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HomeMy WebLinkAbout08-6697 F:\F1LES\Clients\13234 Raugh\13234.1.dcom Created: 9/20/04 0:06PM Revised: 11/11/08 10:05AM Jennifer L. Spears, Esquire MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLER MARTSON LAW OFFICES I.D. 87445 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff CHRISTOPHER RAUGH, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08- U A 7 I T4" CIVIL ACTION - LAW KRISTI RAUGH, ; Defendant IN DIVORCE NOTICE TO DEFEND AND CLAIM RIGHTS You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take prompt action. You are warned that if you fail to do so, the case may proceed without you and a decree of divorce or annulment may be entered against you by the Court. A judgment may also be entered against you for any other claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rights important to you, including custody or visitation of your children. When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. Upon your request, the Court may require you and your spouse to attend up to three sessions. A request for counseling must be made in writing and filed with the Prothonotary within twenty (20) days of receipt of this Notice. IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER'S FEES OR EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM ANY OF THEM. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone (717) 249-3166 1 ` , E CHRISTOPHER RAUGH, Plaintiff V. KRISTI RAUGH, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08- G G 97 CIVIL ACTION - LAW IN DIVORCE DIVORCE COMPLAINT UNDER SECTION 3301(C) AND 3301 (D) OF THE DIVORCE CODE 1. Plaintiff is Christopher Raughwho currently resides at 275 Redwood Lane, Carlisle, PA 17015. 2. Defendant is Kristi Raugh whose last known residence was 275 Redwood Lane, Carlisle, PA 17015. 3. Plaintiff and Defendant have been bona fide residents in the Commonwealth of Pennsylvania for at least six months immediately previous to the filing of this Complaint. 4. The Plaintiff and Defendant were married on December 16, 1995, in Tennessee. 5. There have been no prior actions of divorce or for annulment between the parties. 6. The marriage is irretrievably broken. 7. Plaintiff has been advised that counseling is available and that Plaintiff may have the right to request that the court require the parties to participate in counseling. 8. Plaintiff will file an affidavit when two years have expired from the date of separation. WHEREFORE, Plaintiff respectfully requests the Court to enter a decree of divorce pursuant to Section 3301 of the Divorce Code. Date: November 12, 2008 MARTSQN LAW OFFICES By ears, Esquire Jenni#p 10 Eah Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff VERIFICATION The foregoing Divorce Complaint is based upon information which has been gathered by my counsel in the preparation of the lawsuit. The language of the document is that of counsel and not my own. I have read the document and to the extent that it is based upon information which I have given to my counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the content of the document is that of counsel, I have relied upon counsel in making this verification. This statement and verification are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities, which provides that if I make knowingly false averments, I may be subject to criminal penalti W" P:::o Christopher augh 2 W Z?l CD F:IFILES\Chats\13234 Raugh\13234. Laos Revised: 12/3/08 10:32AM Jennifer L. Spears, Esquire MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLER MARTSON LAW OFFICES I.D. 87445 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff CHRISTOPHER RAUGH, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-6697 KRISTI RAUGH, CIVIL ACTION - LAW Defendant IN DIVORCE AFFIDAVIT OF SERVICE COMMONWEALTH OF PENNSYLVANIA ) COUNTY OF CUMBERLAND SS. I hereby certify that a copy of the Complaint in Divorce was mailed to Defendant Kristi Raugh at 275 Redwood Lane, Carlisle, PA 17013 on November 13, 2008, by certified mail, restricted delivery, return receipt requested. Attached is the Post Office return receipt signed "Kristi J. Raugh" and dated November 28, 2008. I JennSworn to and subscribed before me this day of December, 2008 ,r?J1? *ota4-*?--- COMMO NW EALTH OF PENNSYLVANIA Notarial Seal ftk+°t1!Id r !ry-,•n N-7t , Pubilr Carlisle: i f. ro, „rs i; nand County Mir Commuron mires Aug. 5, 2009 Metnbdt, P@Rftsylvanla Association of Notaries Postal c3 CERTIFIED M AIL R ECEIPT (Domestic Mail Only; No Insuranc e Coverage Provided) rU $0 42 Ln Postage $ . UU13 "I- o Certified Fee $2.70 N1 13,9 y C3 0 Return Reclept Fee (Endorsement Required) $2. ?? P C3 r--1 Restricted DelWery Fee (Endorsement Required) $4. ra Q frl Total Postage & Fees $ f9 rn 0 t o s i. W'--- ti6 or PO Box No. -- Gty , Z%Pr4 _ ,;. ----------- iit°Eampiete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ¦ Print your name and address on the reverse so that we can return the card to you. ¦ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: k PA i101"5r A Si natu / Q'Agrbnt 1 0 Addressee B. Received by ( ) C. Da of De ivery D. Is delivery address different from item 1? Yes If YES, enter delivery address below: 0 No ao E . CGC t/iF 4 Per. ? ML-C h14A.rc j 8'4q PA: v 1 -740 5- T IS 3. Se Type IF-Certified Mail 0 Express Mail 0 Registered 0 Return Receipt for Merchandise 0 Insured Mail 0 C.O.D. 4. Restricted Delivery? (Extra Fee) y? 2. Article Number (rmnsfer from service label) ?003 3110 0004 5 7 7 2 5 7 4 0 Ps Form 3811, February 2004 Dtx WW Return R/osipt 102595.02-M-1540 eF _z ,.: i10 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW DIVORCE Defendant NO. 08-6697 DEFENDANT'S ANSWER TO DIVORCE COMPLAINT AND NEW MATTERS. Defendant, Kristi Raugh, by her attorneys, the Family Law Clinic, hereby responds to Plaintiff's Divorce Complaint as follows: 1. Admitted. CHRISTOPHER RAUGH, Plaintiff V. KRISTI RAUGH, 2. Denied. Defendant currently resides at 20 East Coover Street Apt. A, Mechanicsburg, PA 17055. 3. Admitted 4. Admitted 5. Admitted 6. Admitted 7. Defendant is without sufficient knowledge to either affirm or deny the averment. 8. Defendant is without sufficient knowledge to either affirm or deny the averment. NEW MATTER COUNT II ALIMONY 9. Defendant repeats and realleges paragraphs number 1 through 8. 10. On or about November 12, 2009 Plaintiff filed a Complaint in Divorce. 11. Defendant is not gainfully employed. 12. Defendant worked sporadically during the marriage, and spent most of the marriage as a homemaker. 13. Plaintiff is employed and is financially able to provide for the reasonable needs of the Defendant. 14. Defendant requires reasonable support to adequately maintain herself in accordance with the standards of living established during the marriage. 