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Home My WebLink About01-1617 SAIDIS SHUFF, FLOWER & LINDSAY ATroR,~'YS*AT*LAW 26 W. High Street Carlisle, PA ADELAiDA CASTANEDA WILLIAMS, Plaintiff, VS. GORDON STANLEY WILLIAMS, Defendant. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001 - /(,/7 CIVIL TERM IN DIVORCE NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take prompt action. You are wamed that if you fail to do so, the case may proceed without you and a decree of divorce or annulment may be entered against you by the Court. A judgment may also be entered against you for any other claim or relief requested in these papers by the Plaintiff. You may lose money or property or other rights important to you, including custody or visitation of your children. When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. A list of marriage counselors is available in the Office of the Prothonotary at the Cumberland County Court House, Carlisle, Pennsylvania, 17013. IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYERS FEES OR EXPENSES BEFORE A DECREE OF DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM ANY OF THEM. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 SAIDIS, SHUFF, FLOWER & LINDSAY Attorneys for the Plaintiff James D. Flower, JrtdEsquire ID # 27742 26 West High Street Carlisle, PA 17013 (717) 243-6222 SAIDIS SHUFF, FLOWER & LINDSAY A3'[ORb~YSsAToLAW 26 W. High Street Carlisle, PA ADELAIDA CASTANEDA WILLIAMS, Plaintiff, VS. GORDON STANLEY WILLIAMS, Defendant. : IN THE COURT OF COMMON PLEAS OF · CUMBERLAND COUNTY, PENNSYLVANIA :NO. 2001 - /('/7 CIVIL TERM · IN DIVORCE COMPLAINT COUNT I - IN DIVORCE ADELAIDA CASTANEDA WILLIAMS, Plaintiff, by her attorneys, SAIDIS, SHUFF, FLOWER & LINDSAY, respectfully represents: 1. The Plaintiff is ADELAIDA CASTANEDA WILLIAMS, who currently resides at 380 East Yale Loop, Irvine, California 92614. 2. The Defendant is GORDON STANLEY WILLIAMS, who currently resides at 6991 Linglestown Road, Artemas, Dauphin County, Pennsylvania 17211. 3. The Defendant has been a bona fide resident in the Commonwealth of Pennsylvania for at least six months immediately prior to the filing of this Complaint. The parties lived together in Pennsylvania as a married couple for a period in excess of six months, in Cumberland County, Pennsylvania. 4. The Plaintiff and Defendant were married on June 27, 1998, in Amherst, New York. 5. There have been no prior actions of divorce or for annulment between the parties in this or in any other jurisdiction. 2 SAIDIS SHUFF, FLOWER & LINDSAY 26 W. High Street Carlisle, PA 6. The Plaintiff avers that she is entitled to a divorce on the ground that the marriage is irretrievably broken and Plaintiff is proceeding under Sections 3301 (c) and/or (d) of the Divorce Code. 7. Plaintiff has been advised of the availability of marriage counseling and of the right to request that the Court require the parties to participate in marriage counseling, and does not request counseling. WHEREFORE, Plaintiff requests the Court to enter a decree of divorce. COUNT II - EQUITABLE DISTRIBUTION 8. The averments of Paragraph 1-7 are incorporated herein by reference as though set out in full. 9. In the course of their marriage, the parties have acquired certain property, both personal and real. WHEREFORE, Plaintiff prays this Honorable Court to equitably divide said property. COUNT III - ALIMONY, ALIMONY PENDENTE LITF AND ATTORNEYS' FEES AND CO,ST,~ 10. The averments of Paragraph 1-11 are incorporated herein by reference as though set out in full. 3 SAIDIS SHUFF, FLOWER & LINDSAY 26 W. High Street Carlisle, PA 11. Plaintiff is without property and assets sufficient to provide for her reasonable needs presently and after the entry of a Decree in Divorce, and to pay attorney's fees and court costs. WHEREFORE, Plaintiff prays this Honorable Court to order alimony, and alimony pendente lite, in an amount sufficient to provide for Plaintiff's reasonable needs and to pay for reasonable attorney's fees and costs. SAIDIS, SHUFF, FLOWER & LINDSAY Attorneys for the Plaintiff Date: 5--I 0 I Flower, Jr., E~ui)e 2 ~ 26 West High Street Carlisle, PA 17013 (717) 243-6222 4 l, ADELAIDA CAST&NED.& WILLIAMs, Plaintiff herein, hereby verify that the statements made in this Complaint are true and correct to the best of my knowledge. information and belief I understand that false statements herein are made subject to the penalties of 18 Pa. CS. Section 4904, relating to unswom falsification to authorities 7/ ' ~Adetalda Ca~taneda Williams : IN THE COURT OF COMMON PLEAS OF ADELAIDA CASTANEDA WILLIAMS CUMBERLAND COUNTY, PENNSYLVANIA v. : CIVIL ACTION- LAW : GORDON STANLEY WILLIAMS : NO. 01 - 1617 : : IN DIVORCE ORDER AND NOTICE SETTING HEARING TO: Adelaida Castaneda Williams Carol J. Lindsay Gordon Stanley Williams Andrew C. Spears , Plaintiff , Counsel for Plaintiff , Defendant , Counsel for Defimdant You are directed to appear for a hearing to take testimony on the outstanding issues in the above captioned divorce proceedings at the Office of the Divorce Master, 9 North Hanover Street, Carlisle, Pennsylvania, on the 22nd --_ day of October 2003 9:00 , at a.m., at which place and time you will be given the opportunity to present witnesses and exhibits in support of your case. Date of Orde~ and Notice: /9/03 By the Cou. j't, George E. Hoffer, President Judge By: Divorce Master 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 2 LIBERTY AVENUE, CARLISLE, PA 17,013 TELEPHONE (717) 249-3166 ADELAIDA CASTANEDA WILLIA~MS,: IN THE COURT OF COMMON PLEAS OF Plaintiff VS. GORDON STANLEY WILLIA/~S, Defendant : CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW : : NO. 01 - 161'7 CIVIL : IN DIVORCE CONFERENCE WITH COUNSEL AND PARTIES TO: Carol J. Lindsay Adelaida Castaneda Williams , Andrew C. Spears Gordon Stanley Williams Counsel for Plaintiff Plaintiff , Counsel for Defendant , Defendant A conference has been scheduled at the Office of the Divorce Master, 9 North Hanover Street, Carlisle, Pennsylvania, on the 4th day of December 2003, at 9:00 a.m., with counsel and the parties to discuss the outstanding economic issues to determine if there is a basis of settlement of claims. If issues remain after the conference, a hearing will be scheduled at another date. Very truly yours, Date of Notice: 10/27/03 E. Robert Elicker, II Divorce Master ADELAIDA CASTANEDA WILLIAMS,:IN THE COUI~T OF COMMON PLEAS OF Plaintiff :CUMBERLAND COUNTY, PENNSYLVANIA Vs. :NO. 01 - 1617 CIVIL GORDON STANLEY WILLIA~MS, : Defendant :IN DIVORCE Williams, Defendant, Spears. is Gordon Stanley Williams, RE: Pre-Hearing Conference Memorandum DATE: Monday, September 8, 2003 Present for the Plaintiff, Adelaida Castaneda attorney Carol j. Lindsay, and present for the is attorney Andrew C. This action was commenced by the filing of a complaint in divorce on March 20, 2001, raising grounds for divorce of irretrievable breakdown of the marriage and the economic claims of equitable distribution, alimony, alimony pendente lite, and counsel fees and costs. The complaint states the address of the Plaintiff as 380 East Yale Loop, Irvine, California and the address of the Defendant 6991 Linglestown Road, Artemas, Dauphin County, Pennsylvania. The Master has made reference to the pretrial statement that was filed also does not list an address in Cumberland County for either of the parties. The Master indicated to counsel that he and the Court have the discretion as to whether or not they will accept venue of this case in Cumberland County; however, the Master has advised counsel that rather than have them go through the refiling or an order to have the case transferred to another county, he will at least initially give the parties and counsel an opportunity to settle the case here in Cumberland County. He has advised counsel, however, that he will further determine, depending on how matters go, whether or not he will ultimately ask counsel to move the case to another jurisdiction. Consequently, the Master is going to schedule a hearing on this case and give counsel an opportunity to indicate on the record what needs to be accomplished in order to move the case forward and to engage in negotiations which may be helpful in getting the matter resolved. The parties were married on June 27, 1998. The parties have indicated in their pleadings two different dates of separation; however, counsel have indicated that the date of the separation, whether it be November or December of 1999 is not particularly relevant with respect to valuation of assets. Attorney Lindsay has provided today a spread sheet showing the marital estate values and listing assets that she has determined are subject to equitable distribution. There are some questions that she needs to have answered in order to refine her statement, in particular, the GM savings stock purchase program value. She will address that matter in her comments as well as the proposal to settle the case. Mr. Spears will also raise some issues that he feels are relevant to credits which his client may be entitled to regarding payment of debt for the wife and the assumption of a storage fee for property which wife had remaining in Pennsylvania after she moved to California. Wife is currently living in Arizona and husband in Kentucky. The Master is going to give the parties and counsel an opportunity to get through the issues here in Cumberland County as previously noted and to that end will try to move this case forward by scheduling a hearing. A hearing is scheduled for Wednesday, October 22, 2003, at 9:00 a.m. Notices will be sent to counsel and the parties. Attorney Lindsay has also indicated she has not yet determined whether she will offer testimony on marital misconduct but when she makes her comments on the record, the Master requests she give some statement with respect to the nature of her marital misconduct testimony. Ms. Lindsay. MS. LINDSAY: To begin with, with regard to the issue of marital misconduct, the