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HomeMy WebLinkAbout04-2795MARSHA A. SHETRON, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA v CIVIL ACTION - LAWn ?-7 JAMES H. SHETRON, : NO.2004 - Defendant : DIVORCE NOTICE TO PLEAD You have been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. 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 717-249-3166 MARSHA A. SHETRON, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA v CIVIL ACTION LAW JAMES H. SHETRON, : NO. 2004 - oZ 7G1J? Defendant : DIVORCE COMPLAINT Plaintiff, Marsha A. Shetron, by her attorneys, Broujos & Gilroy, P.C., sets forth the following: I Plaintiff, Marsha A. Shetron, is an adult individual residing at i West Penn, Apt 121, Carlisle, Cumberland County, Pennsylvania. 2 Defendant, James H. Shetron, is an adult individual residing at 228 Brick Church Road, Newville, Cumberland County, Pennsylvania. 3 Plaintiff and Defendant were married on November 25,1994 in Las Vegas, Nevada. 4 Both Plaintiff and Defendant have resided continuously in the Commonwealth of Pennsylvania and in Cumberland County for at least 6 months prior to the commencement of this action. 5 There have been no prior actions for divorce or for annulment of this marriage. 6 The marriage is irretrievably broken. 7 The parties possess various items of real and personal property which is subject to equitable distribution by the Court. 8 The Plaintiff is without sufficient assets to pay her attorney's fees and costs during the litigation of the divorce. 9 Plaintiff is without sufficient assets to support herself during the divorce. 10 Plaintiff is without sufficient assets to sustain herself after the divorce. WHEREFORE, the Plaintiff requests your Honorable Court to enter an order as follows: a. Divorcing the Plaintiff from Defendant. b. Equitably dividing the marital property of the parties. c. Directing that the Defendant pay the Plaintiffs attorneys fees and costs of the divorce litigation. d. Directing that the Plaintiff pay the Defendant Alimony Pendente Lite. e. Directing that the Defendant pay the Plaintiff alimony after the divorce. f. Such other relief as the Court deems appropriate. BROUJOS & GILROY, P.C. By Hu ert X. Gilroy, quire Attorney for Plain 'ff I verify that the statements made in the foregoing document are true -and correct. I understand that false statements herein are made subject to the penalties of IS PA.C.S. Section 4904 relating to unworn falsification to authorities. DATE ?? U? Marsha A. Shetron I verify that the statements made in the foregoing document 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: 5 -30 ` -A\WJk O _ V ? Marsha A. Shetron DR# MARSHA A. SHETRON, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY PENNSYLVANIA v CIVIL ACTION LAW JAMES H. SHETRON, : NO. 2004 - Defendant : DIVORCE COURT ORDER And now, this day of , 2004, upon consideration of the attached petition for Alimony Pendente Lite and/or counsel fees, it is hereby directed that the parties and their respective counsel appear before on at at the Cumberland County Domestic Relations Office, 13 North Hanover Street, Carlisle, Pennsylvania for a conference, after which the conference officer may recommend that an order for Alimony Pendente Lite be entered. You are further ordered to bring to the conference: 1. A true copy of your most recent Federal Income Tax Return, including W-2's as filed. 2. Your pay stubs for the preceding six (6) months 3. The Income and Expense Statement attached to this order, completed as required by Rule 1910.11 (c) 4. Verification of child care expenses 5. Proof of medical coverage which you may have, or may have available to you. If you fail to appear for the conference or bring the required documents, the court may issue a warrant for your arrest. Date Conference Officer YOU HAVE A RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 (717) 249-3166 ? 4 r?T O ? w ? ? MARSHA A. SHETRON, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA v CIVIL ACTION LAW JAMES H.SHETRON, NO.2004- .2?qS Defendant DIVORCE J PETITION FOR ALIMONY PENDENTE LITE Petitioner, Marsha A. Shetron, by her attorneys, Broujos and Gilroy, P.C., sets forth the following: 1. Petitioner is the Plaintiff in the above captioned divorce action and the averments as set forth in the divorce complaint are incorporated as herein by reference thereto. 2. Petitioner is without sufficient assets to sustain herself during the divorce litigation. 3. Petitioner seeks Alimony Pendente Lite. 4. Petitioner requests your Honorable Court to schedule a hearing at the Cumberland County Domestic Relations Office on Petitioner's claim for Alimony Pendente Lite. WHEREFORE, Petitioner requests your Honorable Court to award her Alimony Pendente Lite during pendency of the above captioned divorce proceedings. BROUJOS & GILROY, P.C. By L U Hubert X. G' oy, Esquire Attorney f Plaintiff Broujos Gilroy, P.C. 4 North Hanover Street Carlisle, PA 17013 717-243-4574 I verify that the statements made in the foregoing document 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: A\W'caA 'mil Marsha A. Shetron CIO r r, MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE JAMES H. SHETRON, NO. 2004-2795 CIVIL TERM IN DIVORCE Defendant/Respondent Paeses# 024106637 ORDER OF COURT AND NOW, this 6°i day of August, 2004, upon consideration of the attached Petition for Alimony Pendente Lite and/or counsel fees, it is hereby directed that the parties and their respective counsel appear before R.J. Shaddav on September 14, 2004 at 70.30 A.M. for a conference, at 13 N. Hanover St., Carlisle, PA 17013, after which the conference officer may recommend that an Order for Alimony Pendente Lite be entered. YOU are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by Rule 1910.11© (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. BY THE COURT, George E. Hoffer, President Judge Mail copies on Petitioner 8-6-04 to: < Respondent Hubert Gilroy, Esquire / Date of Order: August 6. 2004 ?' -` I . I. Shadd ay, Conference Officer YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 CC361 (! N C 4:v T. 1 I' 1't r__i iJ G e f ORDER/NOTICE TO WITHHOLD INCOME FOR. SUPPORT State Commonwealth of Pennsylvania CO./City/Dirt. of CUMBERLAND Date of Order/Notice 09/14/04 Tribunal/Case Number (See Addendum for case summary) Employe r/Withholder's Federal EIN Number KEEN TRANSPORT INC PO BOX 389 NEW KINGSTOWN PA 17072-0389 RE:. SHETRON, JAMES H. O Original Order/Notice O Amended Order/Notice O Terminate Order/Notice ft ?I ' I I I y '1 ,t {? Employee/Obligor's Name (Last, First, MI) VO I l 1 U ?? /I 192-34-7345 n I nr Employee/Obligor's Social Security Number J "'?/ OI? gV 'I 5482101377 f J G I 'V ? ""'' Employee/Obligor's Case Identifier (See Addendum for plaintiff names f 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. $ 400.00 per month in current support $ o . oo per month in past-due support Arrears 12 weeks or greater? ® yes Q no $ 0.00 per month in medical support $ 0.00 per month for genetic test costs $ per month in other (specify) for a total of $ 400.00 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: $ 92.3 1 per weekly pay period. $ 184.62 per biweekly pay period (every two weeks). $ 200 0o per semimonthly pay period (twice a month). $ 4oo. oo per monthly pay period. REMITTANCE INFORMATION: r You must begin withholding no later than the first pay period occurring ten 0 0) 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 #10 on pg. 2). If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COURT: Date of Order: - h . O ? - i Service Type M Form EN-028 oM8No.:097"154 WOrkerlD $IATT ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS ? IfiBgheckefl you are required to prfvide a 4opy of this form to your &m?loYee. If yoyry mployee Vorks in a state that is drent rrom the state that issu this or er, a copy must be provi e to our em o ee even if t e box is not checked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned businesses located on a reservation that choose to withhold in accordance with this notice. 2. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 3. Combining Payments: You can combine withheld amounts from more than one 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 employeelobligor. 4.* Re porting the Paydateffiate of Withholding. You MUSt reD011 tile 152VdateVat@ of vv at! IL J _ when sendine the _ _ The se'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. 5.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to 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 #10 below) 6. Termination Notification: You must promptly notify the Requesting Agency when the employeelobligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. WITHHOLDER'S ID: 3407014810 EMPLOYEE'S/OBLIGOR'S NAME: SHETRON. JAMES H. EMPLOYEE'S CASE IDENTIFIER: 5482101377 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 7. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 8. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9. Antidiscrimination: 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 employeelobligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 10.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. §1673 (b)1; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. 11. Additional Info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. Submitted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 Service Type M If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) ?40-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 OMS No.: 097"154 Form EN-028 Worker ID $IATT ADDENDUM Summary of Cases on Attachment; Defendant/Obligor: SHETRON, JAMES H. PACKS Case Number Plaintiff Name ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACKS Case Number Plaintiff Name ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACKS Case Number Plaintiff Name ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACKS Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum Service Type tit oM9 No.: 097"154 Form EN-028 Worker ID $IATT ?? N ?:, o ? r? -;r ' _ mT i ? _ry n^ -?? CIl =' '-r C7 ` r- ? __? i? . _ -- . 1` . ?_. -?, ._ C7 + [.J .. _ i _ •< In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION MARSHA A. SHETRON ) Docket Number 04-2795 CIVIL Plaintiff ) vs. ) PACSES Case Number 024106637 JAMES H. SHETRON ) Defendant ) Other State ID Number PETITION FOR MODIFICATION OF AN EXISTING SUPPORT ORDER eL- A - -ill 1. The petition of /Lt 14 respectfully represents that on SEPTEMBER 14, 2004 , an Order of Court was entered for the support of MARSHA A. SHETRON A true and correct copy of the order is attached to this petition. Service Type M Form OM-501 Worker ID 21502 SHETRON V. SHETRON PACSES Case Number: 024106637 2. Petitioner is entitled to increase Q decrease Q termination Q reinstatement O other of this Order because of the following material and substantial change(s) in circumstance: Y (p CA, CES l/l/k ? c c ti c.?.ca Cck???? C A- C-' V A4- ET WHEREFORE, Petitioner requests that the Court modify the existing order Petitioner ?6rney for Petitioner I verify that the statements made in this complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unworn falsification to authorities. 4-64 4 - Date Service Type M Petitioner Page 2 of 2 Form OM-501 Worker ID 21502 .? C? V ?? /7 c^'a C7 -n er ? _ - i 1-. . ?_... ?-i .? T C ? ,-, ^? _ ? .. [ - ,? -? ~ V N Q -_., ?,. _?{ R? -< MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM JAMES H. SHETRON, IN DIVORCE Defendant/Respondent PACSES # 024106637 ORDER OF COURT AND NOW, this 9th day of June, 2006, a petition has been filed against you, James H. Shetron, to modify an existing Alimony Pendente Lite Order. You are ordered to appear in person at the Domestic Relations Section, 13 North Hanover Street, Carlisle, Pennsylvania, on July 13, 2006 at 1:30 P.M. for a conference and to remain until dismissed by the Court. If you fail to appear as provided in this Order, an Order of Court may be entered against you. You are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by the Rule 1910.11. (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. BY THE COURT, Edgar B. Bayley, President Judge Copies mailed June 9, 2006 to: Petitioner Respondent Hubert X. Gilroy, Esq. Paul J. Esposito, Esq. f Date of Order: June 9, 2006 J. S dday, onference Officer / t? YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 cc361 3 tD J r : c JAMES A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM SHETRON, IN DIVORCE Defendant/Respondent PACSES # 024106637 ORDER OF COURT AND NOW, this 13th day of July, 2006, based upon the Court's determination that Petitioner's monthly net income/earning capacity is $817.57 and Respondent's monthly net income/ea ing capacity is $3530.79, it is hereby Ordered that the Respondent pay to the Pennsylv is State Collection and Disbursement Unit, $1312.00 per month payable as follows: $1312.00 or alimony pendente lite and $0.00 on arrears. First payment due next modified pay date. Arrears se at $2362.58 as of July 13, 2006. The effective date of the order is June 7, 2006. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.§ 3703. Further, if the Court finds, afte hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and its discretion make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. S id money to be turned over by the PA SCDU to: Marsha A. Shetron. Payments must be made by heck or money order. All checks and money orders must be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the Respondent's PACSES Member Number or Social Security Number i order to be processed. Do not send cash by mail. cc360 Unreimbursed medical expenses that exceed $250.00 annually are to be paid as follows 0% by Responde? t and 100% by Petitioner. The Petitioner is responsible to pay the first $250.00 annually in unreimb ed medical expenses. The Petitioner is to provide medical insurance coverage. Within thirty (30) days after the entry of this Order, the Respondent shall submit to Petitioner written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at minimum, of. 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage ontract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms. on the arrears will be held in abeyance and will be resolved through equitable in the parties' divorce proceedings Order includes the Petitioner's unreimbursed medical expenses of $300.00 per month.. This Order shall become final ten days after the mailing of the notice of the entry of the Order to the p ies unless either party files a written demand with the Prothonotary for a hearing de novo before th Court. DRO: R. J. hadday Mailed copi s on: Petitioner July 14, 200 Respondent Hubert X. Gilory, Esq. Paul J. Esposito, Esq. Petitioner's Attorney Respondent's Attorney BY THE COURT, 5,W1 - Edward E. Guid , J. -, ?., ;? =?} "ll ? ?f__ -- f. _ ? ? ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State 024106637 -ComMmonwealth of Pennsylvania Co./City/Dist of CUMBERLAND 04-2795 CIVIL Date of Ord r/Notice 07/13/06 Case Numbe (See Addendum for case summary) reoerai UN number KEEN TRANSPORT INC PO BOX 389 NEW INGSTOWN PA 17072-0389 192-34-7345 Employee/Obligor's Social Security Number 5482101377 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, MI) Addendum for dependent names and birth dates associated with cases on attachment. ORDER INF RMATION: 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 fro the above-named employee's/obligor's income until further notice even if the Order/Notice is not issued by yo r State. $ 1 31 . oo per month in current support $ oo per month in past-due support Arrears 12 weeks or greater? Oyes ® no $ 00 per month in current and past-due medical support $ oo per month for genetic test costs $ per month in other (specify) for a total of 1, 312.00 per month to be forwarded to payee below. You do not h ve to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered s pport payment cycle, use the following to determine how much to withhold: $ 7 per weekly pay period. $ 60 .54 per biweekly pay period (every two weeks). $ 65 oo per semimonthly pay period (twice a month). $ 1,31 . oo per monthly pay period. REMITTANC 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 o 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 dis osable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). If remitting b EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA 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 mployee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SE 14D CASH BYMAIL. BY THECOUR5 Date of Orde : JUL 1 4 7",56 C Edward E. Gu' o, Judge DRO: R. J. Shadday Form EN-028 Service Type M OMB No.: 097M1 54 Worker ID $IATT O Original Order/Notice O Amended Order/Notice O Terminate Order/Notice RE: SHETRON, JAMES H. Employee/Obligor's Name (Last, First, MI) ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS ? If hecke l you are required, top rp (idea opy of this form to your3m?loyee. If mr employee %rks in a state thaVs di er nt rom the state that issu this o er, a copy must be provi a to your emp oyee even if t e box is not chec ed. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies In effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Pa ments: You can combine withheld amounts from more than one employeelobligor's income in a single payment to each agency requ sting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3. paydateMate of 14' , o7 on which amount Yvas withheld ho... the einployee's wages. You must comply with the law of the state of the emplo ee'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/obl Igor 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 elow) 5. Termination N tification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide th information requested and return a copy of this Order/Notice to the Agency identified below. THE EM LOYEE/OBLIGOR NO LONGER WORKS FOR: 3407014810 EMPLOYEE'S CASE IDENTIFIER: 5482101377 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRES 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 emp oyed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimin tion: 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 th obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.