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HomeMy WebLinkAbout09-0313CHARLES A. CLEMENT, JR., Plaintiff V. JODY M. CLEMENT, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. Qq- 313 olyd fv-m CIVIL ACTION - LAW IN DIVORCE NOTICE You have been sued in Court. If you wish to defend against the claims set forth in the following papers, you must take prompt action. You are warned that if you fail to do so, the case may proceed without you and a Decree in Divorce or annulment may be entered against you by the Court. A judgment may also be entered against you for any other claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rights important to you, including custody or visitation of your children. When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. A list of marriage counselors is available in the Office of the Prothonotary at the Cumberland County Courthouse, One 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Phone: (717) 249-3 166 CHARLES A. CLEMENT, JR., Plaintiff V. JODY M. CLEMENT, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA :NO. b4--3i CIVIL ACTION - LAW IN DIVORCE NOTICE OF AVAILABILITY OF COUNSELING To the Within Named Defendant: You have been named as the Defendant in a divorce proceeding filed in the Court of Common Pleas of Cumberland County. This notice is to advise you that in accordance with Section 3302(d) of the Divorce Code, you may request that the Court require you and your spouse to attend marriage counseling prior to a divorce decree being handed down by the Court. A list of professional marriage counselors is available at the Office of the Prothonotary, One Courthouse Square, Carlisle, Pennsylvania. You are advised that this list is kept as a convenience to you and you are not bound to choose a counselor from this list. All necessary arrangements and the cost of counseling sessions are to be borne by you and your spouse. If you desire to pursue counseling, you must make your request for counseling within twenty (20) days of the date on which you receive this notice. Failure to do so will constitute a waiver of your right to request counseling. Prothonotary CHARLES A. CLEMENT, JR., Plaintiff V. JODY M. CLEMENT, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA :NO. Ci9- 3j3 CIVIL ACTION - LAW IN DIVORCE COMPLAINT UNDER SECTION 3301 OF THE DIVORCE CODE 1. Plaintiff is Charles A. Clement, Jr., who currently resides at 999 Oak Lane, Unit G, New Cumberland, Cumberland County, Pennsylvania 17070. 2. Defendant is Jody M. Clement, who currently resides at 908 Drexel Hills Boulevard, New Cumberland, Cumberland County, Pennsylvania 17070. 3. Plaintiff and Defendant have been bona fide residents in the Commonwealth for at least six months immediately previous to the filing of this Complaint. 4. Plaintiff and Defendant were married on December 28, 1984, in New Cumberland, Pennsylvania. 5. There have been no prior actions for divorce or annulment between the parties. 6. The Plaintiff is a citizen of the United States of America. 7. The Defendant is not a member of the Armed Services of the United States of America or its Allies. 8. The marriage is irretrievably broken. The parties to this action have been separated since July 28, 2007. 9. The Plaintiff has been advised of the availability of counseling and that the Plaintiff may have the right to request that the Court require the parties to participate in counseling. 10. Plaintiff requests the Court to enter a Decree in Divorce. 11. This action is not collusive. WHEREFORE, the Plaintiff requests the Court to enter a Decree in divorce dissolving the marriage between the Plaintiff and Defendant. Respectfully submitted, JAMES, SMITH, DIETTERICK & CONNELLY, LLP Dated: 1-'2 ( -0 9 By: P o . Co elly, Jr. tt 1. #15615, P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 Attorneys for Plaintiff Charles A. Clement, Jr. VERIFICATION I, Charles A. Clement, Jr., verify that the statements made in the foregoing Complaint in Divorce are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. Date: ., 02 LL Charles A. Clement, Jr., Plaintiff 00 fin 23 = b ni =? r CJI z 7 CHARLES A. CLEMENT, JR., : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 09-313 JODY M. CLEMENT, : CIVIL ACTION - LAW Defendant : IN DIVORCE ACCEPTANCE OF SERVICE I, Carol J. Lindsay, Esquire, attorney for the above-named Defendant, accept service of the Complaint in Divorce on behalf of my client, Jody M. Clement. Date: 1 7 Q Carol J. Attorney I.D(# Saidis, Flower & Lindsay 26 West High Street Carlisle, PA 17013 (717) 243-6222 (717) 243-6486 (fax) ? ,-, C` _ ? ? i ? :: ?:.. e'? ? ?? ?? ?? ...?? ?? CHARLES A. CLEMENT, JR., IN THE COURT OF COMMON PL 9,iANf Plaintiff CUMBERLAND COUNTY, PENN - r^3 ? ?