testimony would include those allegations of marital misconduct contained in a petition for protection from abuse filed by wife in Cumberland County to No. 2000 7602, and she would also present a photograph taken on December 15, 1999, by the staff of the Carlisle Domestic Shelter Home. With regard to additional information needed to settle this case, wife has provided ~o husband by letter of August 20, 2003, a request to determine whether the valuation on December 10, 1999 -- the valuation date which we have been using -- includes $21,577.00 taken from that account by husband a few weeks prior to separation and used to purchase a home in his name only. If it appears that the date of separation value of the stock savings program should include the additional loan value of $21,577.00 -- in other words, if the date of separation value is reduced by that loan amount, then wife would need to reconsider her offer of settlement. If, however, the balance in the account on the date of separation of $51,392.77, if that amount is the full value of the account, including the loan, then wife has offered to settle the case for payment to her of $7,500.00 and alimony for a brief period of time; that is six months as set out in the pretrial statement, in the amount of $375.00. THE MASTER: are using with regard to that of the account or is that the to clarify, please? Ms. Lindsay, the number that you plan, is that the total value increase in value, do you want MS. LINDSAY: On the asset list, which has been attached to the pre-hearing memorandum as well, 3 $26,829.24 is our calculation for the marital portion of the GM savings stock purchase program. The question that I have raised here is whether that should be increased by another $21,577.00 because unlike some programs where the value of the plan is not reduced by any loan taken out because the plan is considered to continue to have that money in the plan; just subject to a loan, this particular plan may have, and I believe may have, reduced the value of the plan by the loan amount in which case since Mr. Williams took that money and used it for his own purpose, that would be part of the marital portion in our view. So we need to clarify that issue and the offer of settlement is really dependent upon the answer to that question. If the answer is that there is only $26,829.24 of marital value in that plan, then the offer of $7,500.00 to settle the case with the alimony as set out before is our offer. THE MASTER: Mr. Spears. MR. SPEARS: In terms of the marital misconduct, husband will, of course, offer his response to those allegations. In terms of the stock purchase program, I will provide as much information, including statements and the phone numbers for Ms. Lindsay so she oan obtain that information. If it is deemed that there was the increase in value due to a loan decreasing the amount, we will would like to provide information regarding what the present day valuation of the GM stock is, not just the valuation on the date of separation. MS. LINDSAY: And I would agree that the present value of the number of shares that were marital would be relevant. I would just ask yo~ to either get me an answer to my question documented, a letter would be great, or in the alternative get me a release and a phone number for a human being so that THE MASTER: alleged credits that he is MR. SPEARS: I Do you want to address asking for? Husband is asking for a can make the inquiry myself. the credit, $4,000.00 which he will provide documentation prior to the hearing regarding taking wife's furniture out of storage. Also a $2,900.00 credit for paying off a personal debt which wife owed as well as determining credits he would receive for payments of student loans for each party, which were consolidated during the marriage which he has been paying on since the time of separation. THE MASTER: You are going to get the receipts from the storage MR. SPEARS: THE MASTER: company? Yes. And you are also going to get evidence about this loan that he paid off for her. Was it a car loan or what kind of a loan was it, do you know? 5 MR. SPEARS: I believe in wife's statement that she provided today, they refer to it as a personal loan to her. MS. LINDSAY: wife paid off by husband is THE MASTER: was the payee. A $2,900.00 personal loan to what we put on there. What was the loan for and who (A discussion was held off the record) MS. LINDSAY: Counsel has provided a document that indicates that Adelaida Williams asked Ernest Deetz for a loan for help with tuition for her child in the amount of $3,500.00 in 1997 which would have been prior to the parties' marriage, and I expect that what Mr. Williams is claiming is that he paid some or all of that money back. MR. SPEARS: If I could further clarify too -- can we go off the record again? (A discussion was held off the record.) THE MASTER: Ms. Lindsay, would you state for the record how your is client employed? MS. LINDSAY: Adelaida Williams at this time is employed so far as I know, the last time I spoke to her, as a massage therapy instructor where she teaches others to become a massage therapist. I think she probably also does some on her own. THE MASTER: And your client, what is he doing? MR. SPEARS: He is Currently retired from GM and receiving a pension annuity from them and he is attending a seminary in Kentucky. THE MASTER: What school? MR. SPEARS: I am not positive. studying to become a minister. He is THE MASTER: Counsel and the parties are directed to file income statements prior to the hearing to be scheduled in these proceedings on or before Wednesday, October 15, 2003. MS. LINDSAY: Can I just Suggest one other thing to help with a resolution and that is, can we get an indication of whether he can access that stock purchase program to pay her off if need be. cc: Carol j. Lindsay, Attorney for Plaintiff Adelaida Castaneda Williams, Plaintiff Andrew C. Spears, Attorney for Defendant Gordon Stanley Williams, Defendant ADELAIDA CASTANEDA WILLIAMS, Plaintiff GORDON STANLEY WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE DEFENDANT'S PRETRIAL STATE_MENT_ Defendant, Gordon Stanley Williams, files the following Pretrial Statement. 1. List of Marital Assets: At this point, Defendant lacks sufficient knowledge of all of the parties' marital assets. However, the assets that he is aware of, though the amounts are not known, are: Value (a) (b) Savings Bonds 75 Shares of GM Stock $150.00 January 12, 1998 - $56.00 per share January 11, 1999 - $85.97 per share (c) Saving Stock Purchase Program from GM Market value Jmae 27, 1998 - $24,525.96 Market value December 11, 1999 - $29,722.61 2. Ex e~tnesses: Defendant does not intend to call expert witnesses at this time. However, Defendant reserves the right to call an expert from GM Stock Program who would be able to explain the value of Mr. Williams' Stock purchase Program. 280208-1 Other Witnesses: Gordon Williams Adelalda Williams Exhibits of Defendant: · · - · ' ' kOptions. (a) Records from General Motors mdtcatmg Mir. Wflhams Stoc (b) Records from Statements from General Motors regarding Mr. Williams' Savings Stock Program valued on June 27, 1998. (c) Statement from General Motors regarding Mr. Williams' Savings Stock Purchase Program dated December 11, 1999. (d) Information regarding the separate student loans which were consolidated into one loan. Defendant's Income: See income and expense statement of Defendant Gordon Stanley Williams. Defendant~: See income and expense statement of Defendant Gordon Stanley Williams. Valuation of Defendant s Pens~o Not applicable. Counsel Fees: Defendant proposes that both parties be respons![ble for his/her own counsel fees. 9. Personal Pr_~9.perty: The only personal property left to be split up is furniture of Plaintiff Adelaida Castaneda Williams. Defendant is currently storing them at his home in Harrisburg and he will be 280208-1 more than happy to mm them over to Plaintiff. Defendant did have to borrow approximately $8, 000.00 from his Savings Stock Program to pay for storage costs of this furniture. 10. Marital Debt~: Student loans which were consolidated. 11. P_rop. os___ed Resoluti._on of Economic Issues: Assets to Wife: $1,000.00 to represent her share of Mr. Williams' savings stock purchase program for the time in which they were married. Alim~ony to P_laintiff____Wif_e: Due to length of their marriage and the fact that Plaintiff is able to procure employment for herself, Defendant proposes an award of no alimony. Student_Loans Student loans will be unconsolidated and each will party will pay their respective METZGER, WICKERS HAM, KNAUSS & ERB, P.C. By Andrew C. Spears, Esquire Attorney I.D. No. 87737 P.O. Box 5300 Han'isburg, PA 17110-0300 (717) 238-8187 Attorneys for Plaintiff 280208-1 CERTIFICATE OF SERVICE I, Andrew C. Spears, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and exact copy of the Plaintiff's Pretrial Statement with reference to the foregoing action by First Class Mail, postage prepaid, this 0~ day of ,2003, on the following: Carol J. Lindsay, Esquire Saidis, Shuff, Flower & Lindsay 26 West High Street Carlisle, PA 17013 Andrew C. Spears, Esquire 280208-1 ADELAIDA CASTANEDA WILLIAMS Plaintiff GORDON STANLEY WII J IAMS, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE TO: Adelaida Casteneda Williams c/o James D. Flower, Jr., Esquire Saidis, Shuff, Flower & Lindsay 26 W. High Street Carlisle, PA 17013 We are enclosing herewith Interrogatories propounded by Defendant, Gordon Stanley Williams, to be answered by Adelaida Castaneda Williams within thirty (30) from the date of service hereof with a request that a copy of the Answers be served upon counsel for Adelaida Castaneda Williams. Each Interrogatory hereinafter set forth not only calls for ~.e knowledge of Adelaida Castaneda Williams but also for all information that is available to her by reasonable inquiry including inquiry of her representatives and attorneys. These Interrogatories shall be deemed to be continuing Interrogatories. If, between the time of your answers to said Interrogatories and the time of the trial of this case, you, or anyone acting on your behalf, learns of or discovers any further information not contained in your answers, any such additional information shall be promptly furnished to the undersigned by Supplemental Answers. Please attach written materials to any amwer for which written materials are available. If there are none available state the number of the Interrogatory to which it pertains. If there are no written materials relevam to the question, please state. Dated: METZGER, WlCKERSHAM, KNAUSS & ERB, P.C. Melissa L. Stickel, F_,squire Attorney I.D. No. 8.5869 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Defendant employer, state: a) b) ANSWER: C. ¢. State the names of all employers for the last five years to the present and for each d) e) The dates of such employment. The position heM. A description of the duties performed. Reason for termination. Salary. Document #: 207274. I 23. List the sourcez of your income and amounts for ,~ach of the yearn since the date of final separation. ANSWER: Doc~tnt ~. 