* Withholding L mits: You may not withhold more than the lesser of. 1) the amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C. §1673 (b)1; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit pplies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such a : State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amounts Ilowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts Ilowed under the law of the state that issued the order. 10. Additional *NOTE: If you ifir 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 at issued this order with respect to these items. 11. Submitted Service Type If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 OM8 No.: 0970-0154 Form EN-028 WorkerlD $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: SHETRON, JAMES H. Plaintiff Name Docket Attachment Amount $ 0.00 Child(reN's DOB If checked, yoare required to enroll the child(ren) nified above in any health insurance coverage available ugh the employment. ?If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. n ?, -s :.; -?, _? _ .. ,_ - ,; .< In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION MARSHA A. SHETRON ) Docket Number 04-2795 CIVIL Plaintiff ) Vs. ) PACSES Case Number 024106637 JAMES H. SHETRON ) Defendant ) Other State ID Number Order AND NOW to wit, this JANUARY 5, 2007 it is hereby Ordered that: COLLECTION ON THE ARREARS WILL BE HELD IN ABEYANCE AND WILL BE RESOLVED IN EQUITABLE DISTRIBUTION IN THE PARTIES' DIVORCE PROCEEDINGS. THIS ORDER CONSIDERS THE PLAINTIFF'S UNREIMBURSED MEDICAL EXPENSES OF $300.00 PER MONTH. BY THE COURT: JUDGE Form OE-520 Service Type M Worker ID 21205 ? ? 0 ?i ?. u [;r ? ?++ ??f;; - ? ? r .... ..:.? ?t_1 ? ? ? ? ? t? _? - ?;" ? ?" f'1"1 f.?J ? Paul J. Esposito, Esquire I.D. #25454 GOLDBERG KATZMAN, P.C. 320 Market Street P. O. Box 1268 Harrisburg, PA 17108-1268 (717) 234-4161; (717) 234-4161 (facsimile) Counsel for Plaintiff MARSHA A. SHETRON, : THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004-2795 - CIVIL IN DIVORCE JAMES H. SHETRON, Defendant PACSES Case No. 024106637 PETITION FOR MODIFICATION OF AN EXISTING SUPPORT ORDER The Petitioner, JAMES H. SHETRON, respectfully represents that on July 13, 2006, an Order of Court was entered for the support of Marsha A. Shetron. A true and correct copy of said Order of Court is attached to this Petition. Petitioner is entitled to a decrease of this Order because of the following material and substantial change(s) in circumstance: 1. Defendant's income has decreased; 2. Wife's income has increased. WHEREFORE, Petitioner requests that the Court modify the existing Order. GOL?PKRG TZMAN, P.C. 0 P.O. Box 1268 F Paul J. os- Attorney I.D. #25454 320 Market Street Harrisburg, PA 17108-1268 (717) 234-4161 Date: 3 8 , 2007 Attorney for Petitioner/Defendant VERIFICATION I verify that the statements contained in the foregoing PETITION TO MODIFY EXISTING SUPPORT ORDER are true and correct to the best of my knowledge, information and belief. I understand that false statements contained herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. Date:' _ b 7 r'2?.fl ?.?-- ,..JAMES H. SHETR.ON. CERTIFICATE OF SERVICE On this day of, 2007, I certify that a copy of the foregoing was served upon the following counsel of record by delivering same in the manner indicated, addressed as follows: VIA FIRST CLASS MAIL Hubert X. Gilroy, Esquire Broujos & Gilroy, P.C. 4 North Hanover Street Carlisle, PA 17013 Attorney for Plaintiff GOLDBERG KATZMAN, P.C. Paul J. spo ' Supreme Court ID #25454 Attorneys for Petitioner/Defendant (" C? j ^? \ ?? \ ?f ` V MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Respondent CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM JAMES H. SHETRON, IN DIVORCE Defendant/Petitioner PACSES Case Number: 024106637 ORDER OF COURT AND NOW, this 13th day of March 2007, a petition has been filed against you, Marsha A. Shetron, to modify an existing Alimony Pendente Lite Order. You are ordered to appear in person at the Domestic Relations Section, 13 North Hanover Street, Carlisle, Pennsylvania, on April 9, 2007 at 10:30A.M. for a conference and to remain until dismissed by the Court. If you fail to appear as provided in this Order, an Order of Court may be entered against you. You are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by the Rule 1910.11. (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. BY THE COURT, Edgar B. Bayley, President Judge Copies mailed to: Petitioner Respondent Hubert X. Gilroy, Esq. Paul J. Esposito, Esq. i Date of Order: March 13. 2007 YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 cc361 SGP???O =r ___. - ?` _,,. W , L? '_'s ',,,,`? MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Respondent CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM JAMES H. SHETRON, IN DIVORCE Defendant/Petitioner PACSES Case Number: 024106637 ORDER OF COURT AND NOW, this 13th day of March 2007, a petition has been filed against you, Marsha A. Shetron, to modify an existing Alimony Pendente Lite Order. You are ordered to appear in person at the Domestic Relations Section, 13 North Hanover Street, Carlisle, Pennsylvania, on April 16, 2007 at 10:30A.M. for a conference and to remain until dismissed by the Court. If you fail to appear as provided in this Order, an Order of Court may be entered against you. You are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by the Rule 1910.11. (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. BY THE COURT, Edgar B. Bayley, President Judge Copies mailed to: Petitioner Respondent Hubert X. Gilroy, Esq. Paul J. Esposito, Esq. Date of Order: March 13, 2007 . Sha ay, C ference Officer ri / YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 cc361 - c? n ? ? ?? ? _ ?'? %? -? . ?; ? N -?s ; ?.?q..-. .t ?.?, ? L.?J ? } ?•J f MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Respondent : CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM JAMES H. SHETRON, IN DIVORCE Defendant/Petitioner : PACSES Case Number: 024106637 ORDER OF COURT - RESCHEDULE A CONFERENCE AND NOW, this 9th day of April 2007, upon consideration of the Petition for Alimony Pendente Lite and/or counsel fees, it is hereby directed that the parties and their respective counsel appear before R.J. Shadday on April 23, 2007 at 10:30 A.M. for a conference, at 13 N. Hanover St., Carlisle, PA 17013, after which the conference officer may recommend that an Order for Alimony Pendente Lite be entered. This date replaces the prior conference date of April 16, 2007. YOU are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by Rule 1910.110 (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you (6) IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. BY THE COURT, Edgar B. Bayley, President Judge Date of Order: April 9, 2007 Copies mailed to: Petitioner Respondent Hubert X. Gilroy, Esq. Paul J. Esposito, Esq. . Sh $ ay, C ference Officer YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 cc361 DLLs ?=; -rt ::7D r r? -T3 C..? ?7 iLLri +ft. MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM JAEMS H. SHETRON, IN DIVORCE Defendant PACSES Case Number 024106637 ORDER OF COURT AND NOW, this 23rd day of April, 2007, based upon the Court's determination that Plaintiff's monthly net income/earning capacity is $ 837.86 and Defendant's monthly net income/earning capacity is $ 2869.12, it is hereby Ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit, $900.00 per month payable as follows: $849.00 per month for alimony pendente lite and $51.00 per month on arrears. First payment due: next modified wage attachment. Arrears set at $802.23 as of April 23, 2007. The effective date of the order is March 9, 2007. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.§ 3703. Further, if the Court finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and its discretion make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Said money to be turned over by the PA SCDU to: Marsha A. Shetron. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the Respondent's PACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. cc360 w The monthly support obligation includes cash medical support in the amount of $250.00 annually for unreimbursed medical expenses incurred for each spouse. Unreimbursed medical expenses of the oblige that exceeds $250.00 annually shall be allocated between the parties. The party seeking allocation of unreimbursed medical expenses must provide documentation of expenses to the other party no later than March 31St of the year following the calendar year in which the final medical bill to be allocated was received. The unreimbursed medical expenses are to be paid as follows: 0% by Respondent and 100% by Petitioner. () Respondent () Petitioner () Neither party to provide medical insurance coverage. Within thirty (30) days after the entry of this Order, the () Respondent () Petitioner shall submit written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at minimum, of. 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage contract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms. This Order is based upon the defendant's lowered income. This Order considers the Plaintiff s unreimbursed medical expenses of $68.00 per month. This Order shall become final twenty days after the mailing of the notice of the entry of the Order to the parties unless either parry files a written demand with the Prothonotary for a hearing de novo before the Court. Consented: Petitioner Respondent Mailed copies on: April 24, 2007 to: Petitioner Respondent Paul J. Esposito, Esq. Hubert X. Gilroy, Esq. Petitioner's Attorney Respondent's Attorney BY THE CO Edward E. Guido, J. DRO: R.J. Shadday C: a -rr `v Ly, 3N% M Z ? ? -T ;t- ,. om '-R ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania Co./City/Dist. of CUMBERLAND Date of Order/Notice 04/23/07 Case Number (See Addendum for case summary) Employer/Withholder's Federal EIN Number KEEN TRANSPORT INC PO BOX 389 NEW KINGSTOWN PA 17072-0389 O Original Order/Notice O Amended Order/Notice O Terminate Order/Notice Employee/Obligor's Name (Last, First, MI) 192-34-7345 Employee/Obligor's Social Security Number 5482101377 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. $ 849.00 per month in current support $ 51.00 per month in past-due support Arrears 12 weeks or greater? Dyes ® no $ 0.00 per month in current and past-due medical support $ 0.00 per month for genetic test costs $ 0.00 per month in other (specify) for a total of $ 900.00 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: $ 207.12 per weekly pay period. $ 414.25 per biweekly pay period (every two weeks). $ 450. oo per semimonthly pay period (twice a month). $ 900.0o per monthly pay period. REMITTANCE INFORMATION: You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/ obligor's aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is needed (See #9 on page 2). If required by Pennsylvania law (23 PA C.S. § 4374(b)) to remit by electronic payment method, please call Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST 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 MA/L. ,??''''''''`''''? BY THE COURT;f' 1 Date of Order: APR 2 4 2007 DRO: R.J. Shadday Service Type m 024106637 04-2795 CIVIL RE: SHETRON, JAMES H. Edward E. Guido, Judge Form EN-028 Rev. OMB No.: 0970-0154 ?A7?rl(nr I fl .7 4 ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS ? If hecked you are required to provide a copy of this form to your employee. If yo r employee works in a state that is diferent from the state that issued this order, a copy must be providedto your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: 3407014810 EMPLOYEE'S/OBLIGOR'S NAME: SHETRON. JAMES H. EMPLOYEE'S CASE IDENTIFIER: 5482101377 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject 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 (15 U.S.C. §1673 (b)1; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. 10. Additional Info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11.Submitted By: If you or your employee/obligor have any questions, DOMESTIC RELATIONS SECTION contact WAGE ATTACHMENT UNIT 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 Service Type m by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 OMB No.: 0970-0154 Form EN-028 Rev. 1 Worker ID $zATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: SHETRON, JAMES H. PACSES Case Number 024106637 Plaintiff Name MARSHA A. SHETRON Docket Attachment Amount 04-2795 CIVIL$ 900.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number PACKS Case Number Plaintiff Name Plaintiff Name Docket Attachment Amount Docket Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available identified above in any health insurance coverage available through the employee's/obligor's employment. through the employee's/obligor's employment. Addendum Form EN-028 Rev. 1 Service Type M Worker ID $IATT OMB NO.: 0970-0154 r?a 71 a rr, v -t ni ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania Co./City/Dist. of CUMBERLAND Date of Order/Notice 12/31/07 Case Number (See Addendum for case summary) O Original Order/Notice 0 O Amended Order/Notice 044--2795 37 2795 CIVIL O Terminate Order/Notice Employer/Withholder's Federal EIN Number KEEN TRANSPORT INC PO BOX 389 NEW KINGSTOWN PA 17072-0389 RE: SHETRON, JAMES H. Employee/Obligor's Name (Last, First, MI) 192-34-7345 Employee/Obligor's Social Security Number 5482101377 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. $ 849.00 per month in current support $ o . oo per month in past-due support Arrears 12 weeks or greater? Oyes ® no $ 0.00 per month in current and past-due medical support $ 0.00 per month for genetic test costs $ 0,0 0 per month in other (specify) fora total of $ 849.00 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: $ 195.92 per weekly pay period. $ 391.85-per biweekly pay period (every two weeks). $ 424.5o per semimonthly pay period (twice a month). $ 849.00 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). If required by Pennsylvania law (23 PA C.S. S 4374(b)) to remit by electronic payment method, please call Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAMEAND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. BY THE COU Date of Order: JAN 0 2 2008 EDWARD El. IDO, JUDGE DRO: R.J. SHADDAY Form EN-028 Rev. 1 Service Type M OMB No.: 0970-0154 Worker ID $IATT 0499 x 12 52 • % 195"92* 849- x 12* 3 51 . g5* 0 ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS ? If hecke? you are required to provide a opy of this form to your eem loyee. If yo r employee works in a state that is dierent from the state that issued this order, a copy must be providedpto your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Repoith ir, the Paydate/Date of Withholding. N'ou must report the paydateidate of withl rolding wl ien sending tI ie payment. TI e You must comply with the law of the paydate/date of withholding, is the date o.1 vvh6ch amount was withheld hom the employee's wages.. state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: 3407014810 EMPLOYEE'S/OBLIGOR'S NAME: SHETRON. JAMES H. EMPLOYEE'S CASE IDENTIFIER: 5482101377 DATE OF SEPARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance pay. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Antidiscrimination: 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 (15 U.S.C. §1673 (b)1; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more than the amounts allowed under the law of the state that issued the order. 10. Additional Info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11. Submitted By: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 Service Type M OMB No.: 0970-0154 Form EN-028 Rev. 1 Worker ID $2ATT %w ADDENDUM Summary of Cases on Attachment Defendant/Obligor: SHETRON, JAMES H. PACSES Case Number 024106637 PACSES Case Number Plaintiff Name Plaintiff Name MARSHA A. SHETRON Docket Attachment Amount Docket Attachment Amount 04-2795 CIVIL$ 849.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ?Ifchecked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB ? If checked, you are required to enroll the child(ren) ? If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available identified above in any health insurance coverage available through the employee's/obligor's employment. through the employee's/obligor's employment. Addendum Form EN-028 Rev. 1 Service Type M Worker ID $IATT OMB No.: 0970-0154 G ?' `' 6 ?= ? ? ?' i? ?:r .=?? - ? ? " t?%?y1 a In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION MARSHA A. SHETRON ) Docket Number 04-2795 CIVIL Plaintiff ) VS. ) PACSES Case Number 024106637 JAMES H. SHETRON ) Defendant ) Other State ID Number PETITION FOR MODIFICATION OF AN EXISTING SUPPORT ORDER 1. The petition of JAMES H. SHETRON respectfully represents that on APRIL 23, 2007 , an Order of Court was entered for the support of MARSHA A. SHETRON A true and correct copy of the order is attached to this petition. Form OM-501 Service Type M Worker ID 21504 SHETRON V- SHETRON PACSES Case Number: 024106637 2. Petitioner is entitled to O increase Q'decrease O termination O reinstatement O other of this Order because of the following material and substantial change(s) in circumstance: WHEREFORE, Petitioner requests that the Court modify the existing order for support. /I etitioner Attorney for Petitioner I verify that the statements made in this complaint 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 Service Type M titioner Page 2 of 2 Form OM-501 Worker ID 21504 FjL L.';- 2 i!LC 9 k"-;3 12 Fi1 G: [qu MARSHA A. SHETRON, THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM JAMES H. SHETRON, IN DIVORCE Defendant PACSES CASE NO: 024106637 ORDER OF COURT AND NOW, this 12th day of August, 2009, a petition has been filed against you, Marsha A. Shetron, to modify an existing Alimony Pendente Lite Order. You are ordered to appear in person at the Domestic Relations Section, 13 North Hanover Street, Carlisle, Pennsylvania, on September 3. 