Loading...
HomeMy WebLinkAbout08-1766DAVID BLACK, Plaintiff V. BARBARA A. BLACK, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. of - 171j6 &4,.0 CIVIL ACTION - LAW DIVORCE NOTICE TO DEFEND AND CLAIM RIGHTS YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take prompt action. You are warned that if you fail to do so, the case may proceed without you and a decree of divorce or annulment may be entered against you by the Court. A judgment may also be entered against you for any other claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rights important to you, including custody of or visitation with your children. When the ground for divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. A list of marriage counselors is available in the Office of the Prothonotary at the Cumberland County Courthouse, 1 Courthouse Square, 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, 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 S. BEDFORD STREET CARLISLE, PA 17013 (717) 249-3166 or 800-990-9108 DAVID BLACK, Plaintiff V. BARBARA A. BLACK, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ?','v7 1 cr,?. NO. 0? 4e CIVIL ACTION - LAW DIVORCE COMPLAINT IN DIVORCE 1. Plaintiff is David Black, an adult individual whose current mailing address is 102 North Middlesex Road, Carlisle (Cumberland County), Pennsylvania 17013. 2. Defendant is Barbara A. Black, an adult individual whose current mailing address is 109 Wyncote Court, Mechanicsburg (Cumberland County), Pennsylvania 17055. 3. Plaintiff has been a bona fide resident in the Commonwealth for at least six months immediately previous to the filing of this complaint. 4. Plaintiff and Defendant were married on October 1, 1988, in Harrisburg, Pennsylvania. 5. Plaintiff and Defendant have two children: Daniel Florian Black (DOB 7/25/1988) and Sabrina Jo Black (DOB 12/1/1994). 6. There has been no prior action for divorce or annulment between the parties. 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. 8. Defendant is not a member of the Armed Services. 9. Plaintiff avers that the ground on which the action is based is the marriage is irretrievably broken. WHEREFORE, Plaintiff requests the court to enter a Decree in Divorce dissolving the marriage between the parties pursuant to Section 3301(c) of the Divorce Code of 1980, as amended. Respectfully Submitted, Eliz Beth A. Hoffmarf, squire Attorney for Plaintiff 106 Walnut Street Harrisburg, PA (717) 236-2956 1 D #71000 VERIFICATION I verify that the information provided in the attached document is 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.A. §4904, relating to unsworn falsification to authorities. d?oZ Q Date: David lack CERTIFICATE OF SERVICE I, Elizabeth A. Hoffman, Esquire, do hereby certify that a true and correct copy of the attached complaint was sent by certified, restricted mail to the following person: Barbara A. Black 109 Wyncote Court Mechanicsburg, PA 17055 Date: 311 qO y 44"4'? d ?W? liza th A. Hoffman, uire Attorney for Plaintiff 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 1 D #71000 C`r rv ? TANNER LAW OFFICES, LLC 1300 Market Street, Suite 10 Lemoyne, PA 17043 Telephone: (717) 731-8114 Facsimile: (717) 731-8115 BARBARA ANN BLACK, § Plaintiff § V. § DAVID JOHN BLACK, § Defendant § IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-1766 CIVIL CIVIL ACTION - IN DIVORCE PETITION TO PROCEED IN FORMA PAUPERIS To the Prothonotary: Kindly allow Barbara Ann Black, Plaintiff, to proceed in forma pauperis I, Tabetha A. Tanner, attorney for the party proceeding in forma pauperis, certify that I believe the party is unable to pay the costs and that I am providing free legal service to the Plaintiff. By: %?2a 4 4, Tabetha A. Tanner, Esquire Supreme Court I.D. No.: 91979 Attorney for Plaintiff TANNER LAW OFFICES, LLC 1300 Market Street, Suite 10 Lemoyne, PA 17043 (717) 731-8114 t ?'' - , ; t I .,....A _ ?. l?J -t Y- _ TANNER LAW OFFICES, LLC 1300 Market Street, Suite 10 Lemoyne, PA 17043 Telephone: (717) 731-8114 Facsimile: (717) 731-8115 DAVID BLACK, § IN THE COURT OF COMMON PLEAS OF Plaintiff/Respondent § CUMBERLAND COUNTY, PENNSYLVANIA V. § NO. 08-1766 CIVIL BARBARA BLACK, § CIVIL ACTION - IN DIVORCE Defendant/Petitioner § PETITION FOR COUNSELING PURSUANT TO SECTION 3302 OF THE DIVORCE CODE AND NOW, comes the Petitioner, Barbara Black, by and through her attorney, Tanner Law Offices, LLC, and files this Petition for Counseling Pursuant to Section 3302 of the Divorce Code and, in support thereof, respectfully represents as follows: 1. Petitioner is Barbara Black, Defendant in this action, who currently resides at 109 Wyncote Court, Mechanicsburg, Cumberland County, Pennsylvania 17013. 2. Respondent is David Black, Plaintiff in this action, who currently resides at 102 North Middlesex Road, Carlisle, Cumberland County, Pennsylvanai 17055. 3. The parties are husband and wife, having been married on October 1, 1988. 4. On or about March 19, 2008, Respondent filed a Complaint in Divorce under section 3301(c) of the Divorce Code, with the Court of Common Pleas of Cumberland County, Pennsylvania, a copy of which is attached hereto as Exhibit "A". 5. Despite the averments contained in said Complaint, it is believed and averred that the marital differences are not irreparable. 6. It is averred that there is a reasonable prospect of reconciliation. 7. Section 3302(a) provides that upon the request of either party, the Court must require up to three counseling sessions whenever Section 3301(c) of the Divorce Code has been alleged as the grounds of divorce. WHEREFORE, Petitioner, Barbara Black, requests this Honorable Court continue the above-captioned divorce action and order the parties to participate in a maximum of three counseling sessions with a qualified professional as provided in the Divorce Code. Respectfully submitted, By: a" 4' G" W,"t- Tabetha A. Tanner, Esquire Supreme Court I.D. No.: 91979 Attorney for Petitioner TANNER LAW OFFICES, LLC 1300 Market Street, Suite 10 Lemoyne, PA 17043 (717) 731-8114 VERIFICATION I verify that the statements made in this Petition for Counseling Pursuant to Section 3302 of the Divorce Code are true and correct. I understand that false statements made herein may subject me to penalties of Pa.C.S. §4904 relating to unswom falsification to authorities. yli?I?uP Date ?"?bw C, Barbara Black, Defendant f- TANNER LAW OFFICES, LLC 1300 Market Street, Suite 10 Lemoyne, PA 17043 Telephone: (717) 731-8114 Facsimile: (717) 731-8115 DAVID BLACK, § Plaintiff/Respondent § V. § BARBARA BLACK, § Defendant/Petitioner § IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-1766 CIVIL CIVIL ACTION - IN DIVORCE DEFENDANT'S COUNTERCLAIM TO PLAINTIFF'S COMPLAINT IN DIVORCE AND NOW, comes the Defendant, Barbara Black, by and through her attorney, Tanner Law Offices, LLC, and raises additional counts to the above referenced Divorce Complaint as follows: COUNT I - EQUITABLE DISTRIBUTION OF MARITAL PROPERTY UNDER SECTION 3502(A) OF THE DIVORCE CODE 1. Plaintiff and Defendant have acquired marital property as defined by the Divorce Code, which is subject to equitable distribution pursuant to Section 3502(a) of the Divorce Code. 2. Plaintiff and Defendant have been unable to agree as to the equitable division of said property, as of the date of the filing of this Amended Complaint. 3. Defendant requests that this Court equitably divide, distribute or assign the marital property between the parties. WHEREFORE, Plaintiff respectfully requests that this Court enter an order of equitable distribution of marital property pursuant to Section 3502(a) of the Divorce Code. COUNT II - ALIMONY 4. Paragraphs 1 through 3 are incorporated herein by reference as though set forth in full text. 5. Defendant lacks sufficient income potential to maintain herself at a lifestyle similar to that which she enjoyed during the marriage subsequent to the entry of a divorce decree. Plaintiff has the earning potential and ability to maintain Defendant subsequent to the entry of a divorce. WHEREFORE, Plaintiff requests this court enter an order granting her alimony as the Court deems appropriate. Respectfully submitted, -;; ?? wo, A ?alo ? Tabetha A. Tanner, Esquire Supreme Court I.D. No.: 91979 Attorney for Plaintiff TANNER LAW OFFICES, LLC 1300 Market Street, Suite 6 Lemoyne, PA 17043 (717) 731-8114 VERIFICATION I verify that the statements made in this Defendant's Counterclaim to Plaintiff's Complaint in Divorce are true and correct. I understand that false statements made herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. Date: yqLov Barbara Black i .. ° ? rT TANNER LAW OFFICES, LLC 1300 Market Street, Suite 10 Lemoyne, PA 17043 Telephone: (717) 731-8114 Facsimile: (717) 731-8115 DAVID BLACK, § IN THE COURT OF COMMON PLEAS OF Plaintiff/Respondent § CUMBERLAND COUNTY, PENNSYLVANIA V. § NO. 08-1766 CIVIL BARBARA BLACK, § CIVIL ACTION - IN DIVORCE Defendant/Petitioner § RULE TO SHOW CAUSE AND NOW, this Y) ih day of Ma: 2008, upon consideration of the foregoing Petition for Counseling Pursuant to Section 3302 of the Divorce Code, the Court grants a rule upon the Plaintiff, David Black, to show cause why the prayer of the Petitioner should not be granted. RULE RETURNABLE and an answer thereon to be filed no later than the I C day of e. , 2008 at 4 3Q o'clock, P ..M. BY THE COURT: cb IC-1 cloo 93., f? ??Lltivr ' rsw. ?f_,' -,•1rll r?l ?A+ 7 Llt? -So/sr/-7 Elizabeth A. Hoffman, Esquire 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 DAVID BLACK, Plaintiff V. BARBARA A. BLACK, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-1766 CIVIL ACTION - LAW DIVORCE PLAINTIFF'S RESPONSE TO PETITION FOR COUNSELING PURSUANT TO SECTION 3302 OF THE DIVORCE CODE AND NOW comes Plaintiff David Black ("Respondent"), by and through his attorney, Elizabeth A. Hoffman, to show cause why the Petition for Counseling of Defendant Barbara Black ("Petitioner") should not be granted by respectfully providing the following response: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Denied. The "differences" between Respondent and Petitioner are long term and irresolveable. 