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s); DaB you are required to enroll the child(ren) in any health insurance coverage available employee'slobligor's employment. Form EN-026 Worker ID $IATT P IX tf ';;>"'!,\ ~:o-; .; c;.~"{, ,::..::<,:- "."-'.-- j;i~' ~ ~ %? ~ -<:- I C:l _0 -,~ >;? '0-; i{j;;g "71".., B? =;:il;} {;~15' (:SrI) 5~:! -'.1 " ~.) u., - ORDER/NOTICE TO WITHHOLD INCOME FOIR SUPPORT State Commonwealth of Pennsvlvania Co./City/Dist. of CUMBERLAND Date of Order/Notice 03/18/04 Tribunal/Case Number (See Addendum for case summary) RE: BLOSSER, 1?HOMAS E. Employee/Obligor's Name (Last, First, Ml) o Original Order/Notice @ Amended Order/Notice o Terminate Order/Notice EmployerM'ithholder's Federal EIN Number FEDERAL EMERGENY MANAGEMENT C/O PAYROLL DEPT 615 CHESTNUT ST PHILADELPHIA PA 19106-4404 195-32-0332 Employee/Obligor's Social Security Number 5467100814 Employee/Obligor's Case Identifier (See Addendum for plaintiff names _ (! / tI associated with cases on attachment) ]):I, .;;2LJtJ3 - 'i 3.).1.! ilL Custodial Parent's Name (last, First, MI) mrtC;f S 'toy I () 3M" >- See Addendum for dependent names and birth dates associat,ed with cases on attachment. ORDER INFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania, By law, you are required to deduct these amounts from the above-named employee'sfobligor's income until further notice even if the Order/Notice is not issued by your State. $ 650.00 per month in current support $ 0.00 per month in past-due support Arrears 12 weeks or greater? Oyes (2\) no $ 0.00 per month in medical support $ 0,00 per month for genetic test costs $ per month in other (specify) for a total of $ 650.00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the SUPPOlrt order, If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 150.00 per weekly pay period, $ 300.00 per biweekly pay period (every two weeks), $ 325.00 per semimonthly pay period (twice a month). $ 650.00 per monthly pay period, REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten 00) 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'sf obligor's aggregate disposable weekly earnings, For the purpose of the limitation on withholding, the following information is needed (See #10 on pg, 2), If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer SelVice at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL.,. .'......'.','...~ 'f'\>' . r~~r;:~ Date of Order:_MAR 1 9 ZOO/:.L:'3,~"~,?"O;"&ilYTHE COURT> SelVice Type M OMS No.: 0970{)15 J.. t:c Form EN-028 Worker ID $IATT ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS D If ~hecked you are required to prpvide a copy of this form to your employee.. If your employee works in a state that is differentfrom the state that issued this order, a copy must be provided to YOLlr employee even if the box is not checked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribailY-<lwned businesses, and Indian-<lwned businesses located on a reservation that choose to withhold in accordance with this notice. 2. 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. 3, Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding, You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 4.* Repo.t;lIg tile r'aydAl~at! o{V/;t1.I,oldil,g. YOu ,"tJ~t lepv,t lL~ pAydatc/dAt~ of nitl.hold;lIg nile!. S6ld;lIg tile paYII'~lIl. TI,t: p(\ydatelJdl~ of vvitl.l.old;lIg is the ddl~ Oil nl,id. 31110ullt vvas yyitl,l,~ld flOl1l t11~ l."ploy/:e's vvagl5. You must comply with the law of the state of the empioyee's/obiigor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 5. * Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Fed"ral or State withholding limits, you must follow the law of the state of employee's/obligor's principai place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #10 below) 6. Termination Notification: You must promptly notify the Requesting Agency when th,e employee/obligor is no longer working for you, Please provide the information requested and return a copy afthis Order/Notice to the Agency identified below. WITHHOLDER'S ID: 9653000184 EMPLOYEE'S/OBLlGOR'S NAME: EMPLOYEE'S CASE IDENTIFIER: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: BLOSSER, THOMAS E. 5467100814 DATE OF SEPARATION: 7. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 8. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law govems unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9. Anti-discrimination: You are subject to a fine determined under State iaw 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 iaw of the State in which he or she is employed governs. 10. * Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U,S.c. 91673 (b)1; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxesi and Medicare taxes. , 1, 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, Submitted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P,O, 80X 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 lZl.Zl. 240-6248 or by internet wWN.childsupport.state.pa,us Page 2 of 2 Form E N-028 Worker ID $IATT Service Type M OMB No.: 0970-0154 ADDENDUM Summary of Cases on Attachment Defendant/Obligor: BLOSSER, THOMAS E, PACSES Case Number 804103662 Plaintiff Name PATRICIA L, BLOSSER Docket Attachment Amount 03=4324 CIVIL$ 650,00 Child(ren)'s Name(s): PACSES Case Number Plaintiff Name DOB Docket Attachment Amount $ 0,00 Child(ren)'s r,ame(s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's1obligor's employment. o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Docket Attachment Amount $ 0,00 Child(ren)'s Name(s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's1obligor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0,00 Child(ren)'s Name(s): DOB Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's1obligor's employment. o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's1obligor's employment. Service Type M Addendum Form EN-028 Worker ID $IATT OMB No.: 097Q-0154 -,,"- -~:~ r'! f"'j e C1 >. (.":? c..J '" ~~5 () ..L..- -iT ;.;:: -'-- '.~ .--/ T fil :~:.T r--- -0;'7'] :=-':;cr) =;:j rr;~ ~:);;-~ . '-:J (, i _0 l'"\,) W ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of pennsylvania Co./City/Dist. of CUMBERLAND Date of Order/Notice 10/11/05 Case Number (See Addendum for case summary) 804103662 03-4324 CIVIL o Original Order/Notice o Amended Order/Notice @ Terminate Order/Notice FEDERAL EMERGENY MANAGEMENT C/O PAYROLL DEPT 615 CHESTNUT ST PHILADELPHIA PA 19106-4404 RE, BLOSSER, THOMAS E, Employee/Obligor's Name (last, First, Ml) 195-32-0332 Employee/Obligor's Social Security Number 5467100814 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Porent's Name (Last, First, MI) EmployerMlithholder's Federal fiN Number See Addendum for dependent names and birth dates associated with cases on attachment, ORDER /NFORMA TlON: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 0,00 per month in current support $ 0.00 per month in past-due support Arrears 12 weeks or greater? Oyes @ no $ 0 . 00 per month in current and past-due medical support $ 0 . 00 per month for genetic test costs $ per month in other (specify) for a total of $ 0.00 per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 0,00 per weekly pay period. $ 0,00 per biweekly pay period (every two weeks). $ 0,00 per semimonthly pay period (twice a month). $ 0,00 per monthly pay period, REM/TTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydateldate of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCOU Send check to: Pennsylvania seou, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER to (shown above as the Employee/Obligor's Cas.. Identifier) OR SOCIAL SECURITY NUMBER tN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. DID: R.J. Shadday Service Type M OM8 No.; 0970-015<1 Jtrlge form EN-028 Worker ID $IATT Date of Order: Ot;+ . /' 1~,)4I"-!> , ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS o If <;;hecked 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,* RefJull;"g tIle: raydetle/Dalt: of'/v';tl,l,oIJ;"g. YOl.Jlllu~l il:::lJv1t llu:; f-Iaydale/ddle of vv;tIIIIVJJ;lIlS VVlleH ~t:IIJ;llg tile fJaylllelll. Tile payJ,,'lt::.fJeIle vi vv;tl,ltold;Hg isll,e dale: ulI-VVI';LI. alllUullt vvas vv;lLl,dJ f'VIII tLe ~lIltJlvyee':.> VVc15fS. 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/08L1GOR NO LONGER WORKS FOR: 9653000184 EMPLOYEE'S/08L1GOR'S NAME: BLOSSER, THOMAS E , EMPLOYEE'S CASE IDENTIFIER: 5467100814 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 \0 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 I the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.c. 91673 (bl1; or 2) the amounts allowed by the State of the employees/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 underthe 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 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (7171 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 Form EN-02B Worker ID $IATT Service Type M OMBNo,:0910-0154 ADDENDUM Summary of Cases on Attachment Defendant/Obligor: BLOSSER, THOMAS E, PACSES Case Number 804103662 Plaintiff Name PATRICIA L, BLOSSER Docket Attachment Amount 03-4324 CIVIL$ 0,00 Child(ren)'s Name!s): PACSES Case Number Plaintiff Name DOB Docket Attachment Amount $ 0.00 Child!ren)'s Name!s): DOB you are required to enroll the child(ren) in any health insurance coverage available through the employee's/obligor's employment. you are required to enroll the child!ren) in any health insurance coverage available employee's/obligor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Docket Attachment Amount $ 0,00 Child!ren)'s Name!s): DOB o If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. If checked, you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment. PACSES Case Number Plaintiff Name PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Docket Attachment Amount $ 0.00 Child!ren)'s Name!s): DOB If checked, you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment. If checked, you are required to enroll the child(ren) in any health insurance coverage available employee's/obligor's employment. Addendum Form EN-028 Worker ID $IATT Service Type M OMB No.: U97Q-Q154 o ~ r-" c~'\ <::--> (:;4. c> c.) ~\ .\ Q\ ~- .....n -::-,'. s::- (";) t<~