2009 at 1:30 P.M. for a conference and to remain until dismissed by the Court. If you fail to appear as provided in this Order, an Order of Court may be entered against you. You are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by the Rule 1910.11. (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. Copies mailed to: Petitioner Respondent Hubert X. Gilroy, Esq. Paul J. Esposito, Esq. Date of Order: August 12, 2009 BY THE COURT, Edward E. Guido. Judge YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVE. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 cc361 T4 In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Defendant Name: JAMES H. SHETRON Member ID Number: 5 4 8 2 1 0 1 3 7 7 Please note: All correspondence must include the Member ID Number. ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSATION BENEFITS Financial Break Down of Multiple Cases on Attachment PACSES Docket Attachment Amount/Frequency Plaintiff Name Case e Number Number MARSHA A. SHETRON 024106637 04-2795 CIVIL $ 849.00 /MONTH / / TOTAL ATTACHMENT AMOUNT: $ 849.00 Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), is hereby directed to attach the lesser of $ 195.3 9 per week, or 50 %, of the Unemployment Compensation benefits otherwise payable to the Defendant, JAMES H. SHETRON Social Security Number XXX-XX- 7345 , Member ID Number 5482101377 . OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearages, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673 (b)(2) and 23 Pa. C.S.A. § 4348 (g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated AUGUST 9, 2 0 0 9 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. BY THE COURT Date of Order: AUG 18 2009 Service Type M JUDGE Form EN-530 Rev.2 Worker ID $ IATT REU4011hi ' TNT ! mm"P NYITA.RY 20113 AUG 18 PM 2: 14 U PENNSYLVANIA In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Phone: (717) 240-6225 Fax: (717) 240-6248 Defendant Name: JAMES H. SHETRON Member ID Number: 5482101377 Please note: All correspondence must include the Member ID Number. MODIFIED ORDER OF ATTACHMENT OF UNEMPLOYMENT BENEFITS Financial Break Down of Multiple Cases on Attachment Plaintiff Name MARSHA A. SHETRON PACSES Docket Case Number Number 024106637 04-2795 CIVIL TOTAL ATTACHMENT AMOUNT: $ 1,120.00 Attachment Amount/Frequency $ 1,120.00 MONTH / Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), is hereby directed to attach the lesser of $ 257.75 per week, or 50.0 %, of the Unemployment Compensation benefits otherwise payable to the Defendant, JAMES H. SHETRON Social Security Number XXX-XX-7345 , Member ID Number 5482101377 . OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearage, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673(b)(2) and 23 Pa. C.S. § 4348(g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated AUGUST 9, 2009 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. BY THE COU .d Date of Order: SEP 0 4 2009 EDWARD E. GUIDO, DRO: R.J. SHADDAY Service Type M JUDGE Form EN-034 Rev.2 Worker ID $ zATT PLED-vii lCE OF THE PROTHONOTARY 2889 SEP - 4 FM 2: 3 0 CLNBEr,I?Aai.) (;OUNTY PENNTILVANIA. MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM JAMES H. SHETRON, IN DIVORCE Defendant/Respondent : PACSES Case No: 024106637 ORDER OF COURT AND NOW, this 3rd day of September 2009, based upon the Court's determination that the Petitioner's monthly net income/earning capacity is $ 828.80 and the Respondent's monthly net income/earning capacity is $ 3,326.21, it is hereby ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit One Thousand One Hundred Twenty and 00/100 Dollars ($ 1,120.00) per month payable bi-weekly as follows: $ 1,120.00 per month for Alimony Pendente Lite and $ 0.00 per month on arrears. First payment due: in accordance with Respondent's pay schedule. The effective date of the order is September 1, 2009. Arrears set at $ 729.74 as of September 3, 2009. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.§ 3703. Further, if the Court finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and, at its discretion, make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Said money to be turned over by the PA SCDU to: Marsha A. Shetron. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the Respondent's name with their PACKS Member Number or Social Security Number in order to be processed. Do not send cash by mail. cc360 This Order is based upon the Respondent's income of Unemployment Compensation and Social Security benefits. This Order considers the Petitioner's unreimbursed medical expenses of $45.00 per month. The Respondent will have to make supplemental payments to PA SCDU in the amount of $98.00 per month to keep his account current with the 50% of his unemployment compensation being attached for the Alimony Pendente Lite obligation. This Order shall become final twenty (20) after the mailing of the notice of the entry of the Order to the parties unless either party files a written demand with the Prothonotary for a hearing de novo before the Court. Consented: Petitioner Respondent Petitioner's Attorney Respondent's Attorney Mailed copies on: September 4. 2009 to: Petitioner Respondent Jennifer L. Spears, Esq. Paul J. Esposito, Esq. BY THE COURT, t Edward E. Guido, J. DRO: R.J. Shadday FUED-•C t=FlCE OF THE PROTV CTARY 1089 SEP -4 PM 2: 30 CUM&t ` i , C CWY €'EMNRWi ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT 04-2795 CIVIL State Commonwealth of Pennsylvania OOriginal Order/Notice CO./City/Dist. of CUMBERLAND (Amended Order/Notice Date of Order/Notice 09/04/09 tX Terminate Order/Notice Case Number (See Addendum for case summary) QOne-Time Lump Sum/Notice RE: SHETRON, JAMES H . Employer/Withholder's Federal EIN Number Employee/Obligor's Name (Last, First, MI) 192-34-7345 Employee/Obligor's Social Security Number KEEN TRANSPORT INC 5482101377 PO BOX 389 Employee/Obligor's Case Identifier NEW KINGSTOWN PA 17072-0389 (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. $ 0.00 per month in current child support $ o. oo per month in past-due child support Arrears 12 weeks or greater? Dyes ® no $ 0.00 per month in current medical support $ 0.00 per month in past-due medical support $ o. oo per month in current spousal support $ o . oo per month in past-due spousal support $ 0.00 per month for genetic test costs $ o . oo per month in other (specify) $ one-time lump sum payment for a total of $ o.0o per month to be forwarded to payee below. You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match the ordered support payment cycle, use the following to determine how much to withhold: $ 0.00 per weekly pay period. $ 0. 00 per semimonthly pay period (twice a month) $ 0.00 per biweekly pay period (every two weeks) $ 0.00 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, IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S N above as the Employee/Obligor's Case Identifier) OR SOCIAL ;WVR-ITY NU DO NOT SEND CASH BY MAIL. r,toor, BY THE COURT: Pa 17106-9112 PACSES MEMBER ID (shown IN ORDER TO BE PROCESSED. DRO: R. J. Shadday Form EN-028 Rev.5 Service Type M OMB No.: 0970-0154 Worker ID $IATT ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS Ifhhecke i you are required to provide a?opy of this form to yourzyloyee. If yoyr employee works in a state that is A Brent rom the state that issued this order, a copy must be provi to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The paydate/date of withholding is the date on which amount was withheld from the employee's wages. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the withholding order and forward the support payments. 4.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent possible. (See #9 below) 5. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you. Please provide the information requested and return a copy of this Order/Notice to the Agency identified below. 