6. Denied. Respondent has never said nor done anything which could cause Petitioner to believe that "reconciliation" is a possibility. Indeed, the parties have been living separate and apart for 20 months, and Respondent is preparing to end the marriage by finalizing the divorce decree. Accordingly, counseling sessions would be a waste of time and money. 7. This averment is a conclusion of law to which no response is required. WHEREFORE, Respondent requests that this Honorable Court issue an order to deny the petition for counseling and to allow Respondent to continue to finalize the divorce proceedings. Respectfully submitted, Eliza th A. Hoffman, uire Attorney for Respond e t/Plaintiff 106 Walnut Street Harrisburg, PA (717) 236-2956 1D #71000 2 VERIFICATION I verify that the information provided in the attached document is 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.A. §4904, relating to unsworn falsification to authorities. Date: ?qlt D ack CERTIFICATE OF SERVICE I, Elizabeth A. Hoffman, Esquire, do hereby certify that a true and correct copy of the attached document was sent by U.S. mail to the following person: Tabetha Tanner, Esquire Tanner Law Offices, LLC 1300 Market Street - Suite 10 Lemoyne, PA 17043 Date: 611;-10 Y 4Z,4-- '!?Iizat(kh A. Hoffman, quire Attorney for Respondent/Plaintiff 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 1 D #71000 C:2 -ct t , om' - DAVID BLACK, IN THE COURT OF COMMON PLEAS OF PLAINTIFF CUMBERLAND COUNTY, PENNSYLVANIA V. BARBARA A. BLACK, DEFENDANT NO. 08-1766 CIVIL ORDER OF COURT AND NOW, this 18th day of June, 2008, upon consideration of the Defendant's Petition for Counseling and the Response of the Plaintiff, IT IS HEREBY ORDERED AND DIRECTED that a status conference shall be held on Wednesday, July 2, 2008, at 1:30 p.m. in the chambers of Courtroom No. 5 of the Cumberland County Courthouse, Carlisle, Pennsylvania. By the Court, /Elizabeth A. Hoffman Esquire Attorney for Plaintiff ' Tabetha A. Tanner, Esquire Attorney for Defendant bas cc? 1ES m3iLC ?/!8/08 ru -4, UA- M. L. Ebert, Jr., J. I :Z Wd $ ! n 8001 AMONUS hi,, d 3Hi JO DAVID BLACK, IN THE COURT OF COMMON PLEAS OF PLAINTIFF CUMBERLAND COUNTY, PENNSYLVANIA V. BARBARA A. BLACK, DEFENDANT NO. 08-1766 CIVIL ORDER OF COURT AND NOW, this 2nd day of July, 2008, upon consideration of the Defendant's Petition for Counseling Pursuant to §3302 of the Divorce Code, the Plaintiff's Answer thereto and after status conference with counsel, IT IS HEREBY ORDERED AND DIRECTED that the Plaintiff and the Defendant shall attend 3 counseling sessions with a qualified professional; IT IS FURTHER ORDERED AND DIRECTED that prior to the counseling sessions beginning, the Defendant, Barbara A. Black, shall: A. Provide to the Court, the name of a qualified counselor along with the counselor's curriculum vitae and the hourly rate for counseling; B. The Defendant shall pay in full the amount of the 3 counseling sessions to the counselor; C. Counseling sessions shall not extend more than one hour without the express agreement of both parties. By the Court, lizabeth A. Hoffman, Esquire Attorney for Plaintiff J ,Yabetha A. Tanner, Esquire Attorney for Defendant bas ?_a M. L. Ebert, Jr., J. 0) VWA.VOtQd KLNnoo, W OW ;O[WV Lw -.-I DAVID BLACK, Plaintiff V. BARBARA A. BLACK, Defendant TO: BARBARA A. BLACK IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-1766 CIVIL ACTION - LAW DIVORCE NOTICE If you wish to deny any of the statements set forth in this affidavit, you must file a counter-affidavit within twenty days after this affidavit has been served on you or the statements will be admitted. AFFIDAVIT UNDER SECTION 3301(d) OF THE DIVORCE CODE 1. The parties to this action separated in mid-October 2006 and have continued to live separate and apart for over two years 2. The marriage is irretrievably broken. 3. 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. 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. §4904 relating to unsworn falsification to authorities. Date: 4*_ avi BI r?a r%.' r-n. - D Elizabeth A. Hoffman, Esquire 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE PLAINTIFF'S AMENDED COMPLAINT IN DIVORCE AND NOW comes Plaintiff David Black ("Plaintiff'), by and through his attorney, Elizabeth A. Hoffman, to amend the complaint in divorce as follows: COUNT 2 REQUEST FOR DIVORCE DECREE UNDER SECTION 3301(D) OF THE DIVORCE CODE 10. Paragraphs 1 through 9 are incorporated herein and by reference thereto. 11. On January 15, 2009, Plaintiff filed an Affidavit Under Section 3301(d) of the Divorce Code. (Attached as Exhibit "A") 12. The Affidavit was sent by regular mail to Defendant Barbara Black's attorney, Tabetha Tanner, Esquire, on or about January 14, 2009. WHEREFORE, it is respectfully requested that this Honorable Court enter a Decree in Divorce pursuant to Section 3301(d) of the Divorce Code. Respectfully submitted, dt"??4w Eliza th A. Hoffman, quire Attorney for Plaintiff 106 Walnut Street Harrisburg, PA (717) 236-2956 ID #71000 DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE cr; NOTICE TO: BARBARA A. BLACK.; If you wish to deny any of the statements set forth in this affidavit, you must file a counter-affiidavit within twenty days after this affidavit has been served on you or the statements will be admitted. AFFIDAVIT UNDER SECTION 3301(d) OF THE DIVORCE CODE 1. The parties to this action separated in mid-October 2006 and have continued to live separate and apart for over two years 2. The marriage is irretrievably broken. 3. 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. 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. §4904 relating to unsworn falsification to authorities. Date: 11710?? avi Bla-61k f CERTIFICATE OF SERVICE I, Elizabeth A. Hoffman, Esquire, do hereby certify that a true and correct copy of the attached document was sent by U.S. mail to the following person: Tabetha Tanner, Esquire Tanner Law Offices, LLC 1300 Market Street - Suite 10 Lemoyne, PA 17043 Date: 3I O 6"v- ?- / ? Eliza th A. Hoffman squire Attorney for Plaintiff 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 1 D #71000 ILO r. r ., Elizabeth A. Hoffman, Esquire 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE MOTION TO COMPEL DEFENDANT TO WITHDRAW COUNTERCLAIMS AND NOW comes Plaintiff David Black ("Plaintiff'), by and through his attorney, Elizabeth A. Hoffman, to request that an order be issued on Defendant Barbara A. Black ("Defendant"), directing her to withdraw her Counterclaims, and in support thereof Plaintiff respectfully avers the following: 1. On March 22, 2008, Plaintiff filed a Complaint in Divorce. 2. On May 19, 2008, Defendant filed a Counterclaim to the divorce complaint. 3. Said counterclaim contained two counts: Count I was for Equitable Distribution and Count 11 was for Alimony. 4. On May 19, 2008, Defendant also filed a petition for marital counseling. 5. Defendant filed a response in which he maintained that marital counseling would not resolve the parties' differences. 6. On July 2, 2008, the Honorable M.L. Ebert, Jr., held an in-chambers conference with the parties' counsel and subsequently entered an order to grant Defendant's petition but directing Defendant to arrange for the counseling and to pay the costs of the sessions. 7. Defendant never scheduled the marital counseling. 8. On January 7, 2009, Plaintiff filed an Affidavit of Separation as required by Section 3301(d) of the Divorce Code. 9. On January 14, 2009, Plaintiff's counsel served a copy of the affidavit on Defendant via her counsel. 10. Along with the affidavit, Plaintiffs counsel sent a letter Defendant's attorney requesting that she have her client withdraw her counterclaims. Plaintiff's counsel pointed out that Plaintiff had provided Defendant's counsel, as per her request, a copy of the current value of his pension ($10,395.85) and that Defendant had never responded to Plaintiff's inquiry regarding the value of any 401 Ks or pensions which she possessed. Plaintiff's counsel also suggested that both parties had minimal retirement monies and that there seemed to be no reason to pursue an equitable distribution claim. 11. Defendant's attorney never responded to the aforesaid letter. 12. On March 6, 2009, Plaintiff filed an Amended Complaint wherein he included a request for divorce under Section 3301(d) and served a copy on Defendant. 13. On April 7, 2009, Plaintiff's counsel sent Defendant's attorney a Notice of Intention to Request a Divorce Decree, along with a letter wherein it was again requested that the counterclaims be withdrawn. 14. Defendant's counsel never responded to the letter. 15. On May 6, 2009, Plaintiff's counsel finally reached Defendant's attorney 2 on the phone. 16. At that time it was learned that Defendant did not plan to file for a Master, nor did she plan to file a motion to withdraw the counterclaims. 17. By refusing to act in any way on the counterclaims, Defendant's behavior has become deliberately obdurate and vexatious. 18. Not only does she refuse to act on the counterclaims, she has not provided Plaintiff with any information about any pensions or 401 Ks in her name. 19. Defendant has therefore shown that she is not interested in pursuing equitable distribution but, instead, has demonstrated an intent to prevent Plaintiff from obtaining a divorce decree. 