207274.1 34. following: ANSWER: For each of the last two years state the mount expended by you monthly for the a) b) c) d) e) 0 g) h) Pleasure. Travel and transportation. ' Food. Clothing. Housing. Medical. Education. Contribution to retirement or disability plans, sociai security, and premiums paid on any insurance plan (please specify the type of insurance and the amount for each type). Document ii: 20727d.! 42. ANSWER: With respect to your education, training and experience, state: a) The name and address of each high school., vocational school, college or other post-graduate training, the last year completed and dates of attendance. b) The major course of study or training received at each. c) Any other training, experience or skill you have obtained, received or developed. My trip to the LA Concoum By Bev Giffin-Frohm Orange Coast Region The day before the Concours was June 2"d and the moming was cold and rainy in Los Angeles. It looked as if June weather had arrived on schedule and was going to challenge the event masters of the PC/VIA Concours. The weather gods had the event masters in a dilemma. Would the lain stop in time? Will the rain stop in the morning? How many people would show up if it rained? However, by late afternoon the rain stopped, at least in LA. It was still damp in the air but this was like the normal June gloom. The e~ent masters sighed with relief and the show was ready to roll the next morning. The morning started out like your typical June non-surtny moming, so I mede sure I was dressed in layers, I knew we would be at the beach and who knew what the weather would be like in Marina del Rey verses Irvine. I rolled into the designated parldng ama at Burton Chase Park around 7:30am. I thought I was on time, but there were 8 other cars in front of me - this is the sign of a good show. I pulled in behind Marry Stewart end we had a ¢~ance to catch up with each other. Soon they were placing the cars in the park and wa started last minute preparation to get the cars ready to be judged. I always enjoy attending Concours events, as you get to see people from around the Zone and socialize a bit. It is amazing to see us carry on a conversation with someone while cleaning a car. As long as they don't mind speaking to some of your 'other" body parts while doing so. It is amazing ()ur cars are so clean, yet wa continue to find these tenacious bits of dirt that have taken up residence since the last Concours. Someone jo~ed that they dldnl think I could get inside the car any further than I was already, they are probably right, but I was in hot pursuit and ready to evict dirt. I am gled no one took a picture, or at least I hope to heck no one did. In my immediate area we had Marty Stewart, Doc Pryor & Linda Cobbarubias, Darnell Bennet, Mark & Tine Trewatha, Bill & Barb Enke and ~ ~These are great folks and wa proceeded to $,wap stories, trade supplies, and set up our blankets and chairs. As I was working on my car Fred Stewart, the event's Head Judge, asked if I would help with judging. I was selected to help judge *the Wash and Shine class together with Richard Price. The largest classes in the Zone Concours are the Street and Wash and Shine classes. V~ 22 cars to be judged, three were Full Concours, one Un-Restored, eight Street and t~n Wash and shine. You gat a work out, but it is a great way to meet people and promote the Concours. By the time we were half way lhrough judging, the sun started to peek out and the cars gleamed like jewels in the park. In Wash and Shine, we had ten terrific cars; seventy percent of those had come out for the first time and did very well. The scores ranged from 128.1 to 129.8 that is close oompetition for this class. One first timer, IDamell Bennett took Best of Wash and Shine with his beautiful white 1999 Boxster. I think this guy is ready to move up into Street- don't you? Richard and I enjoy~ talking to each owner and giving them helpful hints on car preparation. I hol~ they come out again, because each of their cars were greatl Hem am the results from the show. C2 Patrick, James LAR 58 Speedster 318.0 C9 Gu~ 86 928S 322.5 S3 Giffin-Frohm, Beverly OCR 70 911E 238.4 S4 Enke, Bill & Bmbera SGV 77 9115 Targa 237.3 S4 Picchio, Julio AZR 74 Cermra 238.1 S5 Sell, Lawrence I_AR 93~4 238.5 S6 Scott, Michael I.AR 97 993 237.5 S6 Trewartha, Mark OCR 97 993 Turbo 239.0 S7 DeCocker, Dean SGV 00 Boxster 239.6 S9 E~bank, Bud & Carolyn SBR 78 924 239.4 S9 Kurzban, Scott LAR 91 944 238.6 UR2L Mansolino, Mike OCR 89 Carrera 238.3 WS2 Flerning, Jack LAR 82 911SC 128.7 WS2 Guefin, Jim SGV 128.1 WS2 Pynatte, Charlie LAR 87 911 128.6 WS2 Stewart, Merti GPX 82 911SC 128.9 WS3 Cobarrubies, Linda GPX 97 993 129.3 WS3 Szielenski, Ziggy SDR 89 928S4 128.9 WS3 Widom, Keith LAR 82 928 128.7 WS4 Bennett, Damell GPX 99 Boxster 129.8 WS4 Cottarn, Tyler LAR 99 Boxster 128.3 WS4 Piersel, Frank LAR 01 Boxster 129.5 A big thank you goes to the Los Angeles Region for hosting a gmat event. We had a gmat day with terrific people. more Visit Albums Beverly Frohm: LA Concours 2001: View Photo VISIT ALBUMS l{OI)M t~,rs~l Picture Maker 200 richard and mercy putting the final touches on before judgiing 1 of 2 10/29/2001 12:35 PM Photo.Point. coin- Visit Albums - View Photo wysiwyg'd/2/http'd/albums.phot~poi~:.comt...Phot°?~lOOOT~'l~Za=13zuzzzl~:~~uui°vzv~ Copyright © 2001 Pantellic So~rtware, Inc. All Rights Reserved. Use of this site subject to the Terms & Conditions. 2of2 10/29t2001 12:35 PM FROM : SAIDIS~SHUFF~FLO~ER+LINDSA¥ FAX NO. : 24~65i0 O DEPARTMENT OF TIIE TREASUR!F FINANCL4,L MANAC, EMENT SERVICE P.O. BOX 16~6 BIRMINGIIAM, ALABAMA 35201-14;86 10/01/01 Dec. 21 2001 THIS IS NOT A BILL . PLEASE RETAIN FOR YOUR RECORDS ADELAID C HALIEN 350 E YALE LOOP IRVINE CA 92614 'D,er ADELAID C ItALEN: : _ As authorized by Federal law, we applied all or part of)our Pederal a meat to government agemy (or agencies) collecting you~ debt is listed belovf )' a debt you owe. Tbo U.S, DEPARTMENT OF EDUCATION TIN Num: 537-62-2134 C/O ILLINOIS STUDENT ASSIST COMM 175:5 LAKE COOK ROAD DF./iRFII~D IL 60015 $0fi-irJ4.3$?2 ($00) 934-3572 PURPOSE: Non-Tax F~deral Debt TOP Trace Num: $10551743 Acct Num: IL537622134 Amount This Creditor: $109.68 Creditur: 05 Site: IL Th~ Agency has previously ~ent notice to you at the last ~drt~ known to the Agency. That nolic~ ~xplain~t the a,nount and lype of debt you owe, tl~ rights available ~ you, a~d that {he Agenoy intended to col[~t thc d~bt by int~:epting any Fed~al payments made to you,. including tax refumis. If you believ~ your payment w~s reduced in error or If you have quesrio]u about this debt, you must ~entm the ~ ut ~e eddr~s and telephone number shown aim · -Tree 's. Finenc' . . v?.. 'l~e U S .D~par~ncnt of sue' i~t Management Ser~ce cam~ot resok, e ~suc; .,gardmg debts w~th other a§~'~cies. We will fogv~rd the nloney taken fi'om your Federal payment to the Agenoy to · apphed to your debt b ' balance; however, lbo Ag~cy may not ro~ive the funds for several weeks ~ the payment date. If you inttmd to ~onta~! the Ag~oy, please have this notice av-~ilable. Charl~ A. Wilson Department of abe Treasmy, Financial Management Sen~ice (800) ~04-3107 PAYMENT SUMMARY PAYEE NAME: ADP_J..AID C HALI~q PAYMENT BEFORE REDUCTION: $43s.75 TOTAL AMOUNT OF THIS REDUCTION: $109.~8 PAYING FEDERAL AGENCY: Office of Personnel Management PAYMENT DATE: 10/01/01 PAYMENT TYPE: IgFT ADELAIDA CASTANEDA WILLIAMS Plaintiff VS. GORDSN STANLEY WILLIAMS Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW : 01-1617 : NO. CIVIL 19 : : IN DIVORCE STATUS SHEET DATE .,, ADELAIDA CASTANEDA WILLIkMS, :IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA vs. : NO. 01 - 1617 CIVIL : GORDAN STANLEY WILLIAMS, : Defendant : IN DIVORCE TO: Carol J. Lindsay Melissa L. Van Eck Attorney for Plaintiff Attorney for Defendant DATE: Friday, May 17, 2002 CERTIFICATION I certify that discovery is complete as for which the Master has been appointed. to the claims (a) OR IF DISCOVERY IS NOT COMPLETE: Outline what information is required that is not complete in order to prepare the case for trial and indicate whether there are any outstanding interrogatories or discovery motions. (b) Provide approximate date when discovery will be complete and indicate what action is being taken to complete discovery. DATE COUNSEL FOR PLAINTIFF ( ) COUNSEL FOR DEFENDANT ( ) NOTE: PRETRIAL DIRECTIVES WILL NOT BE ISSUED FOR THE FILING OF PRETRIAL STATEMENTS UNTIL COUNSEL HAVE CERTIFIED THAT DISCOVERY IS COMPLETE, OR OTHERWISE AT THE MASTER'S DISCRETION. AFTER RECEIVING THIS DOCUMENT FROM BOTH COUNSEL OR A PARTY TO THE ACTION, IF NOT REPRESENTED BY COUNSEL, INDICATING THAT DISCOVERY IS NOT COMPLETE, THE DIRECTIVE FOR FILING OF PRETRIAL STATEMENTS WILL BE ISSUED AT THE MASTER'S DISCRETION. HOWEVER, IF BOTH COUNSEL, OR A PARTY NOT REPRESENTED, CERTIFY THAT DISCOVERY