3407014810 THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER : ED THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: ED EMPLOYEE'S/OBLIGOR'S NAME: SHETRON, JAMES H. EMPLOYEE'S CASE IDENTIFIER: 5482101377 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) 0 5 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 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us Page 2 of 2 Form EN-028 Rev.5 Service Type M OMBNo.:0970.0154 Worker ID $IATT ADDENDUM Summary of Cases on Attachment DefendanVObligor: SHETRON, JAMES H. PACSES Case Number 024106637 PACSES Case Number Plaintiff Name Plaintiff Name MARSHA A. SHETRON Docket Attachment Amount Docket Attachment Amount 04-2795 CIVIL$ 0.00 $ 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 PACSES 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 PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Addendum Form EN-028 Rev.5 Service Type M OMB No.: 0970-0154 Worker ID $IATT -OFFICE OF THE PROT IONCTAPY 2019 SEP -8 Pit 2: 4 1 Ct1m PENN'SYL.VANIA MARSHA A. SHETRON Plaintiff In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION vs. JAMES H. SHETRON Co(74 -6 pVZD Defendant Docket Number: 04-2795 CIVIL PACSES Case Number: 024106637 X Other State ID Number: -OX MM m cn ? -C C°) r..s 0 c r- co a• CJ r? -r MF ? C3 CD ---i C? = -Tt CD ©ff7 ---a ^1^9 PETITION FOR MODIFICATION OF AN EXISTING SUPPORT ORDER 1. The petition of JAMES H. SHETRON respectfully represents that on SEPTEMBER 3, 2009, an Order of Court was entered for the support of MARSHA A. SHETRON A true and correct copy of the order is attached to this petition. Service Type M Form OM-501 Worker ID 21203 f SHETRON v. SHETRON PACSES Case Number: 024106637 ty/ 2. Petitioner is entitled to O increase decrease O termination O reinstatement O other of this Order because of the following material and substantial change(s) in circumstance: WHEREFORE, Petitioner requests that the Court modify the existing order for support. Petitioner Attorney for Petitioner I verify that the statements made in this complaint 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 etitioner Form OM-501 Service Type M Page 2 of 2 Worker ID 21203 MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA VS. CIVIL ACTION - DIVORCE NO. 04-2795 CIVIL TERM JAMES H. SHETRON, IN DIVORCE Defendant PACSES CASE: 024106637 rnco D C ORDER OF COURT { AND NOW, this 18th day o f July 2011, a petition has been filed against you, Marsha A. n, o mo an existing Alimony Pendente Lite O rder. You are ordered to appear in person at the Domestic Re ns ctiou.?r" 13 North Hanover Street, Carlisle, Pennsylvania, on August 25, 2011, at 10:30 A.M. for a conferee a,to' remain until dismissed by the Court. If you fail to appear as provided in this Order, an Order of Court may be -^, entered against you. You are further ordered to bring to the conference: (1) a true copy of your most recent Federal Income Tax Return, including W-2's as filed (2) your pay stubs for the preceding six (6) months (3) the Income and Expense Statement attached to this order, completed as required by the Rule 1910.11. (4) verification of child care expenses (5) proof of medical coverage which you may have, or may have available to you IF you fail to appear for the conference or bring the required documents, the Court may issue a warrant for your arrest. Copies mailed to: Petitioner Respondent Jennifer L. Spears, Esq. Paul J. Esposito, Esq. Date of Order: July 18, 2011 _ BY THE COURT, Edward E. Guido, Judge YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT YOU. 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 MAY GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 32 S. BEDFORD ST. CARLISLE, PENNSYLVANIA 17013 (717) 249-3166 cc361 MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANI A VS. CIVIL ACTION - DIVORCE C a "77 NO. 04-2795 CIVIL TERM •v? --= JAMES H. SHETRON, IN DIVORCE Defendant/Respondent PACSES CASE: 024106637 ORDER OF COURT ca ca rT? --r AND NOW, this 26th day of August, 2011, based upon the Court's determination that the Petitioner's monthly net income/earning capacity is $ 1,034.26 and the Respondent's monthly net income/earning capacity is $ 1,519.17, it is hereby ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit Three Hundred Sixty and 00/100 Dollars ($ 360.00) per month payable monthly as follows: $ 360.00 per month for Alimony Pendente Lite and $ 0.00 per month on arrears. First payment due in accordance with the Respondent's pay schedule. The effective date of the order is July 18, 2011. Arrears set at $ 31.67 as of August 26, 2011. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.§ 3703. Further, if the Court C finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare he the Respondent in civil contempt of Court and, at its discretion, make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Ma's Said money to be turned over by the PA SCDU to: Marsha A. Shetron. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 't'one Harrisburg, PA 17106-9110 POW( lifer j J. Es, Payments must include the Respondent's name with their PACSES Member Number or R J Social Security Number in order to be processed. Do not send cash by mail. cc360 MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANI A VS. CIVIL ACTION - DIVORCE • C7 c N a -? NO. 04-2795 CIVIL TERM -oz rnco = --¢ m 2 JAMES H. SHETRON, IN DIVORCE zrn ti C = Defendant/Respondent D PACSES CASE: 024106637 N CM ?? C ) -i ? ORDER OF COURT c w AND NOW, this 26th day of August, 2011, based upon the Court's determination that the Petitioner's monthly net income/earning capacity is $ 1,034.26 and the Respondent's monthly net income/earning capacity is $ 1,519.17, it is hereby ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit Three Hundred Sixty and 00/100 Dollars ($ 360.00) per month payable monthly as follows: $ 360.00 per month for Alimony Pendente Lite and $ 0.00 per month on arrears. First payment due in accordance with the Respondent's pay schedule. The effective date of the order is July 18, 2011. Arrears set at $ 31.67 as of August 26, 2011. Failure to make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the means as provided by 23 Pa.C.S.§ 3703. Further, if the Court finds, after hearing, that the Respondent has willfully failed to comply with this Order, it may declare the Respondent in civil contempt of Court and, at its discretion, make an appropriate Order, including, but not limited to, commitment of the Respondent to prison for a period not to exceed six months. Said money to be turned over by the PA SCDU to: Marsha A. Shetron. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the Respondent's name with their PACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. cc360 .. , a The monthly support obligation includes cash medical support in the amount of $250 annually for unreimbursed medical expenses incurred for the spouse. Unreimbursed medical expenses of the spouse that exceed $250 annually shall be allocated between the parties. The party seeking allocation of unreimbursed medical expenses must provide documentation of expenses to the other party no later than March 31 S` of the year following the calendar year in which the final medical bill to be allocated was received. The unreimbursed medical expenses are to be paid as follows: 0 % by Respondent and 100 % by Petitioner. [] Respondent [X] Petitioner [] Neither party to provide medical insurance coverage. Within thirty (30) days after the entry of this order, the [X] Petitioner [] Respondent shall submit written proof that medical insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at a minimum, of: 1) the name of the health care coverage provider(s); 2) any applicable identification numbers; 3) any cards evidencing coverage; 4) the address to which claims should be made; 5) a description of any restrictions on usage, such as prior approval for hospital admissions, and the manner of obtaining approval; 6) a copy of the benefit booklet or coverage contract; 7) a description of all deductibles and co-payments; and 8) five copies of any claim forms. Other conditions: This Order is based upon the respondent's income of Social Security only as his Unemployment Compensation benefits have been exhausted. The Order considers the Petitioner's unreimbursed medical expenses of $174.00 per month. This Order shall become final twenty (20) after the mailing of the notice 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. Mailed copies on: August 26, 2011 BY THE COUR Edward E. Guido, J. Petitioner Respondent Jennifer L. Spears, Esq. Paul J. Esposito, Esq. DRO: R.J. Shadday ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT Off - a79S Cm 1 l State: Commonwealth of Pennsylvania Co./City/Dist. of: CUMBERLAND Date of Order/Notice: 08/26/11 Case Number (See A en um for case summary) EmployerNVithholder's Federal EIN Number SOCIAL SECURITY ADMINISTRATION STE 1 200 S SPRING GARDEN ST CARLISLE PA 17013-2578 (?) Original Order/Notice Q Amended Order/Notice O Terminate Order/Notice O One-Time Lump Sum/Notice RE: SHETRON, JAMES H. Employee/Obligor's Name (Last, First, MI) 192-34-7345 Employee/obligor's Social Security Number 5482101377 Employee/Obligors 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 amot,#its from the above-named