20. In addition, Plaintiff has provided no evidence to show that she would be entitled to alimony. WHEREFORE, it is respectfully requested that this Honorable Court issue an order to compel Defendant to withdraw her counterclaims and to grant any other relief which the Court deems appropriate. Respectfully submitted, Eliz eth A. Hoffm , Esquire Attorney for Plaintiff 106 Walnut Street Harrisburg, PA (717) 236-2956 ID #71000 3 VERIFICATION I verify that the information provided in the attached document is 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.A. §4904, relating to unsworn falsification to authorities. Date: V6 (?izabeth A. H man CERTIFICATE OF SERVICE I, Elizabeth A. Hoffman, Esquire, do hereby certify that a true and correct copy of the attached document was sent by U.S. mail to the following person: Tabetha Tanner, Esquire Tanner Law Offices, LLC 1300 Market Street - Suite 10 Lemoyne, PA 17043 Date: 4/0? Eliza e h A. Hoffman, E ire Attor y for Plaintiff 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 ID #71000 HLBOr 01"' THE F" r ? 2009 MAY ' 1 F,11 i I F, S ? iJ J DAVID BLACK, PLAINTIFF V. BARBARA A. BLACK, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : NO. 08-1766 CIVIL ORDER OF COURT AND NOW, this 3'd day of June, 2009, upon consideration of the Plaintiffs Motion to Compel Defendant to Withdraw Counterclaims, IT IS HEREBY ORDERED AND DIRECTED that: 1. A Rule is issued upon the Defendant to show cause why the relief requested should not be granted; 2. The Defendant will file an answer on or before June 19, 2009; 3. If no answer to the Rule to Show cause is filed by the required date, the relief requested by Plaintiff shall be granted upon the Court's receipt of a Motion requesting Rule be made Absolute. If the Defendant files an answer to this Rule to Show Cause, the Court will determine if further order or hearing is necessary. 4. The Prothonotary is directed to forward said Answer to this Court. ZErizabeth A. Hoffman, Esquire Attorney for Plaintiff Tabetha Tanner, Esquire Attorney for Defendant bas ?p? es /"t(.!E? 1. By the Court, * I M. L. Ebert, Jr., J. f t; `y' s i -vvino TANNER LAW OFFICES, LLC 1300 Market Street, Suite 10 Lemoyne, PA 17043 Telephone: (717) 731-8114 Facsimile: (717) 731-8115 DAVID BLACK, § IN THE COURT OF COMMON PLEAS OF Plaintiff § CUMBERLAND COUNTY, PENNSYLVANIA V. § NO. 08-1766 CIVIL BARBARA BLACK, § CIVIL ACTION - IN DIVORCE Defendant § DEFENDANT'S ANSWER TO PLAINTIFF'S MOTION TO COMPEL DEFENDANT TO WITHDRAW COUNTERCLAIMS AND NOW, comes the Defendant, Barbara Black, by and through her attorney, Tanner Law Offices, LLC, and provides the following responses to Plaintiff's Motion: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Admitted. 6. Admitted. 7. Admitted. Answering further, Defendant still wishes to have marital counseling, but can in no fashion afford to pay 100% of the counseling expenses. As such, she is unable to obtain the counseling she believes may be beneficial to the couple. Defendant was referred to counsel through Mid Penn Legal Services as qualifying for free legal services and counsel is representing Defendant on a pro bono basis. 8. Admitted. 9. Admitted. 10. Admitted in part. Denied in part. The letter sent to Defendant's counsel on January 14, 2009 "[suggested] that Ms. Black withdraw her claim for a marital settlement agreement" and also acknowledged that there are other issues other than the retirement account at issue, including, but not limited to a marital vehicle that was repossessed and which the parties owe fees toward. However, she made no suggestions as to settlement other than that Defendant should absorb 100% of the repossession fees. 11. Admitted. Defendant's counsel spoke with Defendant who stated that in December Plaintiff and Defendant spoke and Plaintiff told Defendant that he would not be pursuing the divorce at this time, that he "put it on hold to make the holiday easier." Assuming that lines of communication had crossed with Plaintiffs counsel, and feeling that no response was required of Plaintiffs counsel's "suggestion" without merit, knowing the equitable distribution and alimony matters had to be addressed, no response was rendered. 12. Admitted. 13. Admitted. Answering further, Plaintiff's counsel filed a document entitled "Notice of Intention to Request Entry of Final Decree" which was not in the proper format and which did not include the required Counter-Affidavit. Also attached was a proposed Praecipe to Transmit which stated "Related Matters pending: None." It is not Defendant's counsel's responsibility to inform Plaintiff s counsel of the proper format of a Notice of Intention to Request a Divorce or of the requirement to provide a counter-Affidavit, or of the requirement to give 20 days notice before filing the Praecipe, or of the requirement that the Praecipe to transmit must include the actual status of the case (i.e. that there are other claims pending - equitable distribution and alimony) and not her desired status. 14. Admitted. 15. Admitted. 16. Admitted in part. Denied in part. It is admitted that Defendant's counsel stated that there was absolutely no intention of withdrawing the counterclaims as the property still needs to be divided and my client is in need of alimony in the future. It is admitted that Defendant's counsel stated that at this point, Defendant is not ready to proceed to a Master's hearing. Defendant still believes that the marriage can be reconciled and also requires the medical insurance that she would not be entitled to once the divorce is final. Defendant's counsel also stated that if Plaintiff's counsel wishes to move this matter forward in a more expeditious matter than Defendant, she may file for the Master's hearing. Defendant's counsel is acting in Defendant's best interest and is not violating any rule of civil procedure or statutory provision in not filing for a Master's hearing on Plaintiffs' counsel's schedule. 17. Denied. We have discussed the property and the need for alimony. Plaintiff's counsel has never addressed the alimony, has not addressed the vehicles in both parties name or the re-possession costs. She has requested the documents on the retirement account which my client is still trying to obtain. We have no objection to providing this document when it is received and will do so (as expressed to counsel in our telephone conversation on May 6, 2009). 18. Please see response to # 17 above. 19. Denied. Defendant has every intention of pursuing not only her claim for equitable distribution but for alimony as well. Plaintiff is in no way being prevented from obtaining a divorce decree. If he does not feel that the case is moving quickly enough, there are a variety of legal avenues for speeding the process along (however, simply "suggesting" that Defendant withdraw her very valid counterclaims to move the matter along more quickly is not one of them). 20. Admitted. Answering further, Plaintiff has also not filed her client's Inventory, Income and/or Expense Statement, has never sought any information regarding alimony for Defendant, has not made any settlement proposals for said counterclaim and simply stated in a letter of June 12, 2008 (one of only 3 letters sent by Plaintiff s counsel over the past year - other than those attached as cover letters to legal filings) that due to the child support received by Defendant, she did not believe that alimony would be warranted after the divorce. WHEREFORE, Plaintiff respectfully requests that this Court to deny Plaintiff's Motion to Compel Defendant Withdraw Counterclaims. Respectfully submitted, 1,z?a 4 Tabetha A. Tanner, Esquire Supreme Court I.D. No.: 91979 Attorney for Plaintiff TANNER LAW OFFICES, LLC 1300 Market Street, Suite 6 Lemoyne, PA 17043 (717) 731-8114 VERIFICATION I verify that the statements made in this Defendant's Answer to Plaintiff's Motion to Compel Defendant to Withdraw Counterclaims are true and correct. I understand that false statements made herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. Date: Co Ioh6 a l-I ?Q/Lfi?to?c Tabetha Tanner . , . • TANNER LAW OFFICES, LLC 1300 Market Street, Suite 10 Lemoyne, PA 17043 Telephone: (717) 731-8114 Facsimile: (717) 731-8115 DAVID BLACK, § IN THE COURT OF COMMON PLEAS OF Plaintiff/Respondent § CUMBERLAND COUNTY, PENNSYLVANIA V. § NO. 08-1766 CIVIL BARBARA BLACK, § CIVIL ACTION - IN DIVORCE Defendant/Petitioner § CERTIFICATE OF SERVICE I HEREBY CERTIFY that I served a copy of Defendant's Answer to Plaintiff's Motion to Compel Defendant to Withdraw Counterclaims filed in the above-captioned matter upon the following person(s), by regular, first-class U.S. mail, addressed as follows: Elizabeth A. Hoffman, Esquire 106 Walnut Street Harrisburg, Pennsylvania 17101 Date: 0 Respectfully submitted, Tabetha A. Tanner, Esquire Supreme Court I.D. No.: 91979 FILED-0ff"CE UE TFiE P,=",-)- i '''NOTARY 2009 JUN 10 Ph 1: 31 CUFv1F???