15. Defendant lacks sufficient property to provide for her reasonable needs and is currently unable to support herself through full-time employment. WHEREFORE, Defendant requests the Court to enter an award for reasonable alimony, and such other relief as the Court deems just. COUNT III EQUITABLE DISTRIBUTION 16. Defendant repeats and realleges paragraphs number 1 through 15. 17. During the course of the marriage, the parties acquired marital assets and debts subject to equitable distribution under Section 3302 of the Divorce Code, including, but not limited to the following: a) Plaintiff's pension; b) A trailer home; C) A 1999 Accord; d) Various items of personal property. WHEREFORE, Defendant requests that this court equitably divide the marital property and debts between the parties and grant such other relief as the Court deems just. Date 3/Za/O 01 Respectfully submitted, Rachel Allen Certified Legal Intern MEGA RI SMEYER Supervising Attorney FAMILY LAW CLINIC 45 North Pitt Street Carlisle, PA 17013 Telephone: (717) 2413-2968 Fax: (717) 243-3639 VERIFICATION I verify that the statements made in this Answer and New Matter are true and correct to the best of my personal knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. Date: 3 //5 le Kristi J. RVU& Defendant r ? 1 h Y CZ) CHRISTOPHER RAUGH, Plaintiff V. KRISTI RAUGH, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW IN CUSTODY NO. 08-6697 CIVIL TERM PRAECIPE TO PROCEED IN FORMA PAUPERIS TO THE PROTHONOTARY: Kindly allow Kristi Raugh, Defendant, to proceed in forma pauperis. The Family Law Clinic, attorneys for the party proceeding in forma pauuperis, certifies that we believe the party is unable to pay the costs and that we are providing free legal service to the party. Respectfully submitted, Date S/ZG/G '2?t elz-?- Rachel Allen Certified Legal Intern MEGAN RIESMEYER Supervising Attorneys FAMILY LAW CLINIC 45 North Pitt Street Carlisle, PA 17013 717-243-2968 ? ```' ?? s=;.: ..? ?-?„ ---; ? y" i 1 f?;.?.: ? M ?1?5 ? i ?..? - .. .-? ... J ..,...., ?.? ?, .; ?. t k Christopher Raugh IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - DIVORCE Kristi Raugh, Defendant No. 08-6697 INCOME AND EXPENSE STATEMENT OF DEFENDANT, KRISTI RAUGH I verify that the statements made in this Income and Expense Statement are true and correct. I understand that false statements herein are made subj ct to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Date: S 2 /of of ndant 's u INCOME Employer: Employer's Address: Type of Work: Payroll Number: Pay Period (weekly, biweekly, etc.): Gross Pay per Pay Period: Itemized Payroll Deductions: Federal Withholding Social Security Local Wage Tax State Income Tax Retirement Savings Bonds Credit Union Life Insurance Health Insurance Other (specify) 1i Net Pay per Pay Period: $ Other Income: Week Month (Fill in Appropriate Column) Interest Dividends Pension Annuity Social Security Rents Royalties Expense Account Gifts Unemployment Comp. Workmen's Comp. Spousal Support 710.67 1031.33 Total $ $1742.01 TOTAL INCOME $1742.00 EXPENSES Weekly Monthly Home (Fill in Appropriate Column) Mortgage/rent $ $550.00 Maintenance _ Utilities _ Electric _ Gas _ Oil Telephone/cable/internet _ Water _ Sewer _ Employment Public transportation $ Lunch _ Taxes Real estate $ Personal property _ Income _ Insurance Homeowners $ Automobile/Renters _ Life _ Accident _ Health 325.00 117.00 1 09 00 Year Yearly Other _ Automobile Payments $ $477.00 $ Fuel 65.00 _ Repairs _ Medical Doctor $ $30.00 $ Dentist _ Orthodontist Hospital _ Medicine 100.00 _ Special needs (glasses, 14.67 _ braces, orthopedic devices) Education Private school $ $ $ Parochial school College _ Religious _ Personal Clothing $ $1.00 $ Food 200.00 _ Barber/hairdresser 20.00 _ Credit payments Credit card 240.00 Charge account _ _ Memberships _ Loans Credit Union $ $20.00 $ Personal Service Loan 40.00 Miscellaneous Household help $ $ $ Child care Papers/books/magazines 7.58 Entertainment 20.00 Pay TV Vacation Gifts Legal fees Charitable contributions Other child support Alimony payments Other Total Expenses $ $2,376.25 $ PROPERTY OWNED Checking accounts Savings accounts Credit Union Stocksibonds Real estate Other Total INSURANCE Hospital Blue Cross Other Medical Blue Shield Other Health/Accident Disability Income Dental Other Ownership* Description Value $419.00 $75.00 H W J X _ - X _ $494.00 Coverage* Company Policy No H W C Capital Blue Cross YWP80006185801 X Capital Blue Cross YWP80006185801 X Delta Dental 164546624 X Express Scripts 8072455476 X * H=Husband; W=Wife; J=Joint; C=Child SUPPLEMENTAL INCOME STATEMENT (If you are self-employed or if you are salaried by a business of which you are owner in whole or in part, you must also fill out the Supplemental Income Statement.) (a) This form is to be filled out by a person (check one): [error] (1) who operates a business or practices a profession, or [error] (2) who is a member of a partnership or joint venture, or [error] (3) who is a shareholder in and is salaried by a closed corporation or similar entity. (b) Attach to this statement a copy of the following documents relating to the partnership, joint venture, business, profession, corporation or similar entity: (1) the most recent Federal Income Tax Return, and (2) the most recent Profit and Loss Statement. (c) Name of business: Address and Telephone Number: (d) Nature of business (check one) [error] (1) partnership [error] (2) joint venture [error] (3) profession [error] (4) closed corporation [error] (5) other (e) Name of accountant, controller or other person in charge of financial records: (f) Annual income from business: (1) How often is income received? (2) Gross income per pay period: _ (3) Net income per pay period: - (4) Specified deductions, if any: _ €1040 Department of the Treasury-Internal Revenue Service 008 U.S. Individual Income Tax Return 99 IRS UseOnly -Do not write or staple inthis space, For the year Jan. 1-Dec. 31, 2008, or other tax year beginning ending OMB No 1545-0074 Label L Your first name M.I. Last name Suffix . Your social security number (See A KRISTI J RAUGH ; 169-56-7871 instructions on page 14.) fi If a joint return, spouse's first name M.I. Last name Suffix Spouse's social security number Use the IRS L label. Otherwise, H E Home address (number and street). If you have a P.O. box, see page 14. Apt. no. . You must enter . please print R 0 E COOVER ST A our SSN s above. or type. E City, town or post office, state, and ZIP code. If you have a foreign address, see page 14. Checking a box below will not Presidential HANI BURG PA 17056 change your tax or refund. Election Campaign ? Check here if you, or your spouse if filing jointly, want $3 to go to this fund (seepage 14) ? You Spouse 1 QX Single Filing Status 2 1:1 Married filing jointly (even if only one had income) 3F-] Married filing separately. Enter spouse's SSN above 4 ? Head of household (with qualifying person). (See page 15.) If the qualifying person is a child but not your dependent, enter this child's name here. and full name here. ? Check only ? First name Last name SSN one box. First name Last name 5 Qualifying widow(er) with dependent child (see page 16) Boxes citeclited 6a 7X Yourself. If someone can claim you as a dependent, do not check box 6a on 6a Exemptions ? ? ? ? ? ? ? t n6aand6b 1 b [:] Spouse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I No. of children c If more than four dependents, see page 17. Dependents: 1 First name Last name (2) Dependent's social security number (3) Dependent's relationship to you (4) if qualifying child for child tax credit (see page 17) on 6c who: • lived with you 0 • did not live with you due to divorce or separation 0 (see page 18) Dependents on 6c 0 not entered above Add numbers on 1 d Total number of exemptions claimed . . . . . . . . . . . . . . . . . . . . . . . . lines above so L Income 7 Wages, salaries, tips, etc. Attach Form(s) W-2 . . . . . . . . 