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HomeMy WebLinkAbout91-0528ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania Co./City/Dist.Of CUMBERLAND Date of Order/Notice 12/26/07 Case Number (See Addendum for case summary) 503101246 O Original Order/Notice 91-528 CIVIL Q Amended Order/Notice Q Terminate Order/Notice Employer/Withholder's Federal EIN Number BJ'S WHOLESALE CLUB* C/O ATTN: PAYROLL 1 MERCER RD PO BOX 9601 NATICK MA 01760-9601 RE:ESPENSHADE, ARTIE C. Employee/Obligor's Name (Last, First, MI) 194-427714 Employee/Obligor's Social Security Number 6507100313 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachme~ Custodial Parent's Name (Last, First, MI) See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 1, 516.67 per month in current support $ o . o o per month i n past-due support Arrears 12 weeks or greater? Q yes ®no $ 0. oo Per month in current and past-due medical support $ o . oo per month for genetic test costs $ o . oo per month in other (specify) for a total of $ 1, 516.67 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: $ 350.00 ger weekly pay period. $ 700.00 per biweekly pay period (every two weeks). $ 758.34 per semimonthly pay period (twice a month). $ 1.516.67 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. 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 /NCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: Date of order: DEC 2 7 2007 M. L. EBERT, JR-, EDGE DRO: R. J, SHADDAY Form EN-028 Rev. 1 Service Type M OMBNo.:0970-0154 Worker ID $IATT 5'~' ~ ~~~*~~* 2~~ ~ 4~ ~t~p•atJ~ ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS ^ If~heckesl you are required, to provide a~opy of this form to your mployee. If yo r employee vyorks in a state tha is di Brent rrom the state that issued this or er, a copy must be provi~ed to your emp~oyee even if the box is not chec~ed. 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%bligor'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%bligor. 3.* . 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%bligoranct 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%bligor 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: 0433607470 EMPLOYEE'S/OBLIGOR'S NAME: ESPENSFiADE , ARTIE C . EMPLOYEE'S CASE IDENTIFIER: 6507100313 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%bligor'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%bligortrom employment, refusing to employ, or taking disciplinary action against any employee%bligorbBcause 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 govems. 9.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Ad (15 U.S.C. §1673 (b)t; or 2) the amounts allowed by the State of the emptoyee'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. t ~ .Submitted By: If you or your employee%bligor have any questions, DOMESTIC RELATIONS SECTION contact WAGE ATTACHMENT UNIT 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 Service Type M 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: ESPENSHADE, ARTIE C. PACSES Case Number 503101246 Plaintiff Name CONSTANCE M. ESPENSHADE Docket Attachment Amount 91-528 CIVIL $ 1,516.67 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 $ o.oo 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 $ o.oo 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 $ o.oo 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 $ o.oo 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 ~ ~ `~i `~' ~ ~ .:~ ~ ~ r'~ J crt-~ ~-~- S-Z~ t C '7 "C> ['n .-7~ (~J 1'> . ~ _ + ~ J ~_. .~ ~'1 ,l~ CrJ .~C, In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION CONSTANCE M. ESPENSHADE ) Docket Number: 91-528 CIVIL Plaintiff ) VS. ) PACSES Case Number: 503101246 ARTIE C. ESPENSHADE ) Defendant ) Other State ID Number: Order AND NOW to wit, this OCTOBER 9, 2013 it is hereby Ordered that: The Cumberland County Domestic Relation Section dismiss their interest in the f ; above captioned alimony matter pursuant to the demise of the Petitioner, - _� Constance M. Espenshade, on September 26, 2013. r cm r -4 The account is closed with no balance due. r- --� --; 7>'n BY THE COURT: 11\4\ U)-A M.l. Ebert,.Jr. JUDGE Form 0E-520 02/11 Service Type M Worker ID 21205 INCOME WITHHOLDING FOR SUPPORT 3 1 O ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO) O AMENDED IWO • ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT Q TERMINATION OF IWO Date: 10/03/13 ❑ Chilii Support Enforcement(CSE)Agency ® Court ❑ Attorney ❑ Private Individual/Entity(Check One) NOTE:This IWO mwt jar pr ij face. Under certain circumstances you must reject this IWO and return it to the sender(see IWO instructions htto://wdi64 on+ r'dgrams/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. State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 6507100313 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket informaiton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) BJ'S WHOLESALE CLUB RE: ESPENSHADE,ARTIE C. 25 RESEARCH DRIVE Employee/Obligor's Name(Last, First, Middle) WESTBOROUGH MA 01581 194-42-7714 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 Withholder's FEIN 043360747 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 htto://www.acf.hhs.gov/orograms/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. 0433607470 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 fro ,the.empforee/ obligor's income until further notice. $ 0.00 per month in current child support ,ri rz o ;19t $ 0.00 per month in past-due child support- Arrears 12 weeks or greater? 0 j c ' r�, P P PP g ye� nog �;n $ 0.00 per month in current cash medical support cnc I c $ 0.00 per month in past-due cash medical support -- --' $ 0.00 per month in current spousal support 'C° -© -�' $ 0.00 per month in past-due spousal support c� $ 0.00 per month in other(must specify) A ' 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 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/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 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 21205 ❑ 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: OCT 0 3 2013 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 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 Employee/Obligor'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.act hhs.gov/brograms/cse/newhire/eMDloyer/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. 0MB 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 21205 Employer's Name: BJ'S WHOLESALE CLUB Employer FEIN: 043360747 Employee/Obligor's Name: ESPENSHADE,ARTIE C. 6507100313 CSE Agency Case Identifier:(See Addendum for case summary) 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 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: 0433607470 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: 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.Da.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,childsupport.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 21205 ADDENDUM Summary of Cases on Attachment Defendant/Obligor: ESPENSHADE, ARTIE C. PACSES Case Number 503101246 PACSES Case Number Plaintiff Name Plaintiff Name CONSTANCE M. ESPENSHADE Docket Attachment Amount Docket Attachment Amount 91-528 CIVIL $ 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 Amount Docket Attachment 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 Amount Docket Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB Addendum Form EN-028 06/12 Service Type M OMB No 0970-0154 Worker ID 21205