`` MY Q, ?A DAVID BLACK, PLAINTIFF V. BARBARA A. BLACK, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-1766 CIVIL ORDER OF COURT AND NOW, this 3`d day of August, 2009, upon consideration of the Plaintiff's Motion to Compel Defendant to Withdraw Counterclaims and the Defendant's Answer thereto, IT IS HEREBY ORDERED AND DIRECTED that the Plaintiff's Motion to Compel Defendant to Withdraw Counterclaims is DENIED. This Court strongly suggests that the parties file for a Master in order to settle their economic claims. By the Court, Elizabeth A. Hoffman, Esquire Attorney for Plaintiff --AtTabetha Tanner, Esquire Attorney for Defendant bas *-,? ?JA\ M. L. Ebert, Jr., J. FILL}_; OF TNC T:RY 2GO9 AUG --3 P 1 1: 27 f ty `r Elizabeth A. Hoffman, Esquire 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE MOTION FOR APPOINTMENT OF MASTER Plaintiff David Black moves the court to appoint a master with respect to the following claims: (x) Divorce ( ) Annulment (x) Alimony ( ) Alimony Pendente Lite (x) Distribution of Property ( ) Support ( ) Counsel Fees ( ) 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. Plaintiff has submitted his statements of Income and Expense and of Debt and Assets to Defendant, and is waiting discovery from Defendant. (2) Defendant, the non-moving party, has appeared in the action by her attorney, Tabetha Tanner, Esquire. (3) The statutory ground(s) for divorce are Sections 3301(c) and (d) of the Code. (4) The following paragraph is applicable: (c) The action is contested with respect to the following claims: Defendant filed counterclaims requesting alimony and equitable distribution. (5) The action does not involve complex issues of law or fact. (6) The hearing is expected to take 1 to 2 hours at most as Plaintiff has very few assets. Date: l0?2,6 09 &6" X liz th A. Hoffman Attorney for Plaintiff 2 1• VERIFICATION verify that the information provided in the attached document is 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.A. §4904, relating to unsworn falsification to authorities. Date: /o D9 ei4'e'L& vimx_ lizabeth A. Ho an CERTIFICATE OF SERVICE I, Elizabeth A. Hoffman, Esquire, do hereby certify that a true and correct copy of the attached document was sent by U.S. mail to the following person: Tabetha Tanner, Esquire Tanner Law Offices, LLC 1300 Market Street - Suite 10 Lemoyne, PA 17043 Date:1 Dy Eliz th A. Hoffman, quire Attorney for Plaintiff 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 1 D #71000 FILED-tr rlCE IF THE PROTHONMARY 2099 OCT 27 PM 1: 11 DAVID BLACK, Plaintiff V. BARBARA A. BLACK, Defendant ,2009 ORIGINAL OCT 2 (;, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-1766 CIVIL ACTION - LAW DIVORCE ORDER APPOINTING MASTER 0A_ AND NOW, this day oP2009, A- )i &2e2A01 Esquire, is appointed master with respect to the following claims: (1) Alimony (2) Equitable Distribution (3) Divorce BY O 7f URT: o J. Distribution: Master lizabeth A. Hoffman, Esquire, 106 Walnut Street, Harrisburg, PA 17101 ,-'ra'betha Tanner, Esquire W F S ? ! v?z? jo 1 Fl FF OF THE PROTHONOTARY 2009 OCT 28 PM 4: 14 PENNSYLVANIA ORIGINAL DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE PLAINTIFF'S STATEMENT OF ASSETS AND DEBTS ASSETS (1) 1995 Chevrolet K1500 Truck Approximate Value 2500 (2) Pension - Employer (3) Checking account DEBTS (1) VISA Credit Card (2) Sears Credit Card Purchased 2003 Value $10.395.85 as of 7/15/08 Current Balance $100 Current balance $6272.00 Current balance $923.00 VERIFICATION I verify that the information provided in the attached Plaintiffs Statement of Assets is 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.A. §4904, relating to unsworn falsification to authorities. Date: 10/13/01- 0 1 C.- David Black CERTIFICATE OF SERVICE I, Elizabeth A. Hoffman, Esquire, do hereby certify that a true and correct copy of the attached document was sent by U.S. mail to the following person: Tabetha Tanner, Esquire Tanner Law Offices, LLC 1300 Market Street - Suite 10 Lemoyne, PA 17043 Date: & J"' M , Eli eth A. Hoffma , Esquire Attorney for Plaintiff 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 1 D #71000 Tre {}? 1' 11 2041 ?? 21 PIK ORIGINAL DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, Defendant CIVIL ACTION - LAW DIVORCE PLAINTIFF'S INCOME AND EXPENSE STATEMENT INCOME Employer: Quaker City Motor Parts Position: Driver/Warehouse Pay Period (weekly, biweekly, monthly): Biweekly Gross salary per pay period: 1360.00 Deductions: Federal Withholding Tax $ 101.13 Social Security 70.19 Medicare 16.42 State Income Tax 34.76 Local Wage Tax 18.12 Retirement (mandatory) 0 Child support 369.23 Insurance - Health/Dental 227.97 - Life 20.92 Net salary per pay period: $ 501.26 TOTAL NET MONTHLY INCOME $ 1085.23 EXPENSES MONTHLY YEARLY Home Rent $ 243.75 $ 2925.00 Electric 30.00 360.00 Heating 62.50 750.00 Telephone 52.50 630.00 Water & sewer 8.06 96.72 Trash 3.18 38.16 Lawn maintenance 10.00 120.00 Cable, phone, internet 35.50 426.00 Automobile Payments 0 Gas 110.00 1320.00 Maintenance 35.00 420.00 Insurance 33.00 396.00 Personal Clothing 200.00 Dry cleaning Hair Miscellaneous Groceries 150.00 Child's expenses Clothing 200.00 School Extracurricular activities Sport registration fees; Sport camp fees 300.00 Cell phone 52.50 630.00 2 Other expenses Entertainment Gifts Vacation Visa Sears TOTAL EXPENSES Legal Expenses 25.00 58.33 125.00 125.00 30.00 $ 1189.32 1650.00 to date 300.00 700.00 1500.00 1500.00 360.00 $ 14.271.84 3 VERIFICATION I verify that the information provided in the attached Plaintiffs Income and Expense Statement is 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.A. §4904, relating to unsworn falsification to authorities. Date: ?? l J David Black CERTIFICATE OF SERVICE I, Elizabeth A. Hoffman, Esquire, do hereby certify that a true and correct copy of the attached document was sent by U.S. mail to the following person: Tabetha Tanner, Esquire Tanner Law Offices, LLC 1300 Market Street - Suite 10 Lemoyne, PA 17043 Date: /0#(P 09 liz eth A. Hoffman squire Attorney for Plaintiff 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 1 D #71000 HLED-ORMt OF THE PPMONOTARY, 2004 OCT 27 PM I : I I CUMP.J-'fit A'Z}`-J C")UNTY PLEI INSYLVAN A ORIGINAL DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE PLAINTIFF'S PRE-TRIAL STATEMENT -33 1. ASSETS. (a) Marital - None. (b) Nonmarital - Plaintiff -1995 Chevrolet K 1500 Truck 2. EXPERT TESTIMONY - None planned at the present time. Plaintiff reserves the right to present such testimony if needed for rebuttal. 3. WITNESSES - None planned at the present time. Plaintiff reserves the right to present such testimony if needed for rebuttal. 4. EXHIBITS - (a) Pension statement; (b) Domestic Relations order for child support. 5. CURRENT INCOME - Plaintiff will provide documentation of his income within a reasonable time before the conference. 6. EXPENSES - Plaintiff provided an Income and Expense Statement on October 27, 2009. The Statement will be updated within a reasonable time before the conference. 7. PENSION - $15,970.30. Statement of value is attached. 8. COUNSEL FEES - Although he has expended in excess of $1800, Plaintiff is not currently requesting reimbursement of the fees. Defendant's legal services are pro bono. 9. DISPUTED PERSONAL ITEMS - Plaintiff is not disputing any personal items in Defendant's possession. 10. MARITAL DEBTS - None. Plaintiff does not agree that he is responsible for Defendant's living expenses incurred since the date of separation in October 2006. He has been paying child support for the parties one minor child in the amount of $800 per month. Plaintiff also disagrees with Defendant's claim that he is responsible for any debt incurred after the repossession of the 2006 Chrysler Pacifica. This vehicle was used by Defendant since its purchase and remained in her possession after the parties separated. 11. INDIGNITIES - None. 12. PROPOSED RESOLUTION - Deny Defendant's claims for alimony, legal fees, and costs incurred from the repossession of Defendant's vehicle. Defendant has never received spousal support nor alimony pendente lite. She is receiving her attorney's services free of charge. And finally, when she kept the vehicle in her possession, she was solely responsible for making the payments on it. One further resolution is proposed. Given that Defendant is perpetuating the divorce proceedings on virtually non issues, she should be required to pay Plaintiffs legal expenses if she insists on taking her claims any further. Date: LgA?l -0 Z4 A(& - Oth A. Hoffman Attorney for Plaintiff -] H'Oup November 23, 2009 Private & Confidential Mr. William Stackhouse, III Vice President of Finance Quaker City Motor Parts Company 680 North Broad Street P.O. Box 5000 Middletown, DE 19709-5000 Re: Retirement Benefits for David I Black Dear Mr. Stackhouse: play Grcup, Inc. The Wana-raker BLidIding 100 Penn Square East Philadelphia, PA 1910/,3388 USA tel i 1.215.86L2000 fax +1.215.861.2111 www.hayyrou p.com We have calculated the retirement pension payable to David J. Black as of October 1, 2027 (age 65) under the Pension Plan of Quaker City Motor Parts Co. for illustrative purposes related to his divorce proceedings. 1. Daft of Birth .................................................................................................................. 2. Date of Hire ................................................................................................................... 3. Normal Retirement Date .............................................................................................. 4. Early Retirement Date .................................................................................................. 5. Assumed Date of Termination ..................................................................................... 6. Spouse's Date of Birth .................................................................................................. 7. Average Annual Compensation ................................................................................... 8. Vesting Service ............................................................................................................. 9. Benefit Service ........................ ................................ ..................................................... 10. Annual Single Life Pension:.01 x (7) x (9) ...................................................... 11. Benefit Commencing :..................................................................................................... Single Life Pension Payable Annually • Monthly Single Life Pension ................................................................................... 12. Present Value of Single Life Pension, Payable December 31, 2009 ........................... 