employee's/obligor's income until further notice even if the Order/Notice is ncissW bnour State. -- rn C 44 = $ 0.00 per month in current child support = r - _V $ 0.00 per month in past-due child support Arrears 12 weeks or greater? eS r n o $ 0.00 per month in current medical support -<> %0 (? - $ 0.00 per month in past-due medical support n = - $ 360.00 per month in current spousal support = $ 0.00 per month in past-due spousal support tv $ 0.00 per month for genetic test costs na " $ 0.00 per month in other (specify) - cs -e $ one-time lump sum payment for a total of $ 360.00 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: $ 82.85 per weekly pay period. $ 180.00 per semimonthly pay period (twice a month) $ 165.70 per biweekly pay period (every two weeks) $ 360.00 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 DEFEN E AND THE PACSES MEMBER /D (shown above as the Employee/Obligor's Case /de er) ORS jQ$AL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH SY MAIL. BY THE COURT: E. Guido OMB No.: 0970-0154 Form EN-028 Service Type M Worker ID $OINC ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS M If checked you are required to provide a copy of this form to your employee. If your employee works in a state that is different from the state that issued this order, a copy must be provided to your employee even if the box is not checked. 1. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 2. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. 3.* Reporting the Peydate/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. 8384100092 THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER: 0 THE EMPLOYEEIOBLIGOR NO LONGER WORKS FOR: O EMPLOYEE'S/OBLIGOR'S NAME: SHETRON JAMES H. EMPLOYEE'S CASE IDENTIFIER: 5482101377 DATE OF SEPARATION: LAST KNOWN: HOME ADDRESS: LAST KNOWN-FNFONE NUMBER: _ NEW EMPLOYERS NAMEIADDRESS: FINAL PAYMENT AMOUNT: 6. Lump SurrrPayrnents: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or severance parr. If you have any questions about lump sum payments, contact the person or authority below. 7. Liability: if you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 8. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs. 9.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection Act (CCPA) (15 U.S.C. 1673 (b)); or 2) the amounts allowed by the State or Tribe of the employee's/obligor's principal place of employment. Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes, Social Security taxes, statutory pension contributions and Medicare taxes. The Federal limit is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting another family. However, that 50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State, you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section. Arrears greater than 12 weeks: If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the employer should calculate the CCPA limit using the lower percentage. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers who receive a State order, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State law, you may need to take into consideration the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. 10. Additional Info: *NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the law of the state that issued this order with respect to these items. 11 • Send Termination Notice and other correspondence to: DOMESTIC RELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obligor have any questions, contact WAGE ATTACHMENT UNIT by telephone at (717) 240-6225 or by FAX at (717) 240-6248 or by internet www.childsupport.state.pa.us , , ., OMB No.: 0970-0154 Form EN-028 Service Type M Page 2 of 2 Worker ID $OINC t ; ADDENDUM Summary of Cases on Attachmen Defendant/Obligor: SHETRON, JAMES H. PACSES Case Number 024106637 PACKS Case Number Plaintiff Name Plaintiff Name MARSHA A. SHETRON Docket Attachment Amount Docket Attachment Amount 04-2795 CIVIL $ 360.00 $ 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 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 Form EN-028 Service Type M OMB No.: 0970-0154 Worker ID $OINC In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION Cl 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 C "I -- -0 X Phone: (717) 240-6225 Fax: (71 -6 8 r r :;O Defendant Name: JAMES H. SHETRON `t' ?° Member ID Number: 5482101377 ?° -v > c-) ? a Please note: All correspondence must include the Member ID Number. =C? tV ?t+I --? ENT OF UNEMPLOYMENT BENEFITS 73 73 MODIFIED ORDER OF ATTACHM Financial Break Down of Multiple Cases on Attachment Plaintiff Name MARSHA A. SHETRON PACSES Docket Case Number Number 024106637 04-2795 CIVIL TOTAL ATTACHMENT AMOUNT: $ 360.00 Attachment Amount/Frequency 360.00 MONTH 1 / Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), is hereby directed to attach the lesser of $82.85 per week, or 50.0%, of the Unemployment Compensation benefits otherwise payable to the Defendant, JAMES H. SHETRON Social Security Number XXX-XX-7345, Member ID Number 5482101377. OUCB is ordered to remit the amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages. If the Defendant's Unemployment Compensation benefits are attached by another Court or Courts for support and/or support arrearage, DPW may reduce the amount attached under this Order so that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to 15 U.S.C. § 1673(b)(2) and 23 Pa. C.S. § 4348(g). This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the Application for Benefits dated AUGUST 9, 2009 is exhausted, expired or deferred. OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations Section of this Court. Date of Order: 1 / I/ BY THE COURT Edward E. Guido JUDGE Form EN-034 Service Type M Worker ID $IATT F.\FILESTlients\12375 Shetron\12375. Laos Revised: 3/23/12 2.49PM Hubert X. Gilroy, Esquire Jennifer L. Spears, Esquire MARTSON DEARDORFF WILLIAMS OTTO GILROY MARTSON LAW OFFICES I.D. Nos. 29943 and 87445 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff & FALLER r r 23 E 1 2: 5 CUMBERLAND PEP SYU/Ia hl1A MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004-2795 CIVIL ACTION - LAW JAMES H. SHETRON, Defendant IN DIVORCE AFFIDAVIT OF SERVICE COMMONWEALTH OF PENNSYLVANIA ) . SS. COUNTY OF CUMBERLAND ) I hereby certify that a copy of the Complaint in Divorce was mailed to Defendant James Shetron at 228 Brick Church Road, Newville, PA 17241 by certified mail, return receipt requested. Attached is the Post Office return receipt signed "Jim Shetron" and dated June 26, 2004. Jenn' r . Spears, Esquire Sworn to and subscribed before me this 23`d day of March, 2012. ??'G?, KWIGn , Notarl Pu 1 COMMONWEALTH OF PM SYLVANIA Notarial Seal Margaret Ann Nash, Notary Public Carlisle! Bon), Q~ WW county My Conv"11NOn Jl ne 29, 2015 MEMOM P!NlIbYI.VANiA ASSOCIATION OF NOTARIES r M CORWbate ftdrMt 1, Y, SM & AM* co q* to Wm 4 if ,f3ae d D*# y Is dolmd. M Prk1t yatg,.rom aad addrom on the reverse so asst I" own ftk the ca to you. M Mach We and to to back of the m , or an the ftM If space permits 1. Ardch Adhre seed to: y F (e u P M04 2. Ardent Nurtbrr DPowt O-Kvd by ( . C. Dob d D*.Wy D. to d*my *clskow 4Mllptw *om lmm 17 *B H YM wYm d*my eddwo 4dow. ? No a.? wt D >. D BNOMONd D P, elp ftr ~endk+s D IrmW and D CAA. d. Rabieted DMivery7 Xkft FW D *a A ? OarilMeM?e flllrsw 1 AM16W F:\FILES\Clients\12375 Shetron\12375.1.aoc won Revised: 3/14/12 3:24PM "0TH' l t Hubert X. Gilroy, Esquire Jennifer L. Spears, Esquire MARTSON DEARDORFF WILLIAMS OTTO GILROY MARTSON LAW OFFICES I.D. Nos. 29943 and 87445 10 East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff M2 MAR 23 PM 2: 213' & FALDWRLANO U"OO I.Y PENNSYLVANIA MARSHA A. SHETRON, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004-2795 CIVIL ACTION - LAW JAMES H. SHETRON, Defendant IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under § 3301(c) of the Divorce Code was filed on June 18, 2004. 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. Date:-,, *. Marsha A. Shetron, Plainti f 4 4?6 - ? nr t._ I { 4,,,1'r v, Paul J. Esposito, Esquire M(I j } MAR ^ h PH 2: 2 I.D. #25454 t# L L3 GOLDBERG KATZMAN, P.C. Crums Mill Road P ''UMSERLAN[i Cvil 7 P. Box 699 PEN NS NS YL1/ZI I? s 7 Harrisburg, , PA PA 17112 V y j s F?} (717) 234-4161; (717) 234-4161 (facsimile) Counsel for Defendant MARSHA A. SHETRON, THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004-2795 JAMES H. SHETRON, CIVIL ACTION - LAW Defendant IN DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER SECTION 3301(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 in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. Date: }A b rCf l I -12012 r' ames H. Shetron {00590569;v1} Paul J. Esposito, Esquire I.D. #25454 GOLDBERG KATZMAN, P.C. 4250 Crums Mill Road P. O. Box 6991 Harrisburg, PA 17112 (717) 2344161; (717) 234-4161 (facsimile) Counsel for Defendant MARSHA A. SHETRON, v JAMES H. SHETRON, T"H, no X017 MAR 23 P11. 