IS COMPLETE, A DIRECTIVE TO FILE PRETRIAL STATEMENTS WILL BE ISSUED IMMEDIATELY. THE CERTIFICATION DOCUMENT SHOULD BE RETURNED TO THE MASTER'S OFFICE WITHIN TWO (2) WEEKS OF THE DATE SHOWN ON THE DOCUMENT. ADELAIDA CASTANEDA WILLIAMS, Plaintiff : VS. GORDON STANLEY WILLIA/~S, Defendant CUMBERLAND COUNTY, CIVIL ACTION - LAW : : NO. 01 - 1617 CIVIL : : IN DIVORCE IN THE COURT OF COMMON PLEAS OF PENNSYLVANIA NOTICE OF PRE-HEARING CONFERENCE TO: Carol J. Lindsay Andrew C. Spears , Attorney for Plaintiff , Attorney for Defendant A pre-hearing conference has been scheduled at the Office of the Divorce Master, 9 North Hanover Street, Carlisle, Pennsylvania, on the 8th day of September 2003, at 9:30 a.m., at which time we will review the pre-trial previously filed by counsel, define issues, explore the possibility of settlement and, schedule a hearing. statements identify witnesses, if necessary, Very truly yours, Date of Notice: 7/21/03 E. Robert Elicker, II Divorce Master Carol J. Lindsay, Attorney for Plaintiff, has not filed a pretrial statement as of the date of this notice. Andrew C. Spears, Attorney for Defendant, filed a pretrial statement on May 9, 2003. ADELAIDA CASTANEDA WILLIAMS, Plaintiff GORDAN STANLEY WILLIAMS, Defendant : COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : : NO. 01 - 1617 CIVIL : IN DIVORCE TO: Carol J. Lindsay Melissa L. Van Eck Attorney for Plaintiff Attomey for Defendant DATE: Friday, May 17, 2002 CERTIFICATION I certify that discovery is complete as to the claims for which the Master has been appointed. May O~q,2002 COUNSEL FOR DEFENDANT NOTE: PRETRIAL DIRECTIVES WILL NOT BE ISSUED FOR THE FILING OF PRETRIAL STATEMENTS UNTIL COUNSEL HAVE CERTIFIED THAT DISCOVERY IS COMPLETE, OR OTHERWISE AT THE MASTER'S DISCRETION. AFTER RECEIVING THIS DOCUMENT FROM BOTH COUNSEL OR A PARTY TO THE ACTION, IF NOT REPRESENTED BY COUNSEL, INDICATING THAT DISCOVERY IS NOT COMPLETE, THE DIRECTIVE FOR FILING OF PRETRIAL STATEMENTS WILL BE ISSUED AT THE MASTER'S DISCRETION. HOWEVER, IF BOTH COUNSEL, OR A PARTY NOT REPRESENTED, CERTIFY THAT DISCOVERY IS COMPLETE, A DIRECTIVE TO FILE PRETRIAL STATEMENTS WILL BE ISSUED IMMEDIATELY. THE CERTIFICATION DOCUMENT SHOULD BE RETURNED TO THE MASTER'S OFFICE WITHIN TWO (2) WEEKS OF THE DATE SHOWN ON THE DOCUMENT. Document #: 235044.1 ADELAIDA CASTANEDA WILLIAMS, : Plaintiff : VS. GORDON STANLEY WILLIAMS, : Defendant : IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE M6TION FOR__APP_OiNT~MENT OF MASTER AND NOW, Gordon Stanley Williams, Defendant, moves the court to appoint a master with respect to the following claims: ( ) Divorce ( ) Annulment (X) Distribution of Property (X) Alimony ( ) Support (X) Counsel Fees (X) Alimony Pendente Lite (X) Costs and Expenses and in support of the motion states: (1) requested. Discovery is complete as to the claim(s) for wtfich the appointment of a master is (2) Esquire. The Defendant has appeared in the action by his attorney, Melissa L. Van Eck, (3) The statutory ground for divorce is 3301(c) and/or (d) of the Pennsylvania Divorce Code. (4) The action is contested with respect to the following claim: (i) Equitable Distribution. (ii) Alimony, Alimony Pendente Lite and Attorneys Fees and Costs. Document ii.. 219683.1 (6) (7) The hearing is expected to take one (1) day. Additional information, if any, relevant to the motion: None. METZGER_, WICKERSHAM, KNAUSS & ERB, P.C. Melissa L. Van Eck, Esquire · -- I. D. No. 85869 3211 North Front Street P. O. Box 5300 Harrisburg, PA 17110-0300 Attorneys for Defendant rote: ~- q -0 ~ Document #: 219683.1 I, Melissa L. Van Eck, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and Correct copy of' the Motion for Appointment of Divorce Master of Defendant with reference to the foregoing action by first class ma/l, postage prepaid, th/s day of ,2002, on the following: Carol Lindsay, Esquire Sa/dis, Shuff, Flower & Lindsay 26 W. High Street Carlisle, PA 17013 METZGER, WICKERSHAM, KNAUSS & ERB, P.C. ADELAlDA CASTANEDA WILLIAMS, Plaimiff VS. GORDON STANLEY WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE ORDER APPOINTING MASTER ANDNOW, this ~7~ayof ~,-' 2002, ~.ff-a-d~-6//~,Esquire,is appointed master with respect to the following claims: Equitable Distribution. Alimony, Alimony Pendente Lite and Attorneys Fees and Costs. By the Court: flJ Document #: 219683. I ADELAIDA CASTANEDA WILLIAMS, : Plaintiff : VS. GORDON STANLEY WILLIAMS, Defendant 1N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE DEFENDANT'S ANSWER TO PLAINTIFF'S PETITION FOR ALIMONY PENDENTE LI'IE AND NOW COMES the Defendant, Gordon Stanley Williams, by and through his attorney, Melissa L. Stickel, Esquire, and files the following Answer to Plaintiff's Petition for Alimony Pendente Lite. 1. Admitted. 2. Denied. The date of separation was November 11, 1999. 3. Denied. Defendant denies that Plaintiff lacks the ability to earn income sufficient to meet her reasonable needs and to pay attorney's fees. WHEREFORE, Defendant, Gordon Stanley Williams, prays this Honorable Court deny Plaintiff's Petition for Alimony Pendente Lite. METZCs. F-~, WICKERSHAM, KNAUS~ & ERB, P.C. By ~~~ Melissa L. Stickel., Esqu~e ~ ~ Attorney I.D. No. 85869 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Defendant Dated: Document #: 213410 1 CERTIFICATE OF SERVICE I, Melissa L. Stickel, Esquire, do hereby certify that on the date set forth below, I did serve a true and correct copy of the foregoing Defendant",; Answers to Plaintiff's Petition for Alimony Pendente Lite upon the following person at the following addresses indicated below by sending same in the United States Mail, first-class, postage prepaid: Adelaida Castaneda Williams c/o James D. Flower, Jr., Esquire Saidis, Shuff, Flower & Lindsay 26 West High Street Carlisle, PA 17013 METZGER, WICKERSI-[~' ~& ERB, P.C. Attorney ID No. 85869 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Document #: 213410.1 ADELAIDA CASTANEDA WILLIAMS, Plaintiff/Petitioner VS. GORDON STANLEY WILLIAMS, Defendant/Respondent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - DIVORCE NO. 2001-1617 CIVIL TERM DR# 30930 Pacses# 9241.03734 DEMAND FOR HEARING DATE OF ORDER: AMOUNT: FOR: October 16, 2001 $966.00 per month plus $134.00 per month on arrears Alimony Pendente Lite REASONS(S): Plaintiffs income was improperly calculated in that she admitted during support conference that she was working in exchange for rent. This is income which should have been taken into consideration in the calculations. Also Plaintiff contends that she is disabled from a motor vehicle accident in 1997, however, the documents that she provided to the Conference Officer did not state that she did not have the ability to work. PARTY FILING DEMAND FOR HEARING. Date: Gordon S. Williams, Defendant/Respondent METZGER, WICKERSF[AM, KNAUSS & ERB Melissa ~. Van Eck, Esquire Attorney I.D. No. 85869 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Defendant/Respondent Do~*ment il: 218924.1 )ELAIDA CASTANEDA WILLIAMS, Plaintiff, VS. GORDON STANLEY WILLIAMS, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA :NO. 2001- 1617 CIVILTERM : IN DIVORCE PETITION FOR ALIMONY PENDENTE LITE Now comes ADELAIDA CASTANEDA WILLIAMS, by and through her counsel, JAMES D. FLOWER, JR., of SAIDIS, SHUFF, FLOYVER & LINDSAY, and petitions this Honorable Court as follows: 1. The parties hereto are husband and wife, having been joined in marriage on June 27, 1998. 2. The parties separated on or about December 11, 1989. 3. Petitioner is without the ability to earn income sufficient to meet her reasonable needs and to pay attorney's fees. WHEREFORE, Petitioner prays this Honorable Court to order alimony pendente lite in an amount equal to the Pennsylvania State Support Guidelines and reasonable attorney's fees. SAIDIS, SHUFF, FLOWER & LINDSAY Attorneys for Plaintiff SAIDIS SHUFF, FLOWER & LINDSAY O'ames D. FLower, Jr. ~ ~1.[.). #27742 ~/2b West High Street Carlisle, PA 17013 (7'17) 243-6222 VERIFICATION The undersigned, JAMES D. FLOWER, JR., avers that the facts set forth in the within instrument, based upon information and belief, were developed from conversations with Plaintiff and information gained in the investigation of this file, and this verification is made for the reason that Plaintiff is outside of the jurisdiction of the Court, and that her verification could not be obtained within the time allowed for the filing of this pleading, and this verification is made subiect to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. SAIDIS SHUFF, FLOWER & LINDSAY AT~*AT'LAW 26 W. High Street Carlisle, PA DRS ATTACHMENT FOR APL PROCEEDINGS pETITIONER~ DOB: ADDRESS: PHONE: ATTORNEY: PETITIONER'S EMPLOYMENT: HOW LONG? NET PAY: N/A JOB TITLE: HOME MAKER ADELAIDA CASTANEDA WILLIAMS MAY 10, 1953 SSN: 380 EAST YALE LOOP, IRVINE, CA 92614 949-559-1800 JAMES D. FLOWER, JR., ESQUIRE NONE PER OTHER INCOME: (INCLUDE AMOUNT AND SOURCE) 537-62-2134 RESPONDENT: DOB: ADDRESS: PHONE: A~rORNEY: RESPONDENT'S EMPLOYMENT: HOW LONG? NET PAY: $$5,000.00 JOB TITLE; UNKNOWN GORDON STANLEY WILLIAMS JULY 1, 1943 SSN: 366-40-0477 9145 JOYCE LANE, HUMMELSTOWN, PA 17036 UNKNOWN MELISSA L. STiCKEL, ESQUIRE GENERAL MOTORS UNKNOWN PER MONTH OTHER iNCOME: (INCLUDE AMOUNT AND SOURCE) WHEN MARRIED: DATE SEPARATED: JUNE27,1998 DECEMBER15,1999 WHERE; AMEHURST, NEW YORK WHERE LAST LIVED TOGETHER; FOR DRS INFORMATION ONLY ADELAIDA C. WILLIAMS, Plaintiff/Petitioner VS. GORDON S. WILLIAMS, Defendant/Respondent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - DIVORCE NO. 2001-1617 CIVIL TERM IN DIVORCE DR# 30930 Pacses# 924103734 ORDER OF COURT AND NOW, this 28th day of August, 2001, 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. Shadday on October 1 2001 at 1:30 P.