13. ¦ Annual Joint and 50% Continuing to the Spouse Payable January 1, 2010 ......... ¦ Monthly Joint and 50% Continuing to the Spouse Payable January 1, 2010 ....... September 4, 1962 May 21, 2001 October 1, 2027 N/A August 31, 2009 February 10, 1966 $33,633.00 9 years 8.3525 years $ 2,809.20 October 1, 2027 $ 2,809.20 $ 234.10 $ 15,970.30 $ 419.40 $ 34.95 The Plan is required to offer Mr. Black, as an alternative to the lump sum payment of $15,970.30, an immediate Joint & 50% benefit of $3495 commencing January 1, 2010. He must also be advised that, based on the actuarial basis underlying the lump sum calculation, which includes the required interest rates and mortality table under the Pension Protection Act (PPA), the relative value of the immediate monthly benefit as a percentage of the lump sum payment is 49.2%. The above figures are for illustrative purposes o&. The Plan is not allowed to make payments to a participant if he/she remains in active employment. If you have any questions, please do not hesitate to call. Sincerely, Deborah A. Rooney Associate DAR:wdr cc: Jason Fine A-? ,,604,18 / 7- In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION BARBARA A. BLACK ) Order Number 00338 S 2007 Plaintiff ) vs. ) PACSES Case Number 326109140 DAVID J. BLACK ) Docket Number 00338 S 2007 Defendant ) Other State ID Number ORDER OF COURT ® Final Q Interim O Modified AND NOW, 21ST DAY OF SEPTEMBER, 2007 based upon the Court's determination that the Payee's monthly net income is $ o. o o and the Payor's monthly net income is $ o. oo , it is hereby ordered that the Payor pay to the Pennsylvania State Collection and Disbursement Unit EIGHT HUNDRED DOLLARS Dollars ($ aoo. oo ) a month payable BIWEEKLY as follows: first payment due 9/28/07 IN THE AMOUNT OF $369.23 BIWEEKLY. The effective date of the order is 0 9 / 17 j 0 7 . Arrears set at $ 403.22 as of SEPTEMBER 17, 2007 are due in full IMMEDIATELY. All terms of this Order are subject to collection and/or enforcement by contempt proceedings, credit bureau reporting, tax refund offset certification, driver's license revocation, and the freeze and seize of financial assets. These enforcement/collection mechanisms will not be initiated as long as obligor does not owe overdue support. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all the means listed above. For the Support of: Name Birth Date SABRINA J. BLACK 12/01/94 Form OE-518 Rev. 3 r BLACK V- BLACK PACSES Case Number: 326109140 The defendant owes a total of $ a o 0. o o per month payable BIWEEKLY ; $ 800.00 for current support and $ o. oo for arrears. The defendant must also pay fees/costs as indicated below. This order is allocated and monies are to be applied as follows: Frequency Codes: Payment Amount/ $ 800.00 /M $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / $ 0.00 / 1 =One Time M =Monthly Debt Dae n cri ion B iaa CS ALLOC/MED SABRINA J. BLACK Said money to be turned over by the Pa SCDU to: BARBARA A. BLACK . 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 defendant's PACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. Page 2 of 4 Form OE-518 Rev. 3 I BLACK V• BLACK PACSES Case Number: 326109140 The monthly support obligation includes cash medical support in the amount of $250 annually for unreimbursed medical expenses incurred for each child and/or spouse. Unreimbursed medical expenses of the obligee or children 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 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: 5o % by defendant and 50 % by plaintiff. (j)Defendant O Plaintiff O Neither party to provide medical insurance coverage. Within thirty (30) days after the entry of this order, the Q Plaintiff ® Defendant shall submit to the person having custody of the child(ren) 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 IS BASED ON THE PARTIES AGREEMENT. NO INCOMES AND EXPENSES WERE CONSIDERED BY THE DRO. Defendant shall pay the following fees: Fee Total Fee Description $ 10.00 for JUDICIAL COMPUTER FEE $ 25.00 for COURT COSTS $ 0.00 for $0.00 for $ 0.00 for Payment Frequency Payable at $ 10.00 Payable at $ 25. 00 Payable at $ 0 .00 Payable at $ 0. 00 Payable at $ 0. 00 per ONE TIME per ONE TIME per per per Page 3 of 4 Form OE-518 Rev. 3 Service Type ly Worker ID .>i nna BLACK V- BLACK PACSES Case Number: 326109 140 IMPORTANT LEGAL NOTICE PARTIES MUST WITHIN SEVEN DAYS INFORM THE DOMESTIC RELATIONS SECTION AND THE OTHER PARTIES, IN WRITING, OF ANY MATERIAL CHANGE IN CIRCUMSTANCES RELEVANT TO THE LEVEL OF SUPPORT OR THE ADMINISTRATION OF THE SUPPORT ORDER, INCLUDING, BUT NOT LIMITED TO, LOSS OR CHANGE OF INCOME OR EMPLOYMENT AND CHANGE OF PERSONAL ADDRESS OR CHANGE OF ADDRESS OF ANY CHILD RECEIVING SUPPORT. A PARTY WHO WILLFULLY FAILS TO REPORT A MATERIAL CHANGE IN CIRCUMSTANCES MAY BE ADJUDGED IN CONTEMPT OF COURT, AND MAYBE FINED OR IMPRISONED. PENNSYLVANIA LAW PROVIDES THAT ALL SUPPORT ORDERS SHALL BE REVIEWED AT LEAST ONCE EVERY THREE (3) YEARS IF SUCH REVIEW IS REQUESTED BY ONE OF THE PARTIES. IF YOU WISH TO REQUEST A REVIEW AND ADJUSTMENT OF YOUR ORDER, YOU MUST DO THE FOLLOWING: CALL YOUR ATTORNEY. AN UNREPRESENTED PERSON WHO WANTS TO MODIFY (ADJUST) A SUPPORT ORDER SHOULD CONTACT THE DOMESTIC RELATIONS SECTION. ALL CHARGING ORDERS FOR SPOUSAL SUPPORT AND ALIMONY PENDENTE LITE, INCLUDING UNALLOCATED ORDERS FOR CHILD AND SPOUSAL SUPPORT OR CHILD SUPPORT AND ALIMONY PENDENTE LITE, SHALL TERMINATE UPON DEATH OF THE PAYEE. A MANDATORY INCOME ATTACHMENT WILL ISSUE UNLESS THE DEFENDANT IS NOT IN ARREARS IN PAYMENT IN AN AMOUNT EQUAL TO OR GREATER THAN ONE MONTH'S SUPPORT OBLIGATION AND (1) THE COURT FINDS THAT THERE IS GOOD CAUSE NOT TO REQUIRE IMMEDIATE INCOME WITHHOLDING; OR (2) A WRITTEN AGREEMENT IS REACHED BETWEEN THE PARTIES WHICH PROVIDES FOR AN ALTERNATE ARRANGEMENT. UNPAID ARREARAGE BALANCES MAY BE REPORTED TO CREDIT AGENCIES. ON AND AFTER THE DATE IT IS DUE, EACH UNPAID SUPPORT PAYMENT SHALL CONSTITUTE, BY OPERATION OF LAW, A JUDGMENT AGAINST YOU, AS WELL AS A LIEN AGAINST REAL PROPERTY. IT IS FURTHER ORDERED that, upon payor's failure to comply with this order, payor may be arrested and brought before the Court for a Contempt hearing; payor's wages, salary, commissions, and/or income may be attached in accordance with law; this Order will be increased without further hearing by o % a month until all arrearages are paid in full. Payor is responsible for court costs and fees. r Plaintiff s Attorney 9-?°.0 r BY THE COURT• Judge Page 4 of 4 Form OE-518 Rev. 3 Copies delivered to parties . Date DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE AFFIDAVIT OF CONSENT 1. A complaint in divorce under Section 3301(c) of the Divorce Code was filed on March 19. 2008 . 2. The marriage of the plaintiff and the defendant is irretrievably broken, and ninety days have elapsed from the date of filing the complaint. 3. 1 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 consent form are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. §4904, relating to unsworn falsification to authorities. l Date: D Black MW C- =--n r M Q off' r- 4C) C:) mac, ; - 7) r DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER 3301(c) OF THE DIVORCE CODE 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 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 consent form are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. §4904, relating to unsworn falsification to authorities. Date: ba6(d lack c -? r) # W ?z co ©a BCD ` y o ? C1 DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 CIVIL TERM BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE AFFIDAVIT OF CONSENT 1. A complaint in divorce under Section 3301(c) of the Divorce Code was filed on March 19, 2008 2. The marriage of plaintiff and defendant is irretrievably broken, and ninety days have elapsed from the date of filing the complaint. 3. 1 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. §4904 relating to unsworn falsification to authorities. Date: d v c o .-. te OD ? r - ?CD o z? rya -? DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 08-1766 CIVIL TERM BARBARA A. BLACK, CIVIL ACTION - LAW Defendant DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER $3301(c) OF THE DIVORCE CODE 1. I 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 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. §4904 relating to unsworn falsification t Date: L;,-Z / ( -O:x rn W =M :Z= (nf- CD = z-? ?j .? 5 C- Go ?f b W CD Cw MF -0m W CD f Q C+ - iM '?'R MARITAL SETTLEMENT AGREEMENT THIS AGREEMENT made and entered into this day of _, 2011, by and between DAVID BLACK (hereinafter referred to as "HUSBAND"), residing at 171 Pisgah State Road, Shermansdale (Perry County), Pennsylvania, and BARBARA BLACK (hereinafter referred to as "WIFE") residing at 109 Wyncote Court, Cz ?,_r Mechanicsburg (Cumberland County), Pennsylvania. WITNESSETH: ca `x' ° WHEREAS, the parties hereto were duly and lawfully married to eachc?#er?i r, October 1, 1988, in Harrisburg, Pennsylvania; WHEREAS, HUSBAND and WIFE have two children: Daniel F. Black (DOB 7/25/1988) and Sabrina Jo Black (DOB 12/1/1994); WHEREAS, certain unhappy and irreconcilable differences have arisen between the parties in consequence of which they desire to live separate and apart and wish to remain separate and apart for the rest of their lives; WHEREAS, the parties desire to enter into an Agreement under which their respective financial and property rights and all other rights, remedies, privileges, and obligations to each other arising out of the marriage relation or otherwise shall be fully prescribed and bounded thereby; WHEREAS, a Complaint in Divorce was filed in the Court of Common Pleas of Cumberland County at Docket No. 08-1766 Civil Term on March 19, 2008; WHEREAS, each party has had an opportunity to consult with an attorney of his or her own choice; and 1 WHEREAS, the parties hereto each warrant and represent to the other that they fully understand all the terms, covenants, conditions, provisions, and obligations incumbent upon each of them by virtue of this Agreement to be performed or contemplated by each of them hereunder, and each believe the same to be fair, just, reasonable and in the respective individual best interest of each, and not the result of any fraud, duress, or undue influence exercised by either party upon the other or by any other person or persons upon either; NOW THEREFORE, in consideration of the covenants and promises contained herein, the parties hereto, intending to be legally bound hereby, agree as follows: 1. SEPARATION. It is and shall be lawful for the parties hereto, at all times, to live separate and apart from each other and to reside from time to time at such place or places as each of the parties may deem fit and to contract, carry on and engage in any employment, business or trade which either may deem fit, free from control, restraint, or interference, direct or indirect, by the other in all respects as if such parties were single and unmarried. 