2: 23 "'UMIERLAW) COUNT,_, PENNSYLVAtilA THE COURT OF COMMON PLEAS Plaintiff CUMBERLAYD COUNTY, PENNSYLVANIA NO. 2004-2795 CIVIL ACTION - LAW Defendant IN DIVORCE AFFIDAVIT OF CONSENT AND WAIVER OF COUNSELING A Complaint in Divorce under §3301(c) of the Divorce Code was filed on June 18, 2004. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety (90) days have elapsed from the date of filing and service of the Complaint. I consent to the entry of a final decree in divorce after service of notice of intention to request entry of the decree. 4. I have been advised of the availability of marriage counseling and I understand that I may request that the Court require that my spouse and I participate in counseling. I understand that the Court maintains a list of marriage counselors, which list is available to me upon request. Being so advised, I do not request that the Court require my spouse and I to participate in counseling prior to a divorce being handed down by the Court. 5. I acknowledge that I received a copy of the Complaint in Divorce on or about June 21, 2004 , via Acceptance of Service 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. Section 4904, relating to unsworn falsification to authorities. Date: I'1'!a ??C? I , 2012 JAMES H. SHETRON {00 5 90 5 69; v I ) F:\FILESTlients\12375 Shetron\12375.1.pra Revised: 3/23/12 2:49PM Hubert X. Gilroy, Esquire Jennifer L. Spears, Esquire ^a MARTSON DEARDORFF WILLIAMS OTTO GILROY & FALLER ; ?w MARTSON LAW OFFICES , , I.D. Nos. 29943 and 87445 =,- 10 East High Street - W CJ Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff r,, MARSHA A. SHETRON, IN THE COURT OF COMMON PLEA OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004-2795 CIVIL ACTION - LAW JAMES H. SHETRON, : 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: 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 on June 26, 2004. 3. Date of execution of the Plaintiff's affidavit of consent required by Section 3301 (c) of the Divorce Code; March 20, 2012; by the Defendant; March 19, 2012. 4. Related claims pending: None. All claims have been resolved by a Marriage Settlement Agreement dated March 19, 2012. Date Plaintiff's Waiver of Notice in §3301(c) Divorce was filed with the Prothonotary: March 23, 2012. Date Defendant's Waiver of Notice in §3301(c) Divorce was filed with the Prothonotary: March 23, 2012. z"p quire Ten East High Street Carlisle, PA 17013 (717) 243-3341 Attorneys for Plaintiff MARTSO LAW OFFICES f ? By ? Jennie L. S ears Es Date: March 23, 2012 MARSHA A. SHETRON IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. JAMES H. SHETRON No. 2004-2795 DIVORCE DECREE AND NOW, Ko?r )-7 at '%:0g 91K, 101 , it is ordered and decreed that MARSHA A. SHETRON plaintiff, and JAMES H. SHETRON , 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.") A Marriage Settlement Agreement dated March 19, 2012, is incorporated but not merged into this Decree. By the Court, ??o{?? ? co?°y ?a?C? .t?sposi rS? In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION MARSHA A. SHETRON Docket Number: 04-2795 CIVIL Plaintiff vs. PACSES Case Number: 024106637 JAMES H. SHETRON ) Defendant Other State ID Number: Order AND NOW to wit, this APRIL 4, 2012 it is hereby Ordered that: The Alimony Pendente Lite order is terminated effective March 27, 2012, pursuant to the parties" divorce decree of March 27, 2012 under the above captioned docket. The Alimony Pendente Lite case is terminated with a credit of $412.27. -? Ya d rT7 Q11 Cn r- Q Q- D C, .. BY THE COURT: Edwarciz., ;.JUDGE Form OE-520 02/11 Service Type M Worker ID 21205 In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 Phone: (717) 240-6225 Fax: (717) 240-6248 Defendant Name: JAMES H. SHETRON Member ID Number: 5482101377 Please note: All correspondence must include the Member ID Number. ORDER TO VACATE ATTACHMENT OF UNEMPLOYMENT BENEFITS Financial Break Down of Multiple Cases on Attachment Plaintiff Name MARSHA A. SHETRON PACSES Docket Case Number N m r 024106637 04-2795 CIVIL TOTAL ATTACHMENT AMOUNT: Attachment Amount/Frequency 360.00 / Ii NTEF; n , $ 360.00 . The prior Order of this Court directing the Department of Labor and Industry, Office of Unemployment Compensation Benefits (OUCB), to attach $82.84 or 50% per week of the Unemployment Compensation benefits of JAMES H. SHETRON, Social Security Number XXX-XX-7345, Member ID Number 5482101377 is hereby vacated. This Order to Vacate shall be effective upon receipt of the notice of the Order by the Department and shall remain in effect until a further Order of the Court is filed. BY THE COURT Date of Order: AN"" 0 5 2rj i s?EdwardC*Ado JUDGE Form EN-035 Service Type M Worker ID $IATT INCOME WITHHOLDING FOR SUPPORT 0 ? q I b ko 3_7 0 ORIGINAL INCOME WITHHOLDING ORDERMOTICE FOR SUPPORT (IWO) 0 AMENDED IWO 04 - <q7 95 c I b' 1 0 ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT ?) TERMINATION OF IWO Date: 04/04/12 Child Support Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One) NOTE: This IWOfII1 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/`p?ograms/cse/newhiro/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. Statef i nbe/ i erritory Commonwealth of Pennsylvania Remittance Identifier (include w/payment): 5482101377 City'County/Dist.(Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket informalton) Private Individual/Entity _ CSE Agency Case Identifier: (See Addendum for case summary) SOCIAL SECURITY ADMINISTRATION STE 1 200 S SPRING GARDEN ST CARLISLE: PA 17013-2578 Employer/Income Withholder's FEIN Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) RE: SHETRON, JAMES H. Employee/Obligor's Name (Last, First, Middle) 192-34-7345 Employee/Obligor's Social Security Number (See Addendum for plaintiff names associated with cases on attachment) 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 / http://www.acf.hhlr gov/proarams/cse/newhire employer/publication/publication.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. 8384100092 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 employee/ obligor's income until further notice. $ 0.00 per month in current child support $ 0.00 per month in past-due child support - Arrears 12 weeks or greater? O yes .? rA $ 0.00 per month in current cash medical support $ 0.00 per month in past-due cash medical support f-n $ 0.00 Per month in current spousal support S t 1. $ 0.00 per month in past-due spousal support ?? I ==c $ 0.00 per month in other (must specify) r_, <CD -? for a Total Amount to Withhold of $ 0.00 per month. r.._, C:? 3 c-. AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the:,O*r /hy6rrn tRn'. If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: - r`' -,.? $ 0.00 per weekly pay period. $ 0.00 per semimonthly pay peril (twice a -ronth) $ 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.aov/programs/cse/newhire/employer/contacts/ contact mao.htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.: 0970-0154 Form EN-028 01/12 Service Type M Worker ID $OINC ? 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 4p werrdTM%rn the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): r 1f _11611_ Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: APR 0 5 2012 i If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. ? If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER /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: 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 01/12 Service Type M Page 2 of 3 Worker ID $OINC Employer's Name: SOCIAL SECURITY ADMINISTRATION Employer FEIN: Employee/Obligor's Name: SHETRON, JAMES H. 5482101377 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 a 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: 8384100092 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 address: Last known phone number: Final Payment Date To SDU/Tribal Payee: New Employer's Name: Final Payment Amount: New Employer's Address: CONTACT INFORMATION: To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT (Issuer name) by phone at 717 240-6225, by fax at (717) 240-6248, by email or website at: www.childsupport.state. oa 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 childsup tat a 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-028 01/12 Worker ID $OINC ADDENDUM Summary of Cases on Attachment Defendant/Obligor: SHETRON, JAMES H. PACKS Case Number 024106637 Plaintiff Name MARSHA A. SHETRON Docket Attachment Amount 04-2795 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 umber Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB Service Type M PACSES Case Number Plaintiff Name Docket Attachme $ Child(ren)'s Name(s): nt Amount 0.00 DOB PACSES Case Number Plaintiff Name Docket Attachm $ Child(ren)'s Name(s): ent Amount 0.00 DOB PACKS Case Number Plaintiff Name Docket Attachm $ Child(ren)'s Name(s): ent Amount 0.00 DOB Addendum OMB No.: 0970-0154 Form EN-028 01/12 Worker ID $OINC