7 9,668 Attach Form(s) 8a Taxable interest. Attach Schedule B if required . . . . . . . . . . . . . 8a W-2 here. Also attach Forms b 9a Tax-exempt interest. Do not include on line 8a . . . . . . . Ordinary dividends. Attach Schedule B if required . . . . . . . 8b . . . . . . . 9a W-2G and 1099-R if tax b 10 Qualified dividends (see page 21) . . . . . . . . . . . . . . 9b Taxable refunds, credits, or offsets of state and local income taxes (see page 22) . . . . . . . 10 was withheld. 11 Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 498 12 Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . . . . . . . 12 you did not 13 Capital gain or (loss). Attach Schedule D if required. If not required , check here 111- [:J 13 get a g 14 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . 14 see page ge 21 . 15a IRA distributions . . . . . . . 15a b Taxable amount (see page 23) 15b 16a Pensions and annuities . . . . . 16a b Taxable amount (see page 24) 16b Enclose, but do 17 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . . 17 not attach, any 18 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . . 18 payment. Also, 19 Unemployment compensation . . . . . . . . . . . . . . . . . . . . 19 please use 20a Social security benefits . . . . . . 120a I I I b Taxable amount (see page 26) 20b 0 Form 1040-V. 21 Other income. List type and amount (see page 28) ------------------------------------ 21 22 Add the amounts in the far right column for lines 7 through 21. This is your total income . ? 22 10,166 23 Educator expenses (see page 28) . . . . . . . . . . . . . . . 23 Adjusted Gross 24 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach Form 2106 or 2106-EZ . . . . 24 I 25 Health savings account deduction. Attach Form 8889 . 25 ncome 26 Moving expenses. Attach Form 3903 . . . . . . . . . . . . . 26 27 One-half of self-employment tax. Attach Schedule SE . . . . . . 27 28 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . 28 29 Self-employed health insurance deduction (see page 29) . . . . . 29 30 Penalty on early withdrawal of savings . . . . . . . . . . . . . 30 31a Alimony paid b Recipient's SSN ? 31a 32 IRA deduction (see page 30) . . . . . 32 33 Student loan interest deduction (see page 33) . . . . . . . . . 33 34 Tuition and fees deduction. Attach Form 8917 . . . . . . . . . . 34 35 Domestic production activities deduction. Attach Form 8903 . . . . 35 36 Add lines 23 through 31a and 32 through 35 . . . . . . . . . . . . . . . . . . . . . 36 37 Subtract line 36 from line 22. This is your adjusted gross income . ? 37 10,1661 ror uracrusure, rnvaey Am, anct raperworn meauction Act Notice, see page 88. Form 1040 (2008) (HTA) Form 1040 (2008) KRISTI J RAUGH 169-56-7871 Page 2 Tex 38 Amount from line 37 (adjusted gross income). . . . . . . . . . . . . . . . . 38 10,166 and Credits 39a Check { if: ? You were born before January 2, 1944, ? Blind. i Spouse was born before January 2, 1944, E] Blind. f Total boxes checked 111- 39a r•_ Standard Deduction for- • People who b If your spouse itemizes on a separate return or you were adual-status alien, seepage 34 and check here.. ? 391b c Check if standard deduction includes real estate taxes or disaster loss (see page 34) . . . ? 39c 40 Itemized deductions (from Schedule A) or your standard deduction (see left margin) . . . . . . 0 ,450 checked any 41 Subtract line 40 from line 38 . . . . . . . . ... . . . . . . . . . . . . . . . . . . . 41 4,716 box on line 39a,39b,or 39c or who 42 If line 38 is over $119,975, or you provided housing to a Midwestern displaced individual, see page 36. Otherwise, multiply $3,500 by the total number of exemptions claimed on line 6d . . . . . . 42 3,500 can be 43 Taxable income. Subtract line 42 from line 41. If line 42 is more than line 41, enter -0- . . . . . 43 1,216 claimed a dependent, 44 Tax (see page 36)• Check if any tax is from: a? Form(s) 8814 b ? Form 4972. . . . . 44 121 see page 34. 45 Alternative minimum tax (see page 39). Attach Form 6251 . . . . . . . . . . . . . . . . 45 • All others: 46 Add lines 44 and 45 . . . . . . . . . . . . . . . . . . . . . . . . . . . ? 46 121 Single or 47 Foreign tax credit. Attach Form 1116 if required . 47 Married filing t l 48 Credit for child and dependent care expenses. Attach Form 2441 . . . . 48 separa e y, $5 450 49 Credit for the elderly or the disabled. Attach Schedule R . . . . . . . . 49 k , Married filing 50 Education credits. Attach Form 8863 . . . . . . . . . . . . . . . 50 •x`'. jointly or in lif Q 51 Retirement savings contributions credit. Attach Form 8880 . . 51 g ua y widow(er), 52 Child tax credit (see pa a 42). Attach Form 8901 if required . . . . . . g 52 $10,900 53 Credits from Form: a ? 8396 b ? 8839 c E:] 5695 53 Head of 54 Other credits from Form: a F_1 3800 b ? 8801 c7 54 household, 55 Add lines 47 through 54. These are your total credits . . . . . . . . . . . . . . . . 55 1- 1 $8,000 56 Subtract line 55 from line 46. If line 55 is more than line 46, enter -0- . . . . . . . . . . . . . ? 56 121 Other 57 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . 57 58 Unreported social security and Medicare tax from Form: a ? 4137 b Q 8919 . T 58 axes 59 Additional tax on IRA -s• ?other qualified retirement plans, etc. Attach Form 5329 if required 59 ? 60 Additional taxes: a L AEIC payments b ? Household employment taxes. Attach Schedule H 60 61 Add lines 56 through 60. This is our total tax . ? ... ................. 61 121 Payments 62 Federal income tax withheld from Forms W-2 and 1099 . . . . . . . 62 1,052 63 2008 estimated tax payments and amount applied from 2007 return . . . 63 If you have a 64a Earned income credit (EIC) . . . . . . . . . . . . . 64a 207 qualifying child, attach b Nontaxable combat pay election . . . . . . 64b 65 Excess social security and tier 1 RRTA tax withheld (see page 61) 65 Schedule EIC. 66 Additional child tax credit. Attach Form 8812 . . . . . . . . . . . . 66 ;' - 67 Amount paid with re west for extension to file (see age 61) 67 68 Credits from Form: a ? 2439 b E] 4136 c LJ 8801 d E:] 8885 68 69 First-time homebuyer credit. Attach Form 5405 . . . . . . . . . . . 69 70 Recovery rebate credit (see worksheet on pages 62 and 63) . . . . . . 70 71 Add lines 62 through 70. These are our total payments ....... .. ....... ? 71 1 259 Refund 72 If line 71 is more than line 61, subtract line 61 from line 71. This is the amount you overpaid . 72 1,138 73a Amount of line 72 you want refunded to you. If Form 8888 is attached check here. . . ? ? 73a 1 138 Direct deposit? ? b Routing number 231381116 ? c Type: FX Checking ?-Savings See page 63 and fill in 73b, ? d Account number 0451355366 73c, and 73d, or Form 8688. 74 Amount of line 72 you want applied to our 2009 estimated tax . ? 74 Amount 75 Amount you owe. Subtract line 71 from line 61. For details on how to pay, see page 65 . . . . . ? 75 0 You Owe 76 Estimated tax penalty see page 65 76 Third Party Designee Do you want to allow another person to discuss this return with the IRS (see page 66)? 0 Yes. Complete the following. ? No Designee's Phone Personal identification name ? Preparer no. ? (717) 938-2666 number (PIN) ? 74633 Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and Here belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge. Joint return? Your signature Date Your occupation Daytime phone number See page 15. Keep a copy UNEMPLOYED 717 979-7614 for your Spouse's signature. If a joint return, both must sign. Date Spouse's occupation records. Paid Preparer's Date Check if Preparer's SSN or PTIN i t ' s gna ure HERBERT SHOFFNER 2/25/2009 self-employed 0 171-42-9552 Preparer's Firm's name (or SHOFFNER INCOME TAX SERVICE EIN Use Only yours if self-employed), '847 HECK HILL RD Phone no. (717)938-2666 address, and ZIP code LEWISBERRY state PA ZIP code 17339-9142 Form 1040 (2008) J 169567871 RAUGH KRISTI 20 E COOVER ST A MECHANICSBURG 717-979-7614 0800111007 PA-40 - 2008 Pennsylvania Income Tax Return ENTER ONE LETTER OR NUMBER IN EACH BOX. Do Not Use Your Preprinted Label J Occupation UNEMPLOYED Occupation PA 17055 21650 la Gross Compensation. Do not include exempt income, such as combat zone pay and qualifying retirement benefits. See the instructions. 1b Unreimbursed Employee Business Expenses. 1c Net Compensation. Subtract Line 1 b from Line 1 a. N Extension. N Amended Return. R Residency Status. PA ResidenVNonresidenVPart-YeatiResident from to S Single/Married, Filing Jointly/Married, Filing Separately/Final Return/Deceased Date of death N Farmers. School District Name MECHANICSBURG 2 Interest Income. Complete PA Schedule A if required. 3 Dividend and Capital Gains Distributions Income. Complete PA Schedule B if required. 4 Net Income or Loss from the Operation of a Business, Profession, or Farm. 5 Net Gain or Loss from the Sale, Exchange, or Disposition of Property. 6 Net Income or Loss from Rents, Royalties, Patents, or Copyrights. 7 Estate or Trust Income. Complete and submit PA Schedule J. 8 Gambling and Lottery Winnings. Complete and submit PA Schedule T. 9 Total PA Taxable Income. Add only the positive income amounts from Lines 1 c, 2, 3, 4, 5, 6, 7, and 8. DO NOT ADD any losses reported on Lines 4, 5, or 6. 10 Other Deductions. Enter the appropriate code for the type of deduction. N See the instructions for additional information. 11 Adjusted PA Taxable Income. Subtract Line 10 from Line 9. EC Page 1 of 2 FC 9668 0 F 9668 0 0 0 5 0 6 0 7 0 8 0 9 9668 10 0 11 9668 0800111007 1301 m?? 0800111007 1 J PA-40 - 2008 Social Security Number 169567871 L 12 PA Tax Liability. Multiply Line 11 by 3.07 percent (0.0307). 13 Total PA Tax Withheld. See the instructions. 14 Credit from your 2007 PA Income Tax return. 15 2008 Estimated Installment Payments. 16 2008 Extension Payment. 17 Nonresident Tax Withheld from your PA Schedule(s) NRK-1. (Nonresidents only) 18 Total Estimated Payments and Credits. Add Lines 14, 15, 16, and 17. Tax Forgiveness Credit. Submit PA Schedule SP. 19a Filing Status: 01 Unmarried or Separated 02 Married 03 Deceased 19b Dependents, Part B, Line 2, PA Schedule SP 20 Total Eligibility Income from Part C, Line 11, PA Schedule SP. 21 Tax Forgiveness Credit from Part D, Line 16, PA Schedule SP. 22 Resident Credit. Submit your PA-Schedule(s) G-R with your PA Schedule(s) G-S, G-L and/or RK-1. 23 Total Other Credits. Submit your PA Schedule OC. 24 TOTAL PAYMENTS and CREDITS. Add Lines 13, 18, 21, 22, and 23. 25 TAX DUE. If Line 12 is more than Line 24, enter the difference here. 26 Penalties and Interest. See the instructions. Enter Code: If including form REV-1630, mark the box. N 27 TOTAL PAYMENT. Add Lines 25 and 26. 28 OVERPAYMENT. If Line 24 is more than the total of Line 12 and Line 26, enter the difference here. The total of Lines 29 through 35 must equal Line 28. 29 Refund - Amount of Line 28 you want as a check mailed to you. Refund 30 Credit - Amount of Line 28 you want as a credit to your 2009 estimated account. 31 Amount of Line 28 you want to donate to the Wild Resource Conservation Fund. 32 Amount of Line 28 you want to donate to the Military Family Relief Assistance Program. 33 Amount of Line 28 you want to donate to the Governor Robert P. Casey Memorial Organ and Tissue Donation Awareness Trust Fund. 34 Amount of Line 28 you want to donate to the Juvenile (Type 1) Diabetes Cure Research Fund. 35 Amount of Line 28 you want to donate to the PA Breast Cancer Coalition's Breast and Cervical Cancer Research Fund. Signature(s). Under penalties of periury, I (we) declare that I (we) have examined this return, including all accompanying schedules and statements, and to the best of my (our) belief, they are true, correct, and complete. Your Signature Spouse's Signature, if filing jointly Preparer's Name and Telephone Number Date SHOFFNER INCOME TAX SERVICE (717)938-2666 Page 2 of 2 0800211013 0800211013 Name(s) RAUGH KRISTI J 12 297 13 296 14 0 15 0 16 0 17 0 18 0 19a 01 19b 00 20 10166 21 0 22 0 23 0 24 296 25 1 26 0 27 1 28 0 29 0 30 0 31 0 32 0 33 0 34 0 35 0 Firm FEIN Preparers SSN/PTIN 171429552 0800211013 J F1 LEC- (''F .r 1 AI 2U0 9 F,AY C 6 1,£,11: 2 t CHRISTOPHER RAUGH, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. : CIVIL ACTION - DIVORCE KRISTI RAUGH, Defendant : NO. 08-6697 INVENTORY OF DEFENDANT, KRISTI RAUGH Defendant files the following inventory of all property owned or possessed by either party at the time this action was commenced and all property transferred within'the preceding three years. Defendant verifies that the statements made in this inventory are true and correct, to the best of her knowledge, information, and belief. Defendant understands that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unworn falsification to authorities. ASSETS OF PARTIES Defendant marks on the list below those items applicable to the case at bar and itemizes the assets on the following pages. ( ) 1. Real Property (X) 2. Motor Vehicles ( ) 3. Stocks, bonds, securities and options ( ) 4. Certificates of deposit ( ) 5. Checking accounts, cash ( ) 6. Savings accounts, money market and savings certificates ( ) 7. Contents of safe deposit boxes ( ) 8. Trusts ( ) 9. Life insurance policies (indicate face value, cash surrender value and current beneficiaries) (X) 10. Annuities (X) 11. Gifts ( ) 12. Inheritances ( ) 13. Patents, copyrights, inventories, royalties ( ) 14. Personal property outside the home ( ) 15. Business (list all owners, including percentage of ownership, and officer/director positions held by a parry with company) ( ) 16. Employment termination benefits - severance pay, worker's compensation claim/award ( ) 17. Profit sharing plans (X) 18. Pension plans (indicate employee contribution and date plan vests) (X) 19. Retirement plans, Individual Retirement Accounts 20. Disability payments ( ) 21. Litigation claims (matured and unmatured) ( ) 22. MilitaryN.A. benefits ( ) 23. Education benefits (X) 24. Debts due, including loans, mortgages held (X) 25. Household furnishings and personalty (include as a total category and attach itemized list if distribution of such assets is in dispute) ( ) 26. Other MARITAL PROPERTY Defendant lists all marital property in which either or both spouses have a legal or equitable interest individually or with any other person as of the date this action was commenced: Item Description Names Of Number Of Property All Owners 2. 1996 Skyline Mobile Home Christopher Raugh Kristi Raugh 2. 1999 Honda Accord Christopher Raugh Kristi Raugh 2. 2008 Mustang Kristi Raugh 10. Annuities (type unknown) Christopher Raugh 18. IBEW Local 143 Pension Christopher Raugh (type unknown) 19. Retirement Benefits Christopher Raugh (type unknown) 2 25. Piano Christopher Raugh Kristi Raugh 25. Contents of Home Christopher Raugh Kristi Raugh PROPERTY TRANSFERRED Item Description Date Of Person To Whom Number of Property Transfer Consideration Transferred 2. 1995 Honda Civic June 2007 $1,800 3rd Party LIABILITIES Item Description Names Of Names Of Number of Property All Creditors All ebtors 24. Loan for 1996 unknown Christopher Raugh Skyline Mobile Home Kristti Raugh 24. Loan for 2008 Mustang Chase Bank Kristi Raugh 24. Personal Service Loan PSECU Christopher Raugh Kristi Raugh 24. Visa Credit Card PSECU Christopher Raugh Kristi Raugh 24. Christopher's Credit Cards unknown Christopher Raugh NONMARITAL PROPERTY Item Description Reason For Exclusion Number of Property Owner from Marital Property 3 Defendant reserves the right to correct and/or supplement this Inventory to the extent that she acquires additional information regarding assets and/or liabilities. +"' + ', , 1 A 1r ,:I r ! l,' t+N Ji I fPi f C:U Lt r' Christopher Raugh, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION-LAW DIVORCE Kristi Raugh, Defendant NO. 08-6697 CIVIL TERM CERTIFICATE OF SERVICE I, Rachel Allen, Certified Legal Intern, Family Law Clinic, hereby certify that I served a copy of Defendant's Income and Expense Statement and Defendant's Inventory on Plaintiff Christopher Raugh's attorney, Jennifer Spears, by depositing a copy of the same in the United States first class mail, postage prepaid addressed to Martson Law Offices, 10 East High Street, Carlisle, PA 17013 on May 27, 2009. GGiI?' Rachel Allen Certified Legal Intern FAMILY LAW CLINIC 45 North Pitt Street Carlisle, PA 17013 (717) 243-2968 Fax: (717) 243-3639 ALEC 20091.#d'i 3 f F Ait ! I w Christopher Raugh, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION-LAW DIVORCE Kristi Raugh, Defendant NO. 08 - 6638' CIVIL TERM CERTIFICATE OF SERVICE I, Rachel Allen, Certified Legal Intern, Family Law Clinic, hereby certify that I served a true and correct copy of the Defendant's Answer to Divorce Complaint and New Matters on Plaintiff Christopher Raugh's attorney Jennifer Spears, by depositing a copy of the same in the United States first class mail, postage prepaid addressed to Martson Law Offices, 10 East High Street, Carlisle, PA 17013 on March 20, 2009. Rachel Allen Certified Legal Intern FAMILY LAW CLINIC 45 North Pitt Street Carlisle, PA 17013 (717) 243-2968 Fax: (717) 243-3639 A LE OF TH= 29G9 AUG 17 AM 11: 58 It_ED-01= 71C MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLER ` Cil tt. MARTSON LAW OFFICES 2011 MAY 16 AM 9: -= I.D. 87445 10 East High Street .UMBERL A D C1riUJJ Carlisle, PA 17013 pENNSYLVANtA (717) 243-3341 Attorneys for Plaintiff CHRISTOPHER RAUGH, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-6697 CIVIL ACTION - LAW KRISTI RAUGH, Defendant : IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under § 3301(c) of the Divorce Code was filed on November 12, 2008. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. '6? (0 e:Lx Date: &01 / Christoph Raugh, Plaintiff Jennifer L. Spears, Esquire MARTSON DEARDORFF WILLIAMS OTTO GILROY MARTSON LAW OFFICES I.D. 87445 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff THE PR CTH , NO I & FALLEN 23011 MAY 16 AN 9: 4 6 CUMBERLAND C0UI-i-I L. PENNSYLVANIA CHRISTOPHER RAUGH, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-6697 CIVIL ACTION - LAW KRISTI RAUGH, Defendant IN DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER §3301(c) AND § 3301(d) OF THE DIVORCE CODE I consent to the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the prothonotary. I verify that the statements made in this waiver are true and correct. I understand that false statements herein are made subject to the penaltie of 18 Pa. C.S. § 4904 relating to unsworn falsificatio to authorities. Date: Christopher augh, Plaintiff F:\FILESTlients\13234 Raugh\13234.1.aoc won Revised: 5/11/11 9.05 AM I ILED F FI"'C Jennifer L. Spears, Esquire F ii r,: 1 T I= 0 N 0 ? MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLS111 MARTSON LAW OFFICES I 1 MAY 16 AM 9' V I.D. 87445 ^?iMBERL?iNi3 UiUal 10 East High Street Carlisle, PA 17013 PENNSYLVANIA (717) 243-3341 Attorneys for Plaintiff CHRISTOPHER RAUGH, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-6697 CIVIL ACTION - LAW KRISTI RAUGH, Defendant IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under § 3301(c) of the Divorce Code was filed on November 12, 2008. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. ?i Date: U ll Kristi augh, e e an Jennifer L. Spears, Esquire MARTSON DEARDORFF WILLIAMS OTTO GILROY MARTSON LAW OFFICES I.D. 87445 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff _ FILED-0 ?:I THE PRO stik10 is & FALLER 2911 MAY 16 AN 9* 4C, CUMBERLAND COUN'T" PENNSYLVANIA 4# CHRISTOPHER RAUGH, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 08-6697 CIVIL ACTION - LAW KRISTI RAUGH, Defendant IN DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER §3301(c) AND § 3301(d) OF THE DIVORCE CODE I consent to the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the prothonotary. I verify that the statements made in this waiver 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: Kristi Raug , fen F:\F1LES\C1ients\13234 Raugh\13234. I.pca Revised: 5/16/11 10.20AM Jennifer L. Spears, Esquire t '"`'yk f, r! ° `.f° MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLER, MARTSON LAW OFFICES 11Ay 16 PM 2: 29 I.D. 87445 UMBEFtLAkO 10 East High Street P E N N S Y 14", N1A Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff CHRISTOPHER RAUGH, Plaintiff V. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 08-6697 CIVIL ACTION - LAW KRISTI RAUGH, Defendant IN DIVORCE PRAECIPE TO TRANSMIT RECORD To the Prothonotary: Transmit the record, together with the following information, to the court for entry of a divorce decree: 1. Ground for divorce: irretrievable breakdown under Section 3301(c) of the Divorce Code. 2. Date and manner of service of the complaint: Via certified mail, restricted delivery on November 28, 2008. 3. Date of execution of the Plaintiff s affidavit of consent required by Section 3301 (c) of the Divorce Code; May 12, 2011; by the Defendant; May 12, 2011. 4. Related claims pending: All claims have been resolved by a Marital Settlement Agreement dated May 3, 2011. 5. Date Plaintiffs Waiver of Notice in §3301(c) Divorce was filed with the Prothonotary: May 16, 2011. Date Defendant's Waiver ofNotice in §3301(c) Divorce was filed with the Prothonotary: May 16, 2011. MARTS LAW OFFICES By Jennifer ears, Esquire Ten East High Street Carlisle, PA 17013 (717) 243-3341 Date: May 16, 2011 Attorneys for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHRISTOPI-ER RAUGH V. KRISTI RAUGH DIVORCE DECREE AND NOW, D?Q it is ordered and decreed that CHRISTOPHER RAUGH plaintiff, and KRISTI RAUGH , 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.") The Marital Settlement Agreement dated May 3, 2011, is incorporated but not merged into this Order. By the Court, Attest: rothonot NO. 2008-6697 s Mai ORDERMOTICE TO WITHHOLD INCOME FOR SUPPORT State: Commonwealth of Pennsylvania ac )S I 1 b 4 cl a Co./City/Dist. o : CUMBERLAND I Lj4 4 S ?UL?7 Date of Order/Notice: 07/06/11 Case Number (See A en um for case summary) Employer/Withholder's Federal EIN Number HARRISBURG ELECTRICIANS JACT 1501 REVERE ST HARRISBURG PA 17104-3412 RE: RAUGH, CHRISTOPHER D. D4( - LoL °I`1 CI v i I O Original Order/Notice Q Amended Order/Notice Q Terminate Order/Notice O One-Time Lump Sum/Notice Employee/Obligor's Name (Last, First, MI 164-54-6624 Employee/Obligors Social SecuriTITu-m-Fe-r 2052102068 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last. First, MI) See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by your State. CS r.11 CD $ 0.00 per month in current child support -tj Z ; -.t $ 0.00 per month in past-due child support Arrears 12 weeks or greater? ese M-n $ 0.00 per month in current medical support ZX ? r- -per $ 0.00 per month in past-due medical support 1 o $ 520.00 per month in current spousal support ? o -n $ 0.00 per month in past-due spousal support er c3- n $ 0.00 per month for genetic test costs Cz N ?i $ 0.00 per month in other (specify) - $ one-time lump sum payment .? - 70 -,t for a total of $ 520.00 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: $ CC, per weekly pay period. $ 260.00 per semimonthly pay period (twice a month) $ A 0 • (X per biweekly pay period (every two weeks) $ 520.00 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 Identirier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. ..-'r ? 4_,-N .ter - -ao, s? BY THE COURT: 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 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 e#eet 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. 2307246110 THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER: 0 THE ElpIiPLOYEEJOBLIGOR NO LONGER WORKS FOR: O EMPLOYEE'S/OBLIGOR'S NAME: RAUGH, CHRISTOPHER D. EMPLOYEE'S CASE IDENTIFIER: 2052102068 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: LAST KNOWN PHONE NUMBER: FINAL PAYMENT AMOUNT: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673 (b)); or 2) the amounts allowed by the State or Tribe of the employee's/obligor's principal place of employment. Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, that 50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section. Arrears greater than 12 weeks: If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers who receive a State order, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. 10. Additional Info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Send Termination Notice and other correspondence to: DOMESTIC' RELATIONS SECTION 13 N. HANOVER ST P. O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.chiidsupport. state. pa -us Service Type M OMB No.: 0970-0154 Page 2 of 2 Form EN-028 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: RAUGH, CHRISTOPHER D. PACSES Case Number 205110492 PACSES Case Number Plaintiff Name Plaintiff Name KRISTI J. RAUGH Docket Attachment Amount Docket Attachment Amount 08-6697 CIVIL $ 520.00 $ 0.00 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 Service Type M PACKS Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum OMB No.: 0970-0154 Form EN-028 Worker ID $IATT INCOME WITHHOLDING FOR SUPPORT Q ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) t1 ) V l Q AMENDED IWO C) - to (0 G I C? U I I Q ONE-TIMEORDERINOTICE FOR LUMP SUM PAYMENT n TERMINATION OF IWO Date: 02/10/12 ? Child Support Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions http://www acf hhs gov/programs/cse/newhire/employer/publication/publication htm - forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. State/Tribe/7erritory Commonwealth of Pennsylvania Kemittance ioentmer tmciuae wipaymeny: cv;)F wwoo City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket Infonmaiton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) GMR RESTAURANTS INC' Sent Electronically DO NOT MAIL Employer/Income Withholder's FEIN 591219168 Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) Custodial Party/Obligee's Name (Last, First, Middle) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions hftp1/www acf hhs gov/programs/cse/newhire/ employer/publication/publication htm - formal. 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. 5912191680 See Addendum for dependent names and birth dates associated with cases on attachment. ? _ c_., ORDER INFORMATION: This document is based on the support or withholding order from CUMB?R.ANZC =ty, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these am ounts ff?he?lplmy obligor's income until further notice. _ ? -,l 170 $ 0.00 per month in current child support reater? rt - Arrears 12 weeks or 00 hild 0 t d th i ?)> w O ye 60 n ? r g $ . suppo n pas - ue c permon % - $ 0.00 per month in current cash medical support t.) c ? s r $ 0.00 per month in past-due cash medical support rv T ° $ 520.00 perm n h in current spousal support ten ; $ 0.00 permonth in past-due spousal support co $ 0.00 permonth in other (must specify) for a Total Amount to Withhold of $ 520.00 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: $ 119.67 per weekly pay period. $ 260.00 per semimonthly pay period (twice a month) $ 239.34 per biweekly pay period (every two weeks) $ 520.00 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 CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs ten (10) working days after the date of this Order/Notice. Send payment within 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 CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe), obtain withholding limitations, time requirements, and any allowable employer fees at http://www.acf.hhs.gov/programs/cse/newhire/employer/cgntacts/ contact map.htm for the employeelobligor's principal place of employment. Document Tracking Identifier RE: RAUGH, CHRISTOPHER D. Employee/Obligor's Name (Last, First, Middle) 164-54-6624 Employee/Obligor's Social Security Number (See Addendum for plaintiff names associated with cases on attachment) OMB No.: 0970-0154 Form EN-428 01/12 Service Type M Worker ID $IATT ? Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): KEVINA HESS Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: FEBRUARY 10 2012 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 Raayment method if an employer is ordered to withhold income from more than one employee and employs IS 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: httn://www.acf.hhs.aov/pmarams/cse/`newhirelemployer/contacts/contact_map htm Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42 §666(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/ obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. If this iWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency, you must follow the "Remit payment to" instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by State or Tribal law/procedure. Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO, OMB Expiration Date - 05/3112014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. Form EN-428 01/12 Service Type M Page 2 of 3 Worker ID $IATT Employer's Name: GMR RESTAURANTS INC* Employer FEIN: 591219168 Employee/Obligor's Name: RAUGH, CHRISTOPHER D. 2052102068 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 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: 5912191680 0 This person has never worked for this employer nor received periodic income. 0 This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known address: Final Payment Date To SDU/Tribal Payee: New Employer's Name: New Employer's Address: Last known phone number: Final Payment Amount: 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.childsupQort-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.childsupgortstate. pa us. IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. Service Type M OMB No.: 0970-0154 Page 3 of 3 Form EN-428 01/12 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: RAUGH, CHRISTOPHER D. PACSES Case Number 205110492 PACSES Case Number Plaintiff Name Plaintiff Name KRISTI J. RAUGH Docket Attachment Amount Docket Attachment Amount 08-6697 CIVIL $ 520.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACKS Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACKS Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Service Type M 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 OMB No.: 0970-0154 Form EN-428 01/12 Worker ID $IATT INCOME WITHHOLDING FOR SUPPORT Q ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) l] I I L) 4 C) Q AMENDED IWO L X- loloq'7 C IV i I Q ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT Q TERMINATION OF IWO Date: 02113112 ? Child Support Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions http://www acf hhs aov/rograms/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. Statefrribe/Territory Commonwealth of Pennsylvania Remittance Identifier (include w/payment): 2052102068 City/County/Dist.rrribe CUMBERLAND Order Identifier: (See Addendum for order/docket lnformalton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) GMR RESTAURANTS INC* RE: RAUGH, CHRISTOPHER D. Employee/Obligor's Name (Last, First, Middle) Sent Electronically DO NOT MAIL Employer/Income Withholder's FEIN 591219168 Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) Custodial Party/Obligee's Name (Last, First, Middle) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions hitp://www acf hhs aov/programs/cse/newhire/ employer/publication/12ublication.htm - form . If you receive this document from someone other than a State or Tribal CSE agency or a Court, a' copy of the underlying order must be attached. 5912191680 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the em ployee/ obligor's income until further notice. C') $ 0.00 permonth in current child support $ 0.00 permonth in past-due child support - Arrears 12 weeks or greater? Q yam, I'm $ 0.00 per month in current cash medical support Z? w -or" $ 0.00 per month in past-due cash medical support ?'- r :;0 $ 0.00 permonth in current spousal support ?U?- o $ 0.00 per month in past-due spousal support $ 0.00 permonth in other (must specify) N for a Total Amount to Withhold of $ 0.00 per month. t CO 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 CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs ten (10) working days after the date of this Order/Notice. Send payment within 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 CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe), obtain withholding limitations, time requirements, and any allowable employer fees at http://www acf hhs oov/programs/cse/newhire/employer/contacts/ contact map.htm for the employee/obligor's principal place of employment. Document Tracking Identifier 164-54-6624 Employee/Obligor's Social Security Number (See Addendum for plaintiff names associated with cases on attachment) OMB No.: 097M1 54 Form EN-428 01/12 Service Type M Worker ID $IATT ? Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): KEVINA HESS Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: FEBRUARY 13 2012 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 EMPLOYERSANCOME 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 /D (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: htto•/Iw m acf hhs.oov/12roarams/cse/newhir /emp(oyer/contactsicontaa maQ;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 SOU 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 SDUp You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. (#,this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial party, court, or attorr6q), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a Court, Attomey, of Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal C$E-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-428 01112 Service Type M Page 2 of 3 Worker ID $IATT Employer's Name: GMR RESTAURANTS INC* Employer FEIN: 591219168 Employee/Obligor's Name: RAUGH CHRISTOPHER D. 2052102068 CSE Agency Case Identifier: (See Addendum for case summa ?y) 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 Tdbe of the employee/obligor's principal place of employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitted by the State or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the Employer should calculate the CCPA limit using the lower percentage. Additional Information: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by retuming this form to the address listed in the Contact Information below: 5912191680 Q This person has never worked for this employer nor received periodic income. O This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known address: Last known phone number: Final Payment Date To SDU/Tribal Payee: New Employer's Name: New Employer's Address: Final Payment Amount: CONTACT INFORMATION: To 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 (7171240-6225, 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. Service Type M OMB No.: 0970-0154 Page 3 of 3 Form EN-428 01/12 Worker ID $IATT ADDENDUM Summary of Casgs on Attachment Defendant/Obligor: RAUGH, CHRISTOPHER D. PACSES Case Number 205110492 PACSES Case Number Plaintiff Name Plaintiff Name KRISTI J. RAUGH Docket Attachment Amount pocket Attachment Amount 08-6697 CIVIL $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): 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 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 Addendum Form EN-428 01/12 Service Type M OMB No.: 0970-0154 Worker ID $IATT CHRISTOPHER D. RAUGH, • IN THE COURT OF COMMON PLEAS OF Plaintiff/Respondent CUMBERLAND COUNTY, PENNSYLVANIA VS. KRISTI J. RAUGH, Defendant/Petitioner CIVIL ACTION - DIVORCE NO. 08-6697 CIVIL TERM IN DIVORCE PACSES Case No: 205110492 ORDER OF COURT AND NOW to wit, on this 30th day of April, 2014, it is hereby Ordered that the Cumberland County Domestic Relations Section dismiss its interest in the above captioned alimony matter pursuant to the alimony obligation being paid in full. This Order shall become final twenty (20) days after the mailing of the notices of the entry of the Order to the parties unless either party files a written demand with the Office of the Prothonotary for a hearing de novo before the Court. DRO: R.J. Shadday xc: Petitioner Respondent Jennifer L. Spears, Esq. Service Type: M BY THE COURT: %// _ _ • •eW asland, C CD w Form 0E-001 Worker: 21005 INCOME WITHHOLDING FOR SUPPORT O ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO) O AMswosoxwu O ONE-TIMEORDERINOTICE FOR LUMP SUM PAYMENT TERMINATION OF `- ~ -—.- -- ^.. �� 'N \ (8) Court 0 Attorney 0 Private Individual/Entity (Check One) NOTE: This IWO must beregotario4s!facre'Mkrder Certain circumstances you must reject this IWO and return it to the sender (see IWO instructions http://www.acf.hhsO-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. n/� \ }(lUQ� �/^' / /��7-�/~- Date: 06/02/14 Commonwealth of Pennsylvania CUMBERLAND Private Individual/Entity Remittance Identifier (include w/payment): 2052 102068 Order Identifier: for order/docket Informatlon) CSE Agency Case Identifier: (See Addendum for case summary) HARRISBURG ELECTRICIANS JACT 15O1REVERE ST HARRISBURG PA 17104-3412 Employer/Income Withholders FEIN 230724611 Child(ren)s Name(s) (Last, First, Middle) Child(reri)s Birth Date(s) RE: RAUGH, CHRISTOPHER D. Employee/Obligors Name (Last, First, Middle) 164-54-6624 Social Security Number (See Addendum for plaintiff names associated with cases on attachment) CumodialParty/Obigee Name (Lu�First, NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and retum it to the sender (see IWO instructions xop:8wwmw.axrhhs.00v/prognomstnomonno/ oma'0970'015* instructions.d. If you receive this document ftom someone other than a State or Tribal CSE agency or a Court, a copy of the underlyng order must be attached. 2307246110 See Addendum for dependent names and birth dates associated with cases on attachment. o ORDER INFORMATION: This document is based on the support or withholding order from CUMB Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts f he tx-ip10-yae/ obligors income until further notice. = --r-) c-7, � $ 0.00 per month in curn�n� child support' u� c�c`z $ 0.00 per month in past -due child support - Arrears 12 weeks or greater? 0 yes �n no,, c �-1.- < -_� CD �, $ U.00per month incurrent cash medical support c2 :�F `.,'000pe,=""'h'""ao'-dueoashmedica/mu"""rt � 0.00 per month in current spousal support � 0.00 per month in past -due spousal support � 0.00 per month in other (must specify) for a TotaAmount to Withhokl 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 twa weeks) $ 0.00 per monthly pay period. � Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order. REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is within the Commonwealth of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to 55°/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 |innitotiono, time requirmmento, and any allowable employer fees at hbp://vwxw.an[hho.gov/pnogremo/ose/newhira/emp|oyer/contacbs/contaut_map. h1Onfur the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.: 0970-0154 Service Type M Form EN -028 11/13 Worker ID $IATT ❑ Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU in j 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. rraust check this box and return the IWO to the sender. A ,_ f' .: `TH. M>aSta 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: JUN 0.3.2014 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. 0 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 Employer's Name: HARRISBURG ELECTRICIANS JACT Employer FEIN: 230724611 Employee/Obligor's Name: RAUGH, CHRISTOPHER D. 2052102068 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 retuming this form to the address listed in the Contact Information below: 2307246110 O This person has never worked for this employer nor received periodic income. O This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU/Tribal Payee: 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 1717) 240-6225, by fax at (717) 240-6248, by email or website at www.chiidsupport.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 Service Type M Page 3 of 3 Form EN -028 11/13 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: RAUGH, CHRISTOPHER D. PACSES Case Number 205110492 Plaintiff Name KRISTI J. RAUGH Docket Attachment Amount 08-6697 CIVIL $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Service Type M Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum OMB No.: 0970-0154 Form EN -028 11/13 Worker ID $IATT