2. NONINTERFERENCE. Neither party shall in any way molest, disturb, or trouble the other or interfere with the peace and comfort of the other or compel or seek to compel the other to associate, cohabit or dwell with him or her by any action or proceeding for restoration of conjugal rights or by any means whatsoever. 3. DATE OF EXECUTION: The "date of execution" 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 same date. Otherwise, the "date of execution" of this Agreement 2 shall be defined as the date of execution by the party last executing this Agreement. 4. MUTUAL RELEASE. HUSBAND and WIFE each do hereby mutually release and forever discharge the other and the estate of each other for all time to come, and for all purposes whatsoever, of and from any and all rights, title and interests, or claims in or against the property (including income and gain from property hereafter accruing) of the other or against the estate of the other, the estate of such other or any part thereof, whether arising out of any former acts, contracts, engagements or liabilities of such other or 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 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 Pennsylvania, or any state, commonwealth, or territory of the United States, or any rights which either party may have or at any time hereafter shall have for past, present or future support or maintenance, alimony, alimony pendente lite, counsel fees, property division, costs or expenses, whether arising as a result of the marital relations or otherwise, except all rights and agreements and obligations of whatsoever nature arising or which may arise from this Agreement or for the breach of any provisions thereof. It is the intention of HUSBAND and WIFE to give to each other by the execution of this Agreement a full, complete and general release with respect to any and all property of any kind or nature, real, personal, or mixed, which the other now owns or may hereafter acquire, except and only except all rights and agreements and 3 obligations of whatsoever nature arising or which may arise under this Agreement or for the breach of any provision thereof. It is further agreed that this Agreement shall be and constitute a full and final resolution of any and all claims which each of the parties may have against the other for the equitable division of property, alimony, counsel fees and expenses, alimony pendente lite or any other claims pursuant to the Pennsylvania Divorce Code or the divorce laws of any other jurisdiction. 5. ADVICE OF COUNSEL. The provisions of this Agreement and their legal effect have been fully explained to HUSBAND by Elizabeth A. Hoffman, Esquire, counsel for HUSBAND. WIFE's counsel, Tabetha A. Tanner, Esquire, has fully explained to WIFE the provisions of this Agreement and their legal effect. HUSBAND and WIFE agree that this Agreement is, under the circumstances, fair and equitable and that it is being entered into freely and voluntarily 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. 6. FINANCIAL DISCLOSURE. Except as provided for in this Agreement, the parties waive their rights to require the filing of financial statements by the other although the parties have been advised by their respective attorneys that it is their legal right to have these disclosures made prior to entering into this Agreement. Except as provided for in this Agreement, by entering into this Agreement without reliance upon financial disclosure, the parties are forever waiving their right to request or use that as a basis to overturn this Agreement or part thereof. 7. WARRANTY AS TO EXISTING OBLIGATIONS. Each party represents that 4 he or she has not heretofore incurred or contracted for any debt or liability or obligation for which the other party may be responsible or liable except as provided for in this Agreement. Each party agrees to indemnify and hold the other party harmless for and against any and such debts, liabilities or obligations of every kind which may heretofore been incurred by him or her, including those for necessities, except for the obligations arising from this Agreement. 8. PERSONAL PROPERTY. The parties stipulate and agree that all items of personal property have previously been divided between themselves. The parties do hereby specifically waive, release, renounce and forever abandon whatever claims, if any, he or she may have, with respect to any of the items previously divided between themselves. 9. EXISTING DEBTS. HUSBAND agrees to take complete and exclusive responsibility for any and all debts incurred in his individual name and to indemnify and hold WIFE harmless from same. WIFE agrees to take complete and exclusive responsibility for any and all debts incurred in her individual name and to indemnify and hold HUSBAND harmless from same. WIFE further agrees that she has removed HUSBAND's name from her Comcast account, and from any other account in which she included his name, and to take complete and exclusive responsibility for any and all outstanding payments due beginning from the time HUSBAND and WIFE separated to the present and to any time in the future. With respect to the repossessed Chrysler Pacifica which was purchased in both 5 parties' names, WIFE has been discharged of her financial obligation for the judgment through a bankruptcy proceedings in her name alone. HUSBAND's financial obligation with respect to same has not been resolved, and the judgment remains in effect against him alone. 10. APPLICABILITY OF TAX LAW TO PROPERTY TRANSFERS. The parties hereby agree and express their intent that any transfer of property pursuant to this Agreement shall be within the scope and applicability of the Deficit Reduction Act of 1984 (hereinafter referred to "the Act"), specifically, the provisions of said Act pertaining to transfers of property between spouses or former spouses. The parties agree to sign and cause to be filed any elections or other documents required by the Internal Revenue Service to render the Act applicable to the transfers set forth in this Agreement without recognition of gain on such transfer and subject to the carry-over basis provisions of said Act. 11. ALIMONY. HUSBAND agrees to provide alimony to WIFE in the amount of $500 (Five Hundred Dollars) per month for four years from the date of the execution of this Agreement. The parties agree that the alimony shall be paid through a wage attachment by the Domestic Relations Section of Cumberland County. WIFE avers that she has provided HUSBAND with a statement of her year-to- date income. She agrees to notify HUSBAND if she receives an increase in income which results in her receiving substantially more than HUSBAND's income after he pays the alimony set forth in this Agreement. HUSBAND in turn will inform WIFE of any increase in income that rises above three percent. 6 The parties agree to be responsible for their own attorney's fees. 12. INCOME TAX RETURNS. The parties agree to file separate local, state and federal income tax forms for 2010. 13. APPLICABLE LAW. This Agreement shall be construed in accordance with the laws of the Commonwealth of Pennsylvania which are in effect as of the date of the execution of this Agreement. 14. AGREEMENT BINDING ON HEIRS. This Agreement shall be binding and shall inure to the benefit of the parties hereto and their respective heirs,,executors, administrators, successors and assigns. 15. INTEGRATION. 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. 16. NO WAIVER UPON 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 default or breach of any provisions hereof be construed as a waiver of any subsequent default or breach of the same or similar nature, nor shall it be construed as a waiver of strict performance of any other obligations herein. 17. SEVERABILITY. If any term, condition, clause or provision of this Agreement shall be determined or declared to be void or invalid in law or otherwise, 7 then only that term, condition, clause or provision shall be stricken from this Agreement and in all other respects this Agreement shall be valid and continue in full force, effect and operation. Likewise, the failure of any party to meet her or his obligation under any one or more of the paragraphs herein, with the exception of the satisfaction of the conditions precedent, shall in no way avoid or alter the remaining obligations of the parties. 18. BREACH. If either party breaches any provision of this Agreement, the other party shall have the right, at his or her election, to sue for damages for such breach or seek such other remedies or relief as may be available to him or her, and the party breaching this contract shall be responsible for payment of reasonable legal fees and costs incurred by the other in enforcing his or her rights under this Agreement. 8 IN WITNESS WHEREOF, the parties hereto have set their hands and seals this day and year first above written. 4' Black Hess 9 a. QiIL? Witness O8 1 / 1 to 1 ¦ Complete items 1, 2, and 3. Also complete item 4 if Restricted Deliver is desired A. Sived qy . y ¦ Print our name and address on the r y everse so that we can return the card to you. ¦ Attach this card to the back of the mailpiece, C gnature? ?, or on the front if space permits. 1. Article Addressed to: /04 /7055 'Tint Clearly) B. Da of Delivery I. Cl k't 11 Agent Addressee D. Is delivery addressf fferent from item -.r, If YES, enter delivery address 910c, 4 MAR p r 22 uox 2008 y - ( - 3. Se a Type (/ e: , cj Certified Mail ? Express Mail ? Registered ? Return Receipt for Merchandise ? Insured Mail ? C.O.D. 4. Restricted Delivery? (Extra Fee) y? 2. Article Number (Copy froi ?006 2150 0003 8546 1152 PS Form 3811, July 1999 Domestic Return Receipt 102595-00-M-0952 t"' rr in - rn :;u c <> p CO C C1 - < i% C") 3a? 3 L `y I mc) ( CD DAVID BLACK, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA vs. CIVIL ACTION - LAW NO. 08-1766 BARBARA A. BLACK, Defendant IN DIVORCE ORDER AND NOW, this 20`x' day of July, 2011, the economic claims having been resolved as per the Marital Settlement Agreement, the appointment of the Master is hereby vacated. BY THE COURT, 4 o?zL. Kevin . Hess, P. J. Elizabeth A. Hoffman, Esquire For the Plaintiff Tabetha Tanner, Esquire F h or t e Defendant :rlm c ? =z _ M C= Rr.W r" -O o Cl r ^ CD ORIGINAL Elizabeth A. Hoffman, Esquire 106 Walnut Street Harrisburg, PA 17101 (717) 236-2956 DAVID BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-1766 CIVIL TERM a ; - BARBARA A. BLACK, CIVIL ACTION - LAW rn? ?-- Defendant DIVORCE N -< CD c. PRAECIPE TO TRANSMIT RECORD 'Y> C-) " 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 Divorce Code. 2. Date and manner of service of the Complaint: Service by certified, restricted mail and received on March 22, 2008: service of Amended Complaint mailed to Defendant's attorney on or about March 6, 2009. 3. Date of execution of the affidavit of consent required by §3301(c) of the Divorce Code by Plaintiff July 7, 2011; by Defendant June 27, 2011-. 4. Related claims pending: None 5. Date Plaintiff's Waiver of Notice was filed with the Prothonotary: July 14, 2011, by U.S. mail. Date Defendant's Waiver of Notice was filed: July 14, 2011, by U.S. mail. v"4? 4, A4""f? izabeth A. Hoffma squire Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA DAVID BLACK V. BARBARA A. BLACK NO. 08-1766 CIVIL TERM DIVORCE DECREE AND NOW, ?` X011 , it is ordered and decreed that DAVID BLACK , plaintiff, and BARBARA A. BLACK , 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 attached Marital Settlement Agreement is incorporated, but not merged, into this Decree in Divorce. By the Court, ?(v? ? e l4 CPpj rnat?eal -?> AW7 lk"PWn lie d -6' hl? l 'ver ORDERMOTICE TO WITHHOLD INCOME FOR SUPPORT 08-1766 CIVIL State: Commonwealth of Pennsylvania 326109140 O Original Order/Notice Co./City/Dist. of: CUMBERLAND 338 S 2007 (' Amended Order/Notice Date of Order/Notice: 08/24/11 Q Terminate Order/Notice Case Number (See Addendum for case summary) O One-Time Lump Sum/Notice RE: BLACK, DAVID J. Employer/Withholder's Federal EIN Number Employee/Obligor's Name (Last, First, MI) 165-54-3017 QUAKER CITY MOTOR PARTS Employee /Obligors Social Security Number PO BOX 5000 2372101821 MIDDLETOWN DE 19709-5000 Employee/Obligor's Case rd-en-tTmer (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. ?-, -? $ 800.00 per month in current child support _ $ 0.00 per month in past-due child support Arrears 12 weeks or greater? A?s sp r "I $ 0 00 = C _ . per month in current medical support r Z - $_ 0.00 per month in past-due medical support z ? c ) v rYj , r- i ?? $ 500.00 per month in current spousal support [ii [ C:) ? $ 0.00 per month in past-due spousal support c $ 0.00 per month for genetic test costs C-j =C:) $ 0.00 per month in other (specify) $ one-time lump sum payment -- z for a total of $ 1,300.00 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: $ per weekly pay period. $ 650.00 per semimonthly pay period $ 600.00 (twice a month) per biweekly pay period (every two weeks) $ 1,300.00 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 Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIJ6 _ BY THE COURT:• Albert H. Masland OMB No.: 0970-0154 Form EN-028 Service Type M Worker ID $IATT 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 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. 1501464340 THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER: Q THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: O EMPLOYEE'S/OBLIGOR'S NAME: BLACK, DAVID J. _ EMPLOYEE'S CASE IDENTIFIER: 2372101821 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 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 U)MB NC 970- Form EN-028 ADDENDUM Summary of Cases on Attachment Defendant/Obligor: BLACK, DAVID J. PACSES Case Number 034112694 PACSES Case Number 326109140 Plaintiff Name Plaintiff Name BARBARA A. BLACK BARBARA A. BLACK Docket Attachment Amount Docket Attachment Amount 08-1766 CIVIL $ 500.00 00338 S 2007 $ 800.00 Child(ren)'s Name(s): DOB 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 SABRINA J. BLACK 12/01/94 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 $IATT ORDERMOTICE TO WITHHOLD INCOME FOR SUPPORT `? 11 {fll? L' t v ? I State: Commonwealth of Pennsylvania Co./City/Dist. of: CUMBERLAND Date of Order/Notice: 09/23/11 Case Number (See A en um for case summary) Employer/Withholders Federal EIN Number QUAKER CITY MOTOR PARTS C/O NAPA AUTO PARTS 680 N BROAD ST MIDDLETOWN DE 19709-1030 RE: BLACK, DAVID J. O Original Order/Notice Q Amended Order/Notice O Terminate Order/Notice O One-Time Lump Sum/Notice Employee/Obligor's Name (Last, First, MI) 165-54-3017 Employee/Obligor's Social SecuFq7u-mTe_r 2372101821 Employee/Obligoes 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. $ 379.00 per month in current child support $ 0.00 per month in past-due child support Arrears 12 weeks or greater? O yes O no. $ 0.00 per month in current medical support o $ 0.00 per month in past-due medical support 7oX -- ?° $ 500.00 per month in current spousal support rn Co r=? $ 0.00 per month in past-due spousal supporter ^° ?n r $ 0.00 per month for genetic test costs k CA $ 0.00 per month in other (specify) r- $ one-time lump sum payment >?. C7 DO for a total of $ 879.00 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: $ 202.$5per weekly pay period. $ 439.50 per semimonthly pay period (twice a month) $ 405:, 10per biweekly pay period (every two weeks) $ 879.00 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 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: Albert H. Masland OMB No.: 0970-0154 Service Type M Form EN-028 Worker ID $IATT 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. 5101464340 THE PERSON' HAS NEVER WORKED FOR THIS EMPLOYER: Q THE EMPLOYEE/013LIGOR NO LONGER WORKS FOR: Q EMPLOYEE'S/OBLIGOR'S NAME: BLACK, DAVID J. EMPLOYEE'S CASE IDENTIFIER: 2372101821 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: If you or your employee/obligor have any questions, DOMESTIC RELATIONS SECTION contact WAGE ATTACHMENT UNIT 13 N. HANOVER ST 13 BOX by telephone at (717) 240-6225 or CARLISLE 20 17013 by FAX at (717) 240-6248 or by internet www childsupnort state p us OMB No.: 0970-0154 Form EN-028 Service Type M Page 2 of 2 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: BLACK, DAVID J. PACSES Case Number 034112694 PACSES Case Number 326109140 Plaintiff Name Plaintiff Name BARBARA A. BLACK BARBARA A. BLACK Docket Attachment Amount Docket Attachment Amount 08-1766 CIVIL $ 500.00 00338 S 2007 $ 379.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): SABRINA J. BLACK PACSES Case Number Plaintiff Name D ke Attachment Amount $ 0.00 Child(ren)'s Name(s): PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): Service Type M DOB DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): Addendum OMB No- 0970-0154 DOB 12/01/94 DOB DOB Form EN-028 Worker ID $IATT INCOME WITHHOLDING FOR SUPPORT 0 ORIGINAL INCOME WITHHOLDING ORDERINOTICE FOR SUPPORT(IWO) ILA 1+ @ AMENDEDIWO 0 ONE-TIMEORER/NOTICE FOR LUMP SUM PAYMENT cs- ux 0 TERMINATION OF IWO Date: 06/03/13 ❑ 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.cov/pro-grams/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. Statefrriberrerritory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 2372101821 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for orderldocket informaiton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) QUAKER CITY MOTOR PARTS RE: BLACK,DAVID J. NAPA AUTO PRTS Employee/Obligor's Name(Last,First,Middle) 680 N BROAD ST 165-54-3017 MIDDLETOWN DE 19709-1030 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 510146434 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://www.acf.hhs.gov/i)roo[a_ms/cse/newhire emi)loyer/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. 5101464340 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 CUMBERLAUP County, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts froliT--the_5ih­lpIo�yee/ obligor's income until further notice. C= $ 0.00 per month in current child support =M $ 0.00 per month in past-due child support-Arrears 12 weeks or greater? 0 yesn rn- no 7J v:D $ 0.00 per month in current cash medical support tom. Cn CD $ 0.00 per month in past-due cash medical support )> $ 500.00 per month in current spousal support $ 0.00 per month.in past-due spousal support car $ 0.00 per month in other(must specify) for a Total Amount to Withhold of$ 500.00 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: $. 1 IS,SS per weekly pay period. $ 250.00 per semimonthly pay period (twice a month) $ -ZW.-Jja per biweekly pay period(every two weeks) $ 500.00 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 hftp://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/contact-mao. 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 ^ � rl Return tw Sender[Completed bwEmployer/Income Withholder]. Payment must bg directed boan8DUin accordance with 42USCG886/bX5\and(b)(8)on Tribal Payee(see Payments hoGDUbe|ovv . If payment ionot directed to an SDU/Tribal Payee or thisPWO is not regular on its face, you must check this box and return theUWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): jg:2 Print Name of Judge/Issuing Official: VI-Im tsck t 4-Ma Ma t1CL Title,of Judge/Issuing Official: If the employee/obligor works\na State or for a Tribe that is different from the State or Tribe that issued this order,a copy of this IWO must bo provided ho the emp|oyee/ob|ignc 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 i23 PA C.S.