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 Inca (2) your pay stubs for the preceding six (6) mom (3) the Income and Expense Statement attached 1910.11© (4) varificatinn of child care expanses (5) proof of medical coverage which you may have~ IF you fail to appear for the conference or bring the r~ warrant for your arrest. ~led Rule · ~,,:c;ourtmay issue a BY THECOURT, GeorgeE. Hoffer,~esidentJudge Mail copies on 8-28-01 to: Petitioner < Respondent James Flower, Jr., Esquire Melissa Stickel, Esquire Date of Order: August 28, 2001 · ~ "R. J. {~hadday, Conference Offi 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 ADELAIDA C. WILLIAMS, Plaintiff/Petitioner VS. GORDON S. WILLIAMS, Defendant/Respondent DR 30930 PACSES ID 924103734 : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : DOMESTIC RELATIONS SECTION : CIVIL ACTION - LAW . : NO. 2OO1-1617 C[VILTERM ORDER OF COURT AND NOW, this 16th day of October, 2001, based upon the Court's determination that Petitioner's monthly net income/earning capacity is $333.00 and Respondent's monthly net income/earning capacity is $4,118.81, it is hereby Ordered that the Respondent pay to the Pennsylvania State Collection and Disbursement Unit, $1,100.00 per month payable monthly as follows; $966.00 per month for alimony pendente lite and $134.00 per month on arrears. First payment due with next pay date. Arrears set at $2,898.00 as of October 16, 2001. The effective date of the order is August 9, 2001. This Order considers that husband is making payment on a vehicle that was in wife's possession upon separation and isnot in husband's possession. Should the vehicle be returned to husband's possession or a sales transaction is completed the APL Order may be reviewed. Consideration is given for the medical insurance costs paid by husband. 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: Adelaida Williams. Payments must be made by check or money order. All checks and money orders mast be made payable to PA SCDU and mailed to: PA SCDU P.O. Box 69110 Harrisburg, PA 171106-9110 Payments must include the defendant's PACSES Member Number or Social Security Number in order to be processed. Do not send cash by mail. Unreimbursed medical expenses that exceed $250.00 annaally are to be paid 0% by the respondent and 100% by petitioner. The petitioner is responsible to pay the first $250.00 annually in unreimbursed medical expenses. Respondent to provide medical insurance coverage. Within thirty (30) days after the entry of this order, the 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 cover~,ge; 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 shall become final ten days 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. DRO: R. J. Shadday Mailed copies on 10-17-01 to: < Petitioner Respondent James Flower, Jr., Esquire Melissa Stickel,quire BY THE COURT, ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania /3//~~~"~C Co./City/Dist. of C~ER~D Date of Order/Notice ~0/~6/0~ Court/Case Number (See Addendum for case (~) Original Order/Notice O Amended Order/Notice C) Terminate Order/Notice Employer/Withholder's Federal EIN Number GENERAL MOTORS CORP* E m pJoye rANithbeJde r'5 Name C/O ARTHUR ANDERSON BPS CENTR Employer/W[lhholde r's Address PAYROLL SERVICES PO BOX 62650 PHOENIX AZ 85082-2650 WILLIA.MS, GORDON S. Employee/Obli§or's Name (Last, First, MI) 366-40-04,77 Employee/Obligor's Social Secudly Number 0322100482 £mployee/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 associa~ted with cases on attachment. ORDER INFORMATION: This is an Order/Notice to Withhold Income for' Support based upon an order for support from CUMBER~ 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. $ 966.00 per month in current support $ I34.00 per month in past-due support Arrears 12 weeks or greater? (~)yes O no $ 0.00 per month in medical support $ o. oo per month for genetic test costs $ per month in other (specify) for a total of $ 1,100.00 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: $ __ 2__~.5..~_,_.8.~ per weekly pay period. $ 507.69 per biweekly pay period (every two weeks). $ 550. oo per semimonthly pay period (twice a month). $ 1,100. oo 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 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 or~ withholding, the following information is needed (See ~ on pg. 2). If remitting by EFT/FDI, 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 MALL. BY THE COURT: ~MB No,: 0970-0154 .. - ./,~3.//?/~,,) i/ Expi~t'on Date; 12/31/00 Date of Order: OCT I ? Z00! Service Type M Form EN-~28 Worker ID $IATT ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS [] If checked you are required to provide a copy of this form to your employee. 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. ~'~r'~,'~-L~ ", ,,,~,,-'~,'~,,,e ........................................ ,,~,'~ ,,~',,, -,~ ~,,,P,'-'y~ * ,,,~e~*. 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 Orde#Notices clue 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. WITHHOLDER'S ID: 3805725150 EMPLOYEE'S/OBLIGOR'S NAME: WILLIAMS, GORDON S. EMPLOYEE'S CASE IDENTIFIER: 03223.00J82 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)l ~ or 2) the amounts allowed by the State of the em ployee'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. 10. *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. Requesting Agency: DOMESTIC RELATIONS SECTION 13 N. HANOVER P.O. BOX 320 CARLISLE PA 17013 If you or your employee/obli§or have any questions, contact WAGE ATI-ACHMENT UNIT by telephone at (717) 240-6225 by FAX at ~..1.;~ or by Internet @ or Page 2 of 2 OMB No,: 0970-0154 Form EN-028 Service Type M Worker ID $IATT ADDENDUM _Summary of Cases on Mtachment Defendant/Obligor: WILLIAMS, GORDON S. PACSES Case Number 924103734 .Plaintiff Name / ADELAIDA C. WILLIAMS Docket Attachment Amount 01-1617 CIVIL $ 1,100.00 Child(ren)'s Name(s): DOB PACSES C~s~ Number Pla ntiff Name Docket _Attachment Amount $ o.oo Child(ren)'s Name(s): DOB I--IIf 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 NamP _Docket Attachment Amount $ o.oo Child{ren)'s Name(s): DOg identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number .Plaintiff Name Docket Attachment Amount $ o.oo Child(ren)'s Name(s): DOg l--Jif checked, you are required to enroll the child(ren) identified above in any health nsurance coverage available through the emp oyee's/obligor's employment. _PACSES Case Number Plaintiff Name Docket Attachment Amount $ o.o0 Child(ren)'s Name(s): DOB i-Jif checked you are required to enroll the child(mn) identified above in any health nsurance coverage availabl through the emp oyee's/obligor's employment. '~ e PACSES Case Numbe._~r .Pla ntiff Name Docket _Attachment Amount $ o.oo Child(ren)'s Name(s): DOB [] Wchecked you are required to enroll the child(mn) identified above in any health insurance coverage available through the employee's/obligor's employment. ~ l-Jif checked, you are required to enroll the child(mn) identified above [n any health nsurance coverage available through the employee's/obligor's employment. ~ Service Type M Addendum OMB NO.: 0970.0 ? 54 Form EN-028 Worker ID $IATT In the Court of Common Pleas of CUM~ERL~rO County, Pennsylvania DOMESTIC RELATIONS SECTION Plaimiff vs. Defendant To the Clerk of Courts/Prothonotary: Date Attorney ID Number Service Type Form OE-516 Worker ID In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION Plaintiff vs. Defendant ) Docket Number ) ) PACSES Case Number ) ) Other State ID Number To the Clerk of Courts/Prothonotary: Attorney ID Number fl~ l -Ol Date Service Type Form OE-516 Worker ID In the Court of Common Pleas of Phone: (717) 240-6225 CUMBERLAND DOMESTIC RELATIONS SECTION 13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013 AUGUST 28, 2001 Plaintiff Name: ADELAIDA C. WILLIAMS Defendant Name: OOm~ON S. Docket Number: o~.-~6~.? PACSES Case Number: 924~o373 Other State ID Number: Please note: All eorrespona~mce must include the PACSES Case Number. County, Pennsylvania Fax: (717) 240-6248 Income and Expense Statement THIS FORM MUST BE FILLED OUT (If ynu are self-employed or it' you are salaried by a bnsiness of which you are owner in whole or part, you must also fill out the Supplemental Income Statement which appears on page two of this income and expense statement.) INCOME STATEMENT OF Section I: Income and Insurance INCOME: Employer M. 5, ~Db'~'~t~.~FJ4~r;D~' Payroll No, Itemized Payroll Deductions: Federal Withholding Sta{e Income Tax j Cmdil Union Other Deductions (speci0') Gross Pay per Pay Period S ~ $ {") I Social Security S ~ Retirement [ S ;~ t Life Insurance Net Pay per Pay Period $ Pay Period (wkly., bi-wkly., etc.) [ $ d.~ [ Local Waee Tax S ~ ;~ ! Savings Bonds ~ ~ H:a'th Insurance OTHER (Fill in Appropriate Column) ! { { Ownership INCOME WEEK MONTIi i YEAR PROPERTY lnt:r:st $ {t~ S ~ S L) OWNED DESCRI~ION { VAL~ H W J . ~uity { ~. ,~ Savings Accounts Ren~ 0 ~ ~ Credit Union Royalt~s ~ { ~ ~ Stocks/Bonds ~n~ Accoun~ { ~ [ Gifts ~ { ~ ~ Real Ea~le Ummplo~nt ~ O Other Wo~n's TOTAL S ~ S O S 0 Service Type M Income and Expense Statement PACSES Case Number 924103734 INSURANCE COMPANY POLICY# H W C Blue Cross Medical Blue Shield ~ ~ ~ ~er ~ Heal~/Aceidem ~/A Di~bRi~y ~ome ~ * H =Husband; W=Wife; C=Child Section 1I: Supplemental Income Statement This lbrm is to be filled out by a person (1> who operates a business or practices a protbssion, or [] (2) who is a member of a partnership or joint venture, or [] (3) who is a shareholder in and is salaried by a closed corporation or similar entity. Attach tn this statement a copy of the followmg documents re ang o the parthenh p. oint venture, business, profession. ,A.]