_ 'V V. CIVIL ACTION - LAW 1 `'? tom: --tom NO. 09-313 JODY M. CLEMENT, T Defendant IN DIVORCE co ?rT; DEFENDANT'S AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under § 3301(c) of the Divorce Code was filed on January 22, 2009 2. The marriage of plaintiff and defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. 1 consent to the entry of a final Decree in Divorce after service of notice of intention to request entry of the Decree. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. Date: n 18 4JM - le ent DEFENDANT'S WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER-4 3301 W OF THE DIVORCE CODE 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 SAIDIS SULLIVAN LAW 26 West High Street Carlisle, PA 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 to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. Date: O&VU 1. IAJAWd Jody IA. m nt CHARLES A. CLEMENT, JR., : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 09-313 JODY M. CLEMENT, CIVIL ACTION -LAW ° -n Defendant : IN DIVORCE Mme' Z = Ze? c N . of -<a 0v Q BCD PETITION TO REVOKE a4'r' 3 O APPOINTMENT OF MASTER b o? 1. On April 12, 201 0, E. Robert Elicker, III, Esquire, was appointed Master in the above-captioned matter to consider the issues raised in the proceedings. 2. A settlement was reached between the parties pursuant to a Marital Settlement Agreement dated November 17, 2010. 3. The undersigned therefore requests that the appointment of E. Robert Elicker, III, Esquire be revoked. Respectfully submitted, JAMES, SMITH, DIETTERICK & CONNELLY, LLP Dated: (I - )3' w By: ?'? am\( hn Co lly, Jr. . #15615 P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 Attorneys for Plaintiff CHARLES A. CLEMENT, JR., : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 09-313 JODY M. CLEMENT, : CIVIL ACTION - LAW Defendant : IN DIVORCE CERTIFICATE OF SERVICE I, John J. Connelly, Jr., Esquire, of James, Smith, Dietterick & Connelly LLP, attorney for the Plaintiff, Charles A. Clement, Jr., hereby certify that I have served a copy of the foregoing Petition to Revoke Appointment of Master on the following on the date and in the manner indicated below: U.S. MAIL. FIRST CLASS. PRE-PAID Carol J. Lindsay, Esquire Saidis Sullivan Law 26 West High Street Carlisle, PA 17013 JAMES, SMITH, DIETTERICK & CONNELLY, LLP Dated: 11-23-16 By: Attorneys for Plaintiff Hershey, PA 17033-0650 (717) 533-3280 CHARLES A. CLEMENT, JR., Plaintiff V. JODY M. CLEMENT, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 09-313 o a CIVIL ACTION - LAW air- IN DIVORCE .{ A .c A ° 5z r PRAECIPE TO WITHDRAW CLAIMS TO THE PROTHONOTARY: GJ x rn q° C XF5 qt --c Please withdraw the claim for equitable distribution filed by Plaintiff in the above-captioned divorce action. Dated: U43-10 By: JAMES, SMITH, DIETTERICK & CONNELLY, LLP Attorneys for Plaintiff P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 CHARLES A. CLEMENT, JR., : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYIcA11 Q 0 --t v. : NO. 09-313 = M- JODY M. CLEMENT, : CIVIL ACTION - LAWZ ?© Defendant : IN DIVORCE < -v s Q a-n A Z :? C 'm AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under Section 3301(c) of the Divorce Code was filed on January 22, 2009. 2. The marriage of the Plaintiff and Defendant is irretrievably broken, and ninety days have elapsed from the date of both the 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. WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER 43301(c) OF THE DIVORCE CODE 1. I consent to the entry of a final Decree of Divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce 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 above 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: /1//-7//0 0' Charles A. Clement, Jr., Plaintiff NOV 2 9 2010 CHARLES A. CLEMENT, JR., : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 09-313 JODY M. CLEMENT, : CIVIL ACTION - LAW Defendant : IN DIVORCE ORDER AND NOW, this 2-17' day of November, 2010, the appointment of E. Robert Elicker, III, Esquire, as Master in the above-captioned proceeding is hereby revoked. Di bution: 'J. Connelly, Jr., Esquire, P.O. Box 650, Hershey, PA 17033 Carol J. Lindsay, Esquire, 26 West High Street, Carlisle, PA 17013 E. Robert Elicker III Esquire 9 North Hanover Street Carlisle PA 17013 Co P t?s to i :X rn i rU CD -c ri -or ?-= MM -ems CD ?C3 - f w Q Ti C] C _ CD c`e s -: N X, -a BY THE COURT: I CHARLES A. CLEMENT, JR., : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 09-313 JODY M. CLEMENT, : CIVIL ACTION - LAW c? c) Defendant : IN DIVORCE m -am Z irn rrv rn? - a= r- n ?r rn PRAECIPE TO TRANSMIT RECORD 2 oQ r-- za ? z To the Prothonotary: orri 4 x' 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 ( x ) 3301(c) ( ) 3301(d) of the Divorce Code. 2. Date and manner of service of the Complaint: Upon counsel for Defendant as evidenced by the Acceptance of Service on record. 3. Complete either paragraph (a) or (b). (a) Date of execution of the Affidavit of Consent and Waiver of Counseling required by Section 3301(c) of the Divorce Code: by Plaintiff: November 17,2010; by Defendant: November 8, 2010. (b) (1) Date of execution of the Plaintiffs Affidavit required by Section 3301(d) of the Divorce Code: (2) Date of service of the Plaintiffs Affidavit upon the Defendant: 4. Related claims pending: All claims have been settled pursuant to a Marital Settlement Agreement dated November 17, 2010. A* % 5. Date and manner of service of the notice of intention to file Praecipe to Transmit Record, a copy of which is attached, if the decree is to be entered under Section 3301(d) of the Divorce Code: 6. Date and manner of service of Notice of Intention to file Praecipe to Transmit Record, a copy of which is attached, if the decree is to be entered under Section 3301(d) of the Divorce Code: or, date of execution of Waiver of Notice of Intention to Request Entry of a Divorce Decree under Section 3301(c) of the Divorce Code: by Plaintiff: November 17, 2010; by Defendant: November 8, 2010. and, date of filing of the Waiver of Notice of Intention to Request Entry of a Divorce Decree: by Plaintiff: Plaintiffs Waiver is being filed simultaneously with this Praecipe; by Defendant: November 22, 2010. JAMES, SMITH, DIETTERICK & CONNELLY, LLP Dated: ( (-13 -t By: hn onn lly, Jr. 1. .#15615 P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 Attorneys for Plaintiff f FILED-OFFICE OF THE PROTHONOTARY 2010 DEC -I PM 3: 22 CUMBERLAND 00 : COURT OF COMMON PLEAS CHARLES A. CLEMENT, JRpENNSYLVANIt Plaintiff UMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW NO. 09-313 JODY M. CLEMENT, Defendant IN DIVORCE PRAECIPE TO THE PROTHONOTARY: Please withdraw Defendant's Petition for Economic Relief. Respectfully submitted, SAIDIS SU _AN r Carol J. Linds s ire Attorney Id. 44 93 26 West High Street Carlisle, PA 17013 (717) 243-6222 Counsel for Defendant SAIDIS SULLIVAN LAW 26 West High Street Carlisle, PA CERTIFICATE OF SERVICE I hereby certify that on this 1 st day of December, 2010, a true and correct copy of the foregoing document was served upon the party listed below, via First Class Mail, postage prepaid, addressed as follows: John J. Connelly, Jr., Esquire P.O. Box 650 Hershey, PA 17033 SAIDIS SULLIVAN LAW Carol J. Lindsay, Esquire Supreme Court ID No. 44693 26 West High Street Carlisle, PA 17013 717-243-6222 SAIDIS SULLIVAN LAW 26 West High Street Carlisle, PA IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHARLES A. CLEMENT, JR. V. JODY M. CLEMENT : NO. 09-313 DIVORCE DECREE AND NOW, 7« 7 ' , z or o , it is ordered and decreed that CHARLES A. CLEMENT, JR. , plaintiff, and JODY M. CLEMENT , 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 parties' Marital Settlement Agreement dated November 17, 2010 is hereby incorporated, u no merged, into this Decree in Divorce. By the Court, rrULI1UIIUIary iz/Q/ro - aefz--l l2PY - ")( DEC 16201a COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Charles A. Clement, Jr. ; Plaintiff VS. : Jody M. Clement Defendant CIVIL ACTION - LAW IN DIVORCE NO. 09-313 STIPULATION FOR THE ENTRY OF "DOMESTIC RELATIONS ORDER" AND NOW, this day of k48'??l the parties, Charles A. Clement, Jr., Plaintiff, and Jody M. Clement, Defendant, do hereby Agree and Stipulate as follows: 1. The Plaintiff, Charles A. Clement, Jr. (hereinafter referred to as "Member"), is a member of the Commonwealth of Pennsylvania, State Employees' Retirement System (hereinafter referred to as "SERS"). 2. SERS, as a creature of statute, is controlled by the State Employees' Retirement Code, 71 Pa. C.S. §§5101-5956 ("Retirement Code") 3. Member's date of birth and Social Security number are contained in the attached Addendum. 4. The Defendant, Jody M. Clement (hereinafter referred to as "Alternate Payee"), is the former spouse of Member. Alternate Payee's date of birth and Social Security number are contained in the attached Addendum. 0 5. Member's last known mailing address is: c -Q 7-C =-n rn M chi te r" ' P O Box 664 ? '- C--) -" -urn C3 . . . New Cumberland, PA 17070 , rn -a oo- D C- n ? CD - _ o rn 6. Alternate Payee's current mailing address is: c- s' 77 908 Drexel Hill Blvd. New Cumberland, PA 17070 DRO Page 2 It is the responsibility of Alternate Payee to keep a current mailing address on file with SERS at all times. (a) The marital property component of Member's retiirement benefit equals (1) the coverture fraction multiplied by (2) the Member's retirement benefit on the effective date of Member's retirement. (b) The coverture fraction is a fraction with a value less than or equal to one. The numerator is the amount of Member's service, as defined by SERS, as of July 28, 2007 (the date of separation). The denominator is the total amount of Member's service, as defined by SERS, as of the effective date of Member's retirement. (c) 40.0% of the marital property component of Member's retirement benefit is to be allocated to the Alternate Payee as her equitable distribution portion of this marital asset. 8. Member's retirement benefit is defined as all monies paid to or on behalf of Member by SERS, including any lump sum withdrawals or scheduled or ad hoc increases, but excluding the disability portion of any disability annuities paid to Member by SERS as a result of a disability which occurs before Member's marriage to Alternate Payee or after the date of Member's and Alternate Payee's final separation. Member's retirement benefit does not include any deferred compensation benefits paid to Member by SERS or any enhancements to the Member's retirement benefit arising from postseparation monetary contributions made by Member. The equitable distribution portion of the marital property component of Member's retirement benefit, as set forth in Paragraph 7, after the application of the appropriate early retirement actuarial reduction factor, if any, shall be payable to Alternate Payee. Payments to Alternate Payee shall commence as soon as administratively feasible on or about the date the Member actually enters pay status and SERS approves a Domestic Relations Order incorporating this; Stipulation and Agreement, whichever is later. 9. Member hereby nominates Alternate Payee as an irrevocable beneficiary to the extent of Alternate Payee's equitable distribution portion of Member's retirement benefit for any pre- retirement death benefits payable by SERS. This nomination shall become effective upon DRO Page 3 approval by the Secretary of the Retirement Board, or his authorized representative, of any Domestic Relations Order incorporating this Stipulation and Agreement. The balance of any death benefit remaining after the allocation of Alternate Payee's equitable distribution portion ("Balance") shall be paid to the beneficiaries named by Member on the last Nomination of Beneficiaries Form filed with the Retirement Board prior to Member's death. (a) If the last Nomination of Beneficiaries Form filed by Member prior to Member's death (a) predates any approved Domestic Relations Order incorporating this Stipulation and Agreement, and (b) names Alternate Payee as a beneficiary, then: (1) the terms of the Domestic Relations Order shall alone govern Alternate Payee's share of any death benefit, and (2) for purposes of paying the Balance via the last Nomination of Beneficiaries Form filed with the Retirement Board prior to Member's death, Alternate Payee shall be treated as if Alternate Payee predeceased Member. No portion of the Balance shall be payable to Alternate Payee's estate. (b) In addition, Member shall execute and deliver to Alternate Payee an authorization, in a form acceptable to SERS, which will authorize SERS to release to Alternate Payee all relevant information concerning Member's retirement account. Alternate Payee shall deliver the authorization to SERS which will allow the Alternate Payee to check that she has been and continues to be properly nominated under this paragraph. 10. The term and amounts of Member's retirement benefits payable after SERS approves a Domestic Relations Order incorporating this Stipulation and Agreement and after Member files a retirement application with SERS shall be in accordance with Paragraphs 10(a), 10(b) and 10(c) as follows: (a) Member may elect to receive, by lump sum, 0% to 100% of his accumulated deductions. The portion of the accumulated deductions to be paid to the Alternate Payee or her estate shall be determined by multiplying (1) by (2) by (3) where (1), (2) and (3) are as follows: (1) The accumulated deductions as of July 28, 2007, together with statutory interest (currently 4% per year) from July 28, 2007, through the Member's date of retirement. (2) 40.0%. DRO Page 4 (3) Ratio obtained by dividing amount of accumulated deductions the Member elects to receive by the total amount of his accumulated deductions on the effective date of Member's retirement. (b) (1) If the Alternate Payee is living, Member shall elect a joint and survivor annuity as set forth in 71 PA.C.S. 5705(a)(4), or any succeeding statue. The Alternate Payee shall be the irrevocable survivor annuitant. The amount of the annuity shall be the equitable distribution portion (as defined in Paragraph 7) adjusted actuarially for any accumulated deductions paid to the Alternate Payee (pursuant to Paragraph 710(a)) and, since the cost of the survivor annuity is to be paid by the Alternate Payee, further adjusted actuarially so that the amount of the survivor annuity shall equal the amount of the annuity payable to the Alternate Payee during the Member's lifetime. The intent of this option selection is to maintain levelized payments to the Alternate Payee for her life in the event of Member's death after retirement, with the Alternate Payee paying for the survivor annuity through a reduction in her monthly annuity. The Alternate Payee shall receive a portion of the annuity which is payable to the Member during his lifetime, and the same amount, as a survivor annuity, if the Member predeceases the Alternate Payee after retirement. If the Alternate Payee predeceases the Member after retirement, the portion of his annuity payable to the Alternate Payee shall be paid to Alternate Payee's estate for the lifetime of the Member. (b) (ii) If the Alternate Payee is not living, the Member shall elect a maximum single life annuity based upon the equitable distribution portion (as defined in Paragraph 7) adjusted actuarially for any accumulated deductions paid to the Alternate Payee's estate (pursuant to Paragraph 10(a)). Such annuity shall be paid to the Alternate Payee's estate for the lifetime of the Member. (c) Member may choose any option with respect to the excess of his entire benefit over the portion awarded the Alternate Payee or her estate and over any accumulated deductions paid to the Member under Paragraph 10(a). Any option selected shall not reduce the amount that is to be paid to the Alternate Payee or her estate under the provisions of this Order. DRO Page 5 11. Alternate Payee may not exercise any right, privilege or option offered by SERS. SERS shall issue individual tax forms to Member and Alternate Payee for amounts paid to each. 12. In the event of the death of Alternate Payee, prior to the receipt of all of her payments payable to her from SERS under this Order, then any death benefit or retirement benefit payable to the Alternate Payee by SERS shall be paid to Alternate Payee's estate to the extent of Alternate Payee's equitable distribution portion of Member's retirement benefit. 13. In no event shall Alternate Payee have greater benefits or rights other than those which are available to Member. Alternate Payee is not entitled to any benefit not otherwise provided by SERS. The Alternate Payee is only entitled to the specific benefits offered by SERS as provided in this Order. All other rights, privileges and options offered by SERS not granted to Alternate Payee by this Order are preserved for Member. Member and Alternate Payee acknowledge that benefits paid pursuant to this Stipulation and Agreement are and shall remain subject to the Public Employee Pension Forfeiture Act, 43 P.S. §1311, et seq. 14. It is specifically intended and agreed by the parties hereto that this Order: (a) Does not require SERS to provide any type or form of benefit, or any option not otherwise provided under the Retirement Code; (b) Does not require SERS to provide increased benefits (determined on the basis of actuarial value) unless increased benefits are paid to Member based upon cost of living or increases based on other than actuarial values. 15. The parties intend and agree that the terms of this Stipulation and Agreement shall be approved, adopted and entered as a Domestic Relations Order. 16. The Court of Common Pleas of Cumberland County, Pennsylvania, shall retain jurisdiction to amend any Domestic Relations Order incorporating this Stipulation and Agreement, but only for the purpose of establishing it or maintaining it as a Domestic Relations Order; provided, however, that no such amendment shall require SERS to provide any type or DRO Page 6 form of benefit, or any option not otherwise provided by SERS, and further provided that no such amendment or right of the Court to so amend will invalidate this existing Order. 17. Upon entry as a Domestic Relations Order, a certified copy of the Domestic Relations Order and this Stipulation and Agreement and any attendant documents shall be served upon SERS immediately. The Domestic Relations Order shall take effect immediately upon SERS approval and SERS approval of any attendant documents and then shall remain in effect until further Order of the Court. WHEREFORE, the parties, intending to be legally bound by the terms of this Stipulation and Agreement, do hereunto place their hands and seals. ?"&' , ( 1 / !1 Plaintiff/Member Date &ttoy Plaintiff/ ate C. rn?tt?L R4 k/ C- P41f J. LAJ49 y 1all&116 BY THE COURT ?I 6 4,10 1 *efd'Alternate Payee Date / I Attorney r e endant Date Alternat ayee ADDENDUM TO DOMESTIC RELATIONS ORDER For Submission to State Employees' Retirement System Onlv Due to the Federal Privacy Act, many state courts prohibit the inclusion of personal data in public records to prevent identity theft. Therefore, please forward the following information sheet to State Employees' Retirement system when submitting the court certified copy of the Domestic Relations Order. Do NOT file the Addendum with the court. Member Information Name: Charles A. Clement, Jr. Address: P.O. Box 664 Alternate Pavee Information Name: Jody M. Clement Address: 908 Drexel Hill Blvd. New Cumberland, PA 17070 SSN: 159-52-7098 Date of Birth: August 20, 1957 Member Attorney's Information Name: John J. Connelly, Jr., Esq. Address: James, Smith, Dietterick & Connelly, LLP P.O. Box 650 Hershey, PA 17033 Phone Number: (717) 533-3280 New Cumberland, PA 17070 SSN: 229-04-0177 Date of Birth: February 18, 1960 Alternate Pavee Attorney's Information Name: Carol J. Lindsay, Esq. Address: Saidis Sullivan Law 26 West High Street Carlisle, PA 17013 Phone Number: (717) 243-6222 The court certified copy of the Domestic Relations Order and this Addendum should be sent to: State Employees' Retirement System Legal Office 30 North Third Street, Suite 150 Harrisburg, PA 17101-1716