§4374(b)>requires remittance by an electronic payment method |fan employer|sordered to withhold income from more than one employee and employs ISwr more persons,er ifam employer has a history of two pr more returned checks due tommusufGclentfunds. Please call the Pennsylvania State Collections and Disbursement Unit(PA SCD4)£nmp\oywr Customer Service od1~877~676-$580 for instructions. PAPIPS CODE 42 000 00 ' Make Re0mUftance 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 aa theEmployeelObligior's Case Identirter)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 webmite located at: Priori Withholding for support has priority over any other legal process under State law against the same income(USC 42 §GSG(b)(7)). |fa Federal tax levy\min effect, please notify the sender. Combining Payments: When remitting payments 8uanSOUorThba|CSEogency.youmoyoombinevvidhhe|domounteknm 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 TnSDU: You must send child support payments payable by income withholding bz the appropriate SOUor0oa 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 bya Court,Attorney, o 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 annp|oyee/ob|igor's -e You must comply with the law of the State(or Tribal law if | applicable)of the amp|oyeu/ub|igor's principal place of employment regarding time periods within which you must implement ! the withholding and forward the support payments. Multiple IVKOm: |f there io more than one|VVO against this employee/obligor andyouoneunob|eVofu||yhonoroU |VVQmdueVo Federal, State, or Tribal withholding limits,you must honor all IWOs to the greatest extent possible, giving i \tyk>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 ofupcnminglump sum payments bzthis � 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: |f you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the emp|nyee/ob|igor'o 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 |ow/pruneduna. 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 m the form currently muse. Form EN-D28OG/12 Service Type KA Page 2of3 Worker|[]$|AT7 Employer's Name: QUAKER CITY MOTOR PARTS Employer FEIN: 510146434 Employee/Obligor's Name: BLACK, DAVID J. 2372101821 CSE Agency Case Identifier:(See Addendum for case summa Order Identifier:(See Addendum for ordeddocket informattgn 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 p(incipal 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 Tdbe. For Tfibal 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: 5101464340 0 This person has never worked for this employer nor received periodic income. 0 This person no longer works for this employer nor receives pe6odic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU/Thbal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To EmplQyerlincome 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.childsupgort.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/obiigor 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.u 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. BLACK, DAVID J, PACSES Case Number 034112694 PACSES Case Number Plaintiff Name Plaintiff Name BARBARA A. BLACK Docke Attachment Amoun Docke t Attachment Amount 08-1766 CIVIL $ 500.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case_Number PACSES Case Number Plaintiff Name Plaintiff Name ocket Attachment Amgun Docke 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 Do ke 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 INCOME WITHHOLDING FOR SUPPORT p3 I ) 21,99 ti- , O ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO) O AMENDED IWO IMIPMPPRIPMMIN O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT O TERMINATION OF IWO Date: 01/14/14 ❑ Child Support Enforcement(CSE)Agency ® Court ❑ Attorney ❑ Private Individual/Entity(Check One) NOTE:This IWO must be:regaitt oats tacttvitiir certain circumstances you must reject this IWO and return it to the sender(see IWO instructions httD://www.acf.hhs.gov/programs/cse/forms/OMB-0970-0154 instructions.pdf). 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): 2372101821 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket Information) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) GENUINE PARTS COMPANY ESC RE: BLACK, DAVID J. 3100 WINDY HILL RD Employee/Obligor's Name(Last, First,Middle) ATLANTA GA 30339-5605 165-54-3017 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 580254510 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://www.act hhs.gov/programs/cse/forms/ OMB-0970-0154 instructions.odt).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. 5802545100 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 theemployee/ obligor's income until further notice. ` $ 0.00 per month in current child support r r,t c $ 0.00 per month in past-due child support- Arrears 12 weeks or greater? 0 yes i $ 0.00 per month in current cash medical support ? $ 0.00 per month in past-due cash medical support r $ 500.00 er month in current spousal support �' P P PP $ 0.00 per month in past-due spousal support $ 0.00 per month in other(must specify) for a Total Amount to Withhold of$ 500.00 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: $ 115,T1 per weekly pay period. $ 250.00 per semimonthly pay period (twice a month) $ 23017 per biweekly pay period (every two weeks) $ 500.00 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 11/13 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): -‘1eZZiff* Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: JAN 1 5 2014 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.acf.hhs.gov/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—05/31/2014.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 11/13 Service Type M Page 2 of 3 Worker ID$IATT ti Employer's Name: GENUINE PARTS COMPANY ESC Employer FEIN:580254510 Employee/Obligor's Name: BLACK, DAVID J. 2372101821 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: 5802545100 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.childsupoort.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.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 11/13 Service Type M Page 3 of 3 Worker ID $IATT s + ADDENDUM Summary of Cases on Attachment Defendant/Obligor: BLACK, DAVID J. PACSES Case Number 034112694 PACSES Case Number Plaintiff Name Plaintiff Name BARBARA A. BLACK Docket Attachment Amount Docket Attachment Amount 08-1766 CIVIL $ 500.00 $ 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 11/13 Service Type M OMB No 0970-0154 Worker ID $IATT INCOME WITHHOLDING FOR SUPPORT J� l� / O ORIGINAL INCOME WITHHOLDING ORDERMOTICE FOR SUPPORT(IWO) V 3`1"" I 1�L -1(�`L O AMENDED IWO O ONE-TIMEORDERINOTICE FOR LUMP SUM PAYMENT b l/ (F) TERMINATION OF IWO Date: 01/15/14 ❑ Child Support Enforcement(CSE)Agency ® Court ❑ Attorney ❑ Private Individual/Entity(Check One) NOTE:This IWO must(Ee,regu ar(on4�if'sIC;4cir Under certain circumstances you must reject this IWO and return it to the sender(see IWO instructions http://www.acf.hhs.gov/programs/cse/forms/OMB-0970-0154_instructions pdf). 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): 2372101821 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket information) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) QUAKER CITY MOTOR PARTS RE: BLACK,DAVID J. NAPA AUTO PRTS Employee/Obligor's Name(Last, First,Middle) 680 N BROAD ST 165-54-3017 MIDDLETOWN DE 19709-1030 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 510146434 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://www.acf.hhs.gov/r)rograms/cse/­forms/ OMB-0970-0154 instructions.pdt). 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. 5101464340 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!We employee/ obligor's income until further notice. I - $ 0.00 per month in current child support $ 0.00 per month in past-due child support- Arrears 12 weeks or greater? Q yes W_noes, f7 ' $ 0.00 per month in current cash medical support --'k $ 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 $ 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 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 550/0 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 11/13 Service Type M Worker ID $IATT ❑ Return to Sender[Completed by Employer/Income Withholder]. Payment must be directed to an SDU in W 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 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: hftp:/Iwww acf hhs gov/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—05/31/2014.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 11/13 Service Type M Page 2 of 3 Worker ID $IATT Employer's Name: QUAKER CITY MOTOR PARTS Employer FEIN: 510146434 Employee/Obligor's Name: BLACK, DAVID J. 2372101821 CS 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: 5101464340 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 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.chiIdsupport.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.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 11/13 Service Type M Page 3 of 3 Worker ID$IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: BLACK, DAVID J. PACSES Case Number 034112694 PACSES Case Number Plaintiff Name Plaintiff Name BARBARA A. BLACK Doc a Attachment Amount Docke Attachment Amount 08-1766 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 Docke Attachment Amount Docke t 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 Docke Attachment Amount Docke t Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB Addendum Form EN-028 11/13 Service Type M OMB No.:0970-0154 Worker ID$IATT