//,~, corporation or similar emily: (1) the most recent Federal Income Tax Return. and ~ (2) the most recent Prolh and Loas Statement ~:~/ OP'- Name of business: ~ ~ ~_~-- Address and telephone number: Annual income fi'om business: (1) How often is income received'? (2) Gross income per pay period: (3) Net income per pay period: (4) Spe¢itled deductkms, iPany: Page 2 of 3 Form IN-008 Service Type M Worker ID 21205 Income and Expense Statement PACSES C~e Number 924103734 Section III: Expenses Instruclions: Only show extraordinary expenses in this section unless you lilled out Section II on page two, The categories in BOLD FONT are especially impormm Ibr calculating cl:fild support· If you are requesting Spousal Suppor'dAPL or if you asser~ your case cannot be determined according to the guideline grids or lbrmula, this section must be f~lly completed. EXPENSES Maimenancc Utilities Electric ()il Telephone Employment Public Transport. Lunch Taxes Personal Property Accident Health Other Automobile Fuel Repairs Medical (Fill in Appropriate Column) WEEK MONTH YEAR s 12o~ s s/8,'0, oo s s 0 s 0 s ]Total ~EK Expem~: (Fill in Appropriate Column) EXPENSES (continued) WEEK MONTH YEAR Education Private School $ Parochial School Religious Cloming I s : s az , oC,s Food ~gD, 0 O Bar,er/ Hairdresser / Credit Pavments C red il Card / Ch~,ree Memberships Loans Credit Union S Miscellaneous Household Help S j S /~, O~ $ Child care Entertainment [ Pay TV I Vacation j I~gal l~s } 0 Charitable Contributions (~er C~d ~ony MONTH YEAR [ verity, that Ihe statements made in this [ncome and Expense Statement are true and correct, l understand that false statements herein are sul2iecl to file criminal penalties of 18 Pa. C.&/J 4,,~0a.~relatijeg to unswort? lhlsilication to authorities. %5'-'-g¢o/" / ' Date Page 3 of 3 Form IN-008 Service Type M Worker ID 21205 Employer: /~]/~tO~: *t ld M ~/tq,oLOyt~ ,/ .$/MC.~~- Ch~ck if add.ss supplied is: ( ) Employ~m ~cafion ( ) Payroll A~d~ss ( ) Employm~n~ and Payroll [~ations a~ ~e sam~. Please supply your Fede~l Employer Identification Number: ~_/~.~ ~,~ ~ R~: di~~ ~~ PACSES Case No.: SSN:fi37-~2' 2/3q DOB: r-/D-SB E~GS ~RT Furnish Eanfings information for the above-named employee for each pay period during the last six (6) months. It is preferred that you attach a photocopy of your records containing the earnings intbrmafion requested. Attach ' 9 a copy of the employee s most recent W-_ Form. Payroll/Id Number: Employee Address: Nature of Employment: /ohO- Date of Hire: /15/tz~- Last day worked/terminated: ,.5'~'~.T''' g6~ /~' 7 C',dl oack date: -/rrJ~'~a , uu-ome: "/"~'"~ Part-time: _40~/,4~- Gross hourly rate: $ Pay cycle: q,q.) Monthly ~///0 Semi-Monthly (.~,,~ Bi-Weekly 907,~Weekly Payroll Period Ending Date of Pay Gross Pay Deductions Federal Witlfitolding Social Security Local Wage Tax State htcome Tax Retiremem Savings Bonds Credit Uniun Lit~ lnsurauce Health Insurance Other (Specify) Other Net Pay Hours Wurked I verify that the statements nmde in this Earnings Report are true and correct, t understand that false statements herein are subject to the cfinfinal penalties of 18 Pa. C.S. §~90,4..r, elafigg to unswo.rn/fal~ificafion to authorities. Page 2 of 4 Form IN-015 Service Type Worker ID Employer: SSN: .5'3 7- d, Z- 2/ $qt PACSES Case No.: ~.2 q't'& ~-)3~0~c~.~ HEALTH INSURANCE COVERAGE REPORT This form must be completed and returned within ten (10) days. Failure to comply may result in issuance of a subpoena or other appropriate sanctions. Does the employer make medical, dental, eye care, prescription or other insurance coverage available to the employee? Yes P'~Pr No ~3///} Name the dependents covered under the employee's insurance, and indicate which types of coverage they have through your company. Full Name HOS~II~ SS~ ~zauon M~c~ D~t~ Eve non ~er ()( )( )( )( ()( )( )( )( ()( )( )( )( Provide the information indicated for each type of insurance which is available to the employee whether or not any of the above-named dependents are covered at this time: Insurance company (provider): 4/,4 Claims address: Group #: ~/~ Plan #: ?/~- Policy #: Effective coverage date: ,t~/~t Type of Coverage: Cost of coverage for dependents: Insurance company (provider): Claims address: Group #: Effective coverage date: Cost of coverage for dependents: Plan #: Policy #: Type of Coverage: Page 3 of 4 Form IN-015 Service Type Worker ID _]~~7~ACSES Case Number: ~:~/~/]~.~ ~///~yt~a Insurance company (provider): Claims address: Group #: /O-'f,4-- Plan #: Effective coverage date:/ Cost of coverage for dependents: T~ype of Coverage: / D/A Insurance company (provider): Claims address: Group #: Effective coverage date: Cost of coverage for dependents: Plan #: ]t2/~- Policy #: P~,,~- Type of Coverage: /o/,+ / / If the above-named dependents are not currently .covered by insurance, please state the earliest date coverage could be provided ~,//}. _ PLEASE PROVIDE FORMS NECESSARY TO ADD DEPENDENTS, AS THE EMPLOYEE MAY BE ORDERED TO PROVIDE COVERAGE FOR THEM. I verify dmz the statements made on this Health Insurance Coverage Information form 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. Zi(le Please return the completed documents to: DOMESTIC P. ELATIONS SECTION 13 N. HANOVER ST P.O. BOX 320 CARLISL~ PA 17013 Phone: (717) 240-6225 Fax: (717) 2404248 Page 4 of 4 Form IN-015 Service Type Worker ID UletlllRI ~' O BOX 178 . iMPORTANT| ~ G~NESEO, IL 61254 ~ur~N(s)~vo. ~ Yes I Nc) I Nms:C,t~xb~g or t~e. , ~ "Yes"wi not --- ~ A I ~ae~ur~or ~want S3to ~othis ~? ~ ' ' ' '- ' -. ~ Single .... Fllln~8 ~~one had m~) --~" WILLIES ~~) ~n ~,lm you as a ~eper,~ent on ~m or h,~ tax ~ ~omp~ murn.~=ox~ .......... , , , ~ 1. ; ; ; ~ ~ 1~ ~ ~ move , 7 Inco~ 23 Adjusted 24 Gro~ Income 25 2~ Wages, salarY's, bps, otc At. ch Form(s) W- 2 7 TaxabJe interest ,ad~c,h Scheduio R if ~ uir~:l ..... · Taz. exempt Interel& DO NOTIncJuae on line 8~ Ordinary dividends. Attac~ S¢~ed ute B if red uirea ...... lg0 i Taxable refunds, credits, or off~te ofs~te an(~ local income taxes (see page 21 ) .Nimony mc~Wed .............. 12 BuImell income or (inu). A~tach Schedule C arC.- EZ 13 Cai~ital gain or (io~a), At~cn Schedule D . Other gains or (Io~). Attach Form 4797 ......... 14 Total IRA c[d~J~ utJons I l~a b Taxable amnt . Totelpensionsandannu~iee [16~ I 3, 996 '1 bTaxableamnt . A~d the amounta in the far right column f~r tines 7 through 21. This is your total Income IRAdeduction(seepage25) .... j 23 J Medical ~avings account deduction..Nt ac.h Form 8853 25 Moving expenles. Attach Form 39(33 ...... 26 One- half of self- employment tax. A~tach Sc~ed ule SE. 27 Keogh anc~ ~lf- employed SEP and SIMPLE plans. '~ P~ne~y o n early withal rawal o f saving s 30 AJimonypaio bReCipinnr$SSN ~' 31a Add Ime~ 23 through 31a ............... Subtract tine 32 from line 22. This b, you r ed~umed ~lroe.~ income 2,400' 18 20b ~2 (797.) 2,400. 1 603. 1,603. Form 1040 (1998 ,Form 1~10 (1098) Ta~. a~d ' Crladlt~ for M~ Ho~ of M~ ~g w~ow(m): M~ ~5~ Other Taxela 537-62-2134 ADELAID~ HALEN " 134 34)~aount from tM ~ (~djueted 9rosa in~ ........ b ~u am mar~ filing ~pamm~. ~d ~ur ~OU~c~em~ dad u ~ns o~' ~u am a dua~ ~s alma. ~ ~age 23 and ~e ........ n ~e lair ofyour i~m~d ~ed~ ~om S~ute ~ line 28, O1~ ~nd~rd 37 ~ If tine ~ ~ $93,4~ or ~, mu~ply $2,7~ by ~e to~l number of exemO~3ns ~aim. O on line ~. if line ~ is over S9=,~0, ~the wo~l on page ~ fettle amount t° emer . 3~ T~ Inc~e. Sub~a~ line ~ ~om line 37. If hne 38 · mo~e ~an ;~ne 37, enter - ~ , T~S. page~.Ch~,any~from aOFo~(s)8814 ~DF,°~4972 41 Cr~for~iMand~epen~ent~ree~s.~c~Form2441. ~12 i 42 C~A~r~ee~ort~ed~aD~.A~chSch~u~R . , Fern ~ c~ ~ Fo~ 1116 if r~uir~ ...... 47 ~h~. C~e~ ~m a ~ Fo~ 3~ b ~ Fo~ ~d ~1 ~mugfl 47 ..................... 51 ~e min~um~. ~ Fo~ 6251 .......... 52 ~l~cu~ and M~are t~ on bp in,me not r~o~e= to em;Io~er..~a~ Fo~ T~ on I~. other ~nt plane, an~ M~.~acn Fo~ 5329 ~t requ;:~ . ~van~ earn~ inco~ ~ pa~en;s f~m Fo~(s) W- 2 .... Payments FormsW- 2 and W- 2G onpagel. ~o~ I~R if~w~ w~. Refund Have it Se~ g. age 37 and fllhn Mb, Amount You ~e Sign Here 56 67 60 61 62 63 65 · d 68 Addlines49through55. Thisieyourtotaltax , , , Federal income tax withheld from Forms W- 2 anti 1099 _57_ 1998 esUmated tax paymems& amount applied from 1997 ret~,m 58 Ea'-ned income credit. Attach $ch EIC if you have a q u alifyin9 ~,,~ and ~/pe P 59a Add ibonal ct1 iici tax creclit. AtTach Form 8812 ..... 60 Amount pa~ with Form 486~ (reQuest for extension) .... Exoess social security and RRTA tax withheld (see p age 431 Otherpay~ents. Check,ff~om ,~Form2439 b~Form,136 AdO tines 5T through 63. These are your total payments ...... .~ount of line 65 you want REFUNDED TO YOU RouUng number/ "1. c Type [-~ Checking ~-I Savings Account numOer[ J Amt. of line 65 you want APPUED TO 1999 ESTIMATED TAX If line 56 is more than line 64. subtract line 64 from line 56. This is the AMOLJNT YOU OWE. Keep a Copy of~is return for your Plaid Preparer'-, For cletaiks on now to pay, see page 38 ............ fi9 Esdmatedtaxpenalt':/.AlsoincJuaeonl~ne68 , , , , , 1 69 I Date Your occupation I lk Your S~gnature $ ELF Date l) Spouse's signature. If a joint return. BOTH must sign. Pmpere~e ~ ~nature ~ Date Check if 3./26/99 self- emp~oyee ~ Use Only K~ Rrm'sname(eryours k H AND R BLOCK if~* employed ) and addr~ DAVEN~>ORT, IA parle 2 1,603: 3,550. (1,947.) 2,700. 0. 0. 65 : O. )* 66a Daytime telephone number optional) Preparer s ~oc~J security no. 484-42-0265 EIN 42-095].072 " ZIP cote 52807-000u Fo,m 1040 (1998) t040 (11191) FO1040- 2V 1.24 Profit or Loss From ess l OMBNo. 1545-0074 (sot· I 1998 par~e mhlpl, joint ventU/~l, etc., m~t file F~ 101~ or Form 10~ B. 'SCHEDULE C =(Form 1,340) NMTle of proprietor 537--62-2134 ~DEL~IDA C i, 561210 sERVICE : INSTRUCTION HIS N HER BEAUTY CLINIC E Bu~n~d~ P O BOX 178 G.. o ~~usin~ d udn ~ Income 4 ~of ~oda~ (~ I~e42 on 9~e2) ................... g Gn~ prollt. Sui~tract ina 4 from line 3 .................... ' fuel tex c ·<tit or refuncl (see page C 3) G Ot~e¢ lac=me, including Federal and ~tate gasoline or r - . ...... r home onl, on iine 30. 41r403. 41.403. 41r403. 41,403. 28 Total e~q~en~ee befom expen~es forbusiness use ofhome. Add lines 8 through 27 in c°iumns ~ ~ 2B 8 AclverflM~g ....... 8 3! 034 19 per, sion anti profit- s~aring plans , ~(~p~e~) . 9 a Vehicles, ma,~ine~,and~u[pment 20a b Other business p~pe~ 20b 1 6 F 5 5 3 (~p~e ~ 3) ...... t0 21 ~paim and ma~tenan~ . 11 Co~nsand~ 11 516. ~ SuDolws(nol:in~u~nPa~lll} ~ ~ 6(007 12 ~p~on ....... 12 ~ 23 T~es and I~n~ 13 ~n ~d ~n 179 a Travel .........~ 1,322 ~ ~u~n (not ~ud~ I m ~ III) (~ page C- 4) . 13 b Meals and 14 ~p~ be~ pr~s te~ainmem (o~ffi~ on ~ne 19) .... 14 c ~r ~%of 15 In~ (offi~an h~) 1~ I f 400., llne2~ ~bje~ 2S 2 , 134 I~ L~ai and ~ro~nal 26 Wages (le~ em~lo~t cr~s) . 26 7,400 ~ ....... 17 650. 2~ O~erexpen=es(~om 18 ~ t8 p~e2) , , ~ ~, 3,184 (797.) (797.) 32a ~ A~linvestment is at risk. 32b[~ Some investment is not at risk. Tent·dye p milt (IoM). Subtract line 28 from line 7 .......... ~xpen~ for D usine~s u~e of your home. Attach FO/Tn B82~ .... 31 Net profit or {lo41). Subtract line 30 from line 29. · If a profit, e~tsr on Form 104~. Ilne't2. end ALSO on Schedule SE, line 2 (statutorY employe~s, see page C- $). Estates and trusts, enter on Form 1041, Jine 3. · If a loss. you MUSTgo on to llne 32. 32 If you have · tou, check the box that d e~G"ib es your investment in this activity (~ page C- 6). · If you checked 32a. enter the loss on Fon~ IB40, line 12, and ALSO on Scheclule SE, line 2 ($t~utory employees, see page C- 6). Estates and trusts, enter on Foam 1041. line 3 · If you check, ed 32b. you MUST attac~ Form ~1 ~. KBA For Papa rwork Reduction Act Notice, see Form 1040 Instructions. Schedule C (Fort?11040) t99, ~och C- 1040 (_1 ~gg) F[X~- lVl.g SChed uW C (Fon'a 1040) 199~ Xi' ~TD~ C HALEN 537-62-2134 P~ge2 34 ysms them any change ~ detsrmining q uan~ities, corns, or velu~ions ~etwaen opening and cJosing inventory? If ,'yes,' atmc~ expl~naUon .......................... E~Y. [~No 35 Inventory at b~inning of year. If different from last year's ciosing inventory, atmc~ explanation .... 31 Purc~ll~ ~ COlt of itsms withdr'awn for personal u~ ............... 37 CoZ of hM)or. Do not include.ny amounts paid to yourself ................ 3~ M~tm~M and supptJei .......................... 40 Agld ines 35 through 39 ........................ 4"[ Inventory at end of y~er ....................... 42 Sut)tract line41 fTom line 40. EDter the relult here en(t on Pa o 1. line4 Information on Your Vehicle. Comptetethispart ON/Y~fyou arec~aiming carort~ck expenses on line 10 anti are not required to file Form 4562 for this P uStness. See the ins~'uctio ns ~0r line 13 on p age C-4to find out If )~ou PHONE 3,184. 4~ To~l ,.G~, e~_p.i--,~i. Enter hem ancl on e 1,line27 3,184. KBA Schedule C (Form 1040) · t998 Form IL- 040 ~ome TaxR turn Strip '~ (~) pflntort~peyourpersonelL'lformationbelow. Iffllingjointty, besureyour (~) Che~thel=oxt~etimienthles Coral~let~ Social Secunt~ numbers ara in ~e order t~ey appear on your federal return the filing statue ttlet you ct~ec~ked on your federal your taxpayer 53'/-62-2].34 344- 40--04-/'1 return. Ctieck only one box. Mm'hod fi#rig join~ ~ O BOZ 3.78 G~.~,Z s ~.o (C~ Che~k the t~ox if at least two. thirds of your total fad oral g rou income came from farming · A (~ WlreanynfyourwegeleernedinW~conl~nw~ileanllllooisrestdentduring19987 r-]Yes ~No T IfYes. w~ ~e W'~consin wages you rec~ved T A St~p 2 I Wi.~yourfedemiadjus~edgrossincomefl'omeitheryourU.S, 1040, Line33; I 603 C 1 , H Figure your U.S. 104QA. Line18;U.$.1040EZ, Line4;orTeleFiiewomsl~eet, L~neH. A Irlcom~ 2 WYiteyourf~dera[lytax. exemptinterestanddiviclendlncomeh'oma'ither 2 your U.S. 1040 or 1040A, Lthe Bb. C 3 ~Ah, iteanyotfleradditlonatoyourincomethataretaxabieinillthois. 5~ethe O 3 p instructions for de[ails. Specify your additions. Y 4 Add Lines 1 througt~ 3. This isyour income. 4 O F St~p 3 5 WrJteyourf~cierelh/taxeti Soc~aISecurityand feclerallytaxed W Figure your mtirenlentincomefi'om eitheryourU.S. 1040or 104QA. 5 2, base }llCOm~ 6 WriteanyactNe-du~militarypayyoueamedifyou~cJuded W this pay th {Jne 1. fi 2 7 Write your Illinois Income Tax refund if you included this refund on O 7 Attach c~ple~ U.S. 1040, Line 10. If you & ofa~yrlqulrld 6 Write the U.S. govemmentobligetionsandU.S, agency income I I~iser'&l or Illlno$ f?om e~ther your U.S. 1040, Scheduie B, or U.S. 1040A. Scrod u~e 1. 8 9 Icheduiel, and our Publ~'-,ation 101 for<retails. $~eci~'yyour subtractions. Do O 11 $ubtractLinel0fl'omLine4. Thisisyourbeseincome. 11 R M St~p 4 12 Complete t~e caloulat~on below to figure your [llthois exemption aBowence. S Figure your · ~/ritethe numberof humI~rlden~tiriadlnthe exemption your fecleral return, on eomeone alle'e return. · ,o..¢. [X-] + 1 X S1,300 I,, · 1,30,0, older blind older blind Add Lines a and b. Th= is your tot~lexemption allowance. ¶2 3. / 3 0 0, St~p 5 Reeidentaonly- nonreeiden~ and pan. yearmeident, s,$klpStep$.=ndgotoSteb6- 13 Subtract Line 12 f~om Line 11. Th~s is your net income. Figure your w~te the amount here end on Line 15. net income ~.~'-~-- ~., skip step 6 ami ~o to ste~ 7. ~DBZ~'r DA C · ;stop $ . Nonresidents · part. year residents HALZN Non~dent~ _,a pa~- year n~ktente only - meident~, skip Step 6 a.... do to St~ ?. t4 Chac~thePoxthetsppiisstoyoududng 1998. L.~ Nonresident Complet~ Sc~ed uie NR, and write your Illinois income from Step 5, [Jne 45. Attech· cof3y of your comp[atari Schaciule NR. 14 Step 7 t6 Figure you tax 16 Step 8 Figure your 17 payments and credits 19 Attach your W- 2~to page 1. 20 Altac~ any required Wule~ ~nd other .;~.~' 2t Step 9 2J Figure your ove~ayment or your tax due 24 Step 10 Figure your penalty Step 11 26 Figure your donations ~y donation will redum Your refun~ or ncneaas the 27 ~ ~unt ~u ~e. ~ S~p 12 :~ F~um your refund or ~e ~ amount you O~ 3t Re~enta, write your net income from Line 13. Reaident~, muit~oly Line 15 by 3% (.03), and wrRe the result on Line 16. This is your tax. Sched ute NR. Step 5, Line 51. 537-62-2134 ['~ Peri- Yoar reNdent 16 303 Write the ~3tel amount of Illinois In come Tax t~at was withheld from your pay as ~hown on your W- 2 fon'na, generally Box 18. Wdte any estimated payments you made w~h Forms IL- 1040- ES and IL- 505- L Include any o'edJt from your 1997 ovwpayment. If you palo income tax to anothe~ state, complete III[nots Schedule CR. Wrfte the amount from Sc~e0ule CR, Line 8. If you pax:l II~in bis P~o~3 arty Tax, complete the Homeowner a Proper[~ Tax Credit VVorl~heet in the ina[mc[lone, and wdte the amount fram Line3 · and the amount fl'om Line 8, If you r~mpist~d Schedule 1299- C, wnte the amount from Section IL Part V~tl, Line 41. Acid LJnas 17 through 21. This is your total payments and credits. 17 18 19 . · 20 21 0 ff L~ne 22 is greater than Line 16, suPtract Line 16 from Line 22. This is your overT~aymenL If Line 16 is greater than Line 22, subtract Line 22 from Line 16. This is your~ 23 Wdte your penaW amount from Form iL- 2210, Step 3, Line 18. Check the box ~f you compl®ted Form IL- 2210, Step 5, or if you c~ecked the box on Form IL- 2210, Step I. Line 4. 25 If you wi~h to donate to one or more of the following voluntary contribution funds, write the amount Wltdli~ Preservation a Homeless Assistence d Child ~buse Prevention b Breast Cancer Reasarch AIz~eimei~s R~asar ch AO0 t ine~athreugh e. Thisisyour totalvolunta~ycontdbutJons. 26 If You wish to donate to your school d is[rid[, complete the worksheet in the instructions, end write the amount from Line 4 27 A~d [.Jnas 25 through 27. This is your total penait~ and donaUons 26 29 31 0 If you have an overpayment on line 23 and this amount is greater than Line 26, subtract Line 26 from Line 23. Wdte the amount of Line 29 that you want to be applied to your 1999 estimated tax. Subtract Line 30 from Line 29. Th~s is your refund. 3O Step 13 Sign and date your return 32 If you have tax 0ua on Line 24, add Lines 24 and 28. o~ If you have, an ove~ayment on Line 23 and this amount is less than Line 28, subtract Line 23 from Line 28. This is the amount you owe. 32 Under pen aities of perjury. I state that J have examined this return and. to the beat of my knowle~§e, it is true. correct, and complete. (309) 944-5370 9 Your ~gnature Date Daytime phone number Spouse's signature H AND R BLOCK 01/26/99 42-0951072 (319) 326-3539 Paid prepare~'s S~gnature Date Preparer's FEIN or $SN Preparer's phone number Mall ttti~ return to: Illinois Department of Revenue, Springfield. IL 62719- 0001 ~L ' 10'~0 ~ge 2 ~1- ~2/SSI AP DR ME ZZ SE WA P.X NS DC ID FO~ 1040 (1~1~) [L1040- 2V 1 13 Date IA 1040 Iowa Individual Income Tax Long For" rfl~allg~arbaglnning 1998est. ,,~ing E] Checklfflmt-tJme Iowaflrer. STE~ 1: Place ~'our label below or flit in the b~anks If ¥ou do not have i Mbel. Last name You r flr~ namel miciclle initial Social S~curfly Number · A. ~L~'N ADELAIDA C 537-62-2134 Spouse's ~t name Spouse'sfir~t name/micldleinitlal I SoclalSecur~Numbe,r B, Current maili~g address (number and s~ree~ apartment, lot or suite number) or PO Box P O BOX 1'/8 -- City, Stare, ZJP GENESEO *fL 61254 name, if apg licab lo, and your ad`"resa the same as on last FOR OFFICE USE ONLY Your Occupation SELF Spouse's Occupation Residence on 1 STEP 2 Filing Status: Mark one box only. -- ~, Yea ~ No CountyNo. · Sch. Di~tNo. · ~l Single: VVere~oucJaime`"esadependentonanotherperson'slowarsturn?~ Ye~ ~ NO& 00 0000 ~}J ~ ~ng ~y on ~ ~,; ~ return. SDOU~ uM ~lumn B. ~ I ~ ' - ~n~ WILLIES SSN 344-40-0477 ~ in~me:$ 6]~ ~"'=~7~%~wM~(er)w~%F'o~t~i~' ~ Na~: SSN: · I x $ 40 = $ 4u a-- F~monal Credit: Enter I or Enter 2 If filing joint or head of houcenold ~eYO~J.~F~(u.: E~teflforeechspousewhois65oroJderand/orlforeachspou!mwhoisblind .· 0 x $ 20 = $ STEP 3 E,xemp(Jon~ n; mn y Dependent.:Esr·r1 foreecndependent ............................ & 0 x $ 40 - $ '---7. `". Emer fl~ re·nee st de~emJent~ ham: .... ' ~ ~ ~ x$ 4~ =$ ISPOUSE STEP 4 1. 2. Figure 3. your income 5. 7. 9. 10. 15. S~P S Fi~ ~J~' 19. s-- I~monatCmdlt: E~' 1 .......................................... · -- Ent~lifU~'olderand/orllfMInd .................................. · x $ 20 - $ Depen~lentl:Enrerlforeachdependen~ ............................. · x $ 40 · $ d. Ente~ first n ~.T,~ of depandents ham: ·.TOTAL S, A. You or Joint B. Spouse/Status 3 A. You or Joint Wag~, sales·s, tips, etc. 1. Alimony received ............................. 4. Bua/ne~s incoma/(ioss) from Federal Sch. C or C- EZ... 5. Capital gainl(Ioss) fi-om Federal Schedule O. See page 6 6. Otfler ga~ns/(Iosses) from Federal form 4797. See page 6 7. Taxed M IRA disa~ uf~ons ......... 8. Tax~ble pefl~ns and annuities. See page 6. g. R~nts, royalties, pa~nemhips, e~tares, etc. See p age 7.. 10. Farm income/(lesa) fi-om Federal Schedule F ...... 11. Unemployment compenestion ................... 12. Taxable Sccial Security benefits. See page 7 ......... 13. Ol~or income. See page 8 ...................... 14. B. Spouse/Status 3 GR.C~INCOME. ADDlinee I- 14 , ,, , ,. ................ ............... Payments to an iRA. KEOGH or SEP .............. 16. One- hetf of ·sit- employment tax 17. Health insurance`"ed uchon. See page 8 .......... 18. PenlEy on early wither r~wal of savrng$ 19. Altmony paid ............................... 20. Pension/retirement income exclusion. See page 9 ..... 21. · Iowa capital gains deduction. See page 9 ........... 23. · Other adjustments. See page 10 .................. 24. Total ad ju~nt~. ADO lines 16- 24 ............. L~ .%~.. !.~C.O.b'~ ~XE~'[PT T ON NET iNCOME. SUBTRACTIine 25 h'om line 15. See page 11 for Pos-~ie sxem0tion fr°m tax , , Fe~eralincome tax ref~n`" received in 1~8 ......... 27 * ,Soil. empIoymenV houcehotd employ/lien{ taxes ...... 28. · A~i`"ltk3n ~r Federal taxes. ADO lines 27 and 28 ............................. Total ADO lines 26 and 29 ................................................. Fad·mi tax withheld ........................... 31. · Fad·mi estimated tax psyrnents made in 1998 ....... 32. · Addlt~ona~Federalrexpai`" in 1998for 1997&prioryeers $3. · De~luct=n for Federaltaxes. ADD lines 31,32, an`" 33 ............................. 35. BALANCE SUBTRACTiine 34 fi-om line 30. Enter here an," on line 36, page 2 (797) 2(400 ~5. , 1.603 30. 2g. sTE~ 7 sTEP 8 Figure your and cor,~bu- tlor~ 537-62-2134 B. Spouse/Status 3 ,. You or Joint B. Spouse/Status $ A. You or Joint tComptete lingo 37- 4~ ONLY if you Iteml~. STEP 9 st. your 63. 65. 66, 67. 68. STEP 10 se. 70. your m~nd Ar AIDA C HALEN ~6. BALANCE From ~ta 1, line 35 ................................................... 36. 3~. iowa income tax ifincJuded in ~ne 37. ......... 38. 36, BALANCE. SUBTRACT line 38 from line 37 39. 40. Otoor de<:luc~ons. See page 13 ............. 40. 41. Deduction. Che~ one box [-] Item[zed. A~ici lines 39 an= 40. ~.J Standard. See page 14 ..... 41 42. T.&~A~---EIHCO-M--[SUBTRACTline41fromline36 ,,, .............. r,' ''r42 44. Iowa lump- sum tax. 25%ofF,~erettaxfromform4972. 4.4. a 45. Iowamink-numtax. AttachlA6251.Seepage15 .,. 45. a 46. TotaJ tax, A~)D lines 45, 44 and 45 ....................... 46. 0 47. Total exemption cn~dit amount(s) fTom Step $, page 1.. 47. 48. iowaeemed incomecredit:6.S%ofFederalcredlt .. 48. · 49. Tu~on and t~lbook ;m~lit ..................... 49. a 50, Total credita. ADO lines 47, 4~ and 49 .......................... 50. · 0 51, BALANCE. SUBTRACT Tine 50 fl'om tine 46, If lees t~ an zero, enter zero ..................... 51. A 52. Credit for nonre~lan~or pa;l- year resident- See page 15. Attach IA126 anci Fe~erat return ...... 52. · 53. BAIJ~CF_ SUBTRACTiine 52 fi-om line 51 ...................... 53 0 54. O~er Iowa c,-edits. See page 15 ............................. 54, A 55. BALANCE. SUBTRACT#neS~ fromlJne53 ......................................... 55. - ,.0 56, Schooldist~ct surtax/EMS surtax. See page 16. Tables begin on page 26 56. · 0 57. TotaITa,v~ ADD lines 55 and 56 .............................. 57. A 0 58. Totsltsx before contrlbutiona, ADDCoiumnaA and Ban line 57 anti eflter here ............................ 58, 0 59, Con~utions. Seepage 16 Contn~utionswillreduceyour refunci ora<id/othe an~ount you owe, Amounts rnus~bein wholedoJlars. F~h,'V~lcllh~ 59a: · State Fair 59b: · Domestic A~buse 59c; a, ADD Enter total ....... 59. 0 -- -- 60. 0 TOTAL TAXAND CONTRIBUTIONS. ADD Une~ 58 and 59 , Iowa income t~x w~lhelcl from ~ox 18 of your VV- 2(s).. 61. Esthete anti voucher payments made for tax year 1998 62. Out. of- state tax ~edit..Ntach IA 130 ............ 63. Motor vehicle fuel tax credit. ,Ntsch !A 4136 ........ 64. Child and depencient care credit. See page 17 ...... 65. O~er re~rv~a~is cmdita. See page 17 ............. 66. TOTAL ADD lines 61 - 66 ...................... 67. .......... i':,o .... 120 STEP 11 POUT1CAL CHECKOFF. See p age 18. This checkoff close not increase the amount of tax you owe or decrease your refumJ. SPOUSE $1.50~o RepuPlkmn Pony [~ Sl.50 to Refom~ Part~ SI.S0to Democratic Pa~y $1.S0to Campaign Fund LJ TOTALCREDtTS. ADDcotumnsAand Ban rine67andentefhere ,, ,,,, ............ ........... 68. 120 if ~Jne 68 is mo re th an [in e 60, SUBTRACT line 60 from line 68. This is the amount you over~ aid 69. · 1 2 0 70. 12~) Amount of line 69 to Pe REFUNDED to you ..................................................... 72. If line 68 i~ tess than line 60, SUBTRACTline 68 from line 60. Thi~ is the AMOUNT OF TAX YOU OWE .......... 72, · 0 73. penalty for unciorpaym®nt of astir,noted tax. From {A2210 or iA 2210F .................................... 73. · 74. Penaltyan¢ interest Seepage 18 74a. Penalty ,,, · 74b. Interes~ · ADDEntertotal 74. 0 75. TOTALAMOUNT DtJE. ADDlines72,7~and 74, an0 enterhere ........................ PAYTHiSAMOUNT75. · Make check i=~fable to: TREASURER, STATE OF IOWA. Attach ;~a~ment to p;a~ voucher IA 1040V- 1 g96. STEP 12 STEP 13 COW- CALF REFUND Attach IA 132. NEXT YEAR, I would like to re~.,eive: DO NOT use these amounts to increase your · YOURSELF (check one) · refuncl (line 69) or reduce tho amount you owe Sl.50to Republican F~ny ~ 0, a booklet with prepnnted I=hel (line 72). See page 16. $1.50 to Roform i~arty ~ 2. a postcard with a p reprintecl laDa~ only Spouse: $ $1.50 to Democratic Party (not available to electromc filers) · $1 50 to Campaign Fund El 1. neither a OooK!et nor a la~Pel You. $ 01/26/!99F~ SIGN H~E SION HERE Form 1040 (1998) IA1040- 2 DAVENPORT IA 52807 (309) 944-5370 (319) 326-3539 42-09S1072 MAIL TO: IOWA INCOME TAX P~OC ESSI NG DEPARTMENT OF REVENUE AND I:INANCE This return is due April 30,1999. HOOVER STATE OFFICE BUI LDI NG DES MOl NES, ICRNA 50319- 0120 949 260.4465 DEA:BT5248962 DATE. 07~3/01 ACTOS 461~C4 T~BLET NDC: 6476 .IN[~ 1-24 DR. GROSSMAN, MARSHALL . MD 949-559 1800 DT%(]O INT<{] TS WILl lAMS, ADEL AIDA YOUR PHARMACIST RECOMMENDS QTY: 30.00 RPH: DJH PAY: $ 26.00 949 25044~6 C~: DT~249962 OATE~ 08124/01 949-559 1800 WILLIAMS. ADELAIDA YOUR PHARMACIST RECOMMENDS 06785 2270{)O DAW: 0 DAYS: 030 REFILL 1 TIMI: WILLIAMS, ADEt'AIDA,~v,.~, ~ ,:*,* NDC: 93- ' '"°' pAlO ~q~E~ {~M PAY: ~ 15.00 949 260-44~6 OEA:Bl'~249~62 DATE~ 0BI24~1 WILLIAMS,, ADELAIOA YOUR pHARMACIST RECOMMENDS IIIIIIIIIIllllll PAY: 6.00 10/02/2001 0]: 06 0l ' 05766' 227000 hAW:0 D&¥S:0°~0 REFILL 1 TIM5 WILLIAMS. ADELAIDA RX Placed on Hold 949 250-4465 OEA:BT§~49962 949 559 1800 WILLIAMS. ADELAIDA 05765 227000 .... ,~ HOLD ~WtLLI~S, ADELAtOA ~49 ~59 ~800 ~TA~E I TABLET BY MOUTH ~TWI~E DAILY GLYBUflTDE 6MG T~B IbiS) QTY' ~0.~ ~x ~eR~ MARSHALL MD949 727 0744 DR. GRO~;SM&N, ' REFILL '1 TIME 06765 2270O2 DAW: 0 D~Y$: 090 REFILL 1 TIME WILLIAMS, ADELAIDA RX Placed on Hold 949 2~0-4486 WILLIAMS, ADELAIDA ~TAKE I TABLET BY M ~ONCE DAILY REFILL 1 TiME O5766 2270O3 DAW: 0 O&YS: 090 REFILL 1 TIME WlLLIAM$.-XI~ELAIDA RX Placed on Hold 9a~ 2~0~46~ DE^:~T5249962 949 659 1R00 WILl ',AMS, ADELAIDA ~ ,..,~. ~o.uc~'~,~ 949 06765 227003 ,~t,'~,, HOLD RX ~LLIAMS, ~D~LAtDA ~TAKE 1 TABLET BY MOUTH __TWICE DARY R~FILL 1 TIME 10/0~/2001 0~: 0F:, 0~ WILLIAMS. AD£LAIDA NDC' 64.764-~1l !-2,* DR. ~RO~MA#. MARSHALL · ~O. 949 250-4465 DEA:BT6249962 DATE:07/31~l I)l ~COIjNT<U P I E T % WILLIAMS, ADELAtDA YOUR pHARI~AACIST RECOMMENDS P~GE RPH: 'IIIIIIIIIIIIIii1111 06766 227003 DAW: O DAYS: 030 REFILL 1 TIME WILLIAMS. ADELAIDA OLUCOP#AGI ~i00MIB TABLET NDC: 00087- 5 DR, GROSS~RSHALL * MD. PAID pREIC~I~NI$ OM II~VINk c', Pall QTY: 60.00 RPH: DJH PAY: I 28.00 949 260~,486 DEA: BT5249962 DATE: 07125/01 949 559 1800 WILLIAMS. ADELAIDA YOUR PHARMACIST RECOMMENDS 111111111111 06766 227000 DAW:0 nAYS: 030 REFILL; T'ME WILLIAMS, ADELAIDA QLY~URIDE 'qlG TAB (MIC) NDC: 000931~'H~ 10 LL DR. GROSSMAN, MARSHA . MD. PAY: $ 15.00 949 2E0~465 DEA: 8TS249962 DATE: 07/25J01 ~J49 559 ~800 WILLIAMS, ADELAIDA YOUR PHARMACIST RECOMMENDS QTY: 60.00 RPH: DJH lllllillllllllll PAY: 5.00 10/02/2001 03:05 01 DISCUI INT <OUTL FI !~ PAGE 057~'5 212534 DAW:O 0AY$~ 030 NO REFILL5 LEF~ WILLIAMS. ADELAIDA 949 2504465 DEA:BT5249962 DATE:06127~l ~,,Y,?~RIDE JO TAll IMIC) NDC. 66953,.~,44-~0 DR, GROSSlu~,N, MARSHALL · MD. N/R R ',lAMS, ADELAIOA YOUR PHARMACIST RECOMMENDS QTY: 64.00 llllllllllllllJl PAY: ~ 5.00 05755 212~30 DAW: 0 DAYS: 034 REFILL 1 TIME WILLIAMS, ADELAIDA Z~.~TR~ IOM~ TABLET NDC: 00310-0~3l- 10 DR. (~ROSSMAN, MARSHALL MD 949 2&0-44~5 DEA:BT5249962 DATE:06127~1 949 559-1800 WILLIAMS, ADELAIDA YOUR PHARMACIST RECOMMENDS QTY: 34.00 RPH: OJH lJlllllllJJlll 05765 212530 DAW: 0 13A'1~: (~4 REFILL 1 TtMI: WILLIAMS, ADELAIDA ZESTRIL IOMG TABLET NDC: OQ3104H 3:J-10 DR. GROSSMAN, ~RSHALL . ~. PAY: $ 15.00 949 260-4486 DEA: r~T5249962 DATE: 07/31/01 949 559 1800 RPH: WILLIAMS, ,RDELAIDA YOUR PHARMACIST RECOMMENDS I lJllllllllllllll PAY: 15.00 05785 212529 WILLIAMS, ADELAIDA GLUCOPHA~ B00MG TABLET NDC: 00087'~0&0-05 DR. GROSSMAN, MARSHALL . MD. 949 250-4465 DCA: BT6249952 DATE: 05/24/01 949 559 1800 NIR R RPH: ZN1 Iltlllllllllllllll 08786 216104 DAW:0 DAYS: 030 REFILL 1 rIME WILLIAMS, ADELAIDA PAY: ~ 15.00 940 250-4485 DEA: BT5249962 DATE: 05124/01 949 559 1800 N/R R WILLIAMS, ADELAIDA YOUR PHARMACIST RFCOMM£NDS WILLIAMS. ADEI AIOA YOUR PHARMACIST RECOMMENDS PAGE QTY: 30.00 RPH: ZN1 08765 226367 DAW; 0 DAYS: 034 REFILL 4 TIMES WILLIAMS, ADELAIDA GLUCOPH~QE BOOMG TABLET NDC' DR. ~RO~MAN, MARSHALL . MD. PAID pt~SC~'TION$ GM PAY: $ 17.32 949 260-4466 DEA;BT5249962 DATE:0fl128~l 949 559 1800 NIR N WILLIAMS, ADELAIDA YOUR PHARMACIST RECOMMENDS GTY: 58.00 RPH: ZN1i PAY: t 15.00 ' 05765' 212534 WILLIAMS. A, DELAIDA 949 2604465 O~A:BT52499§2 QLYBURIDE 6)~O TAB (MIC} NDC: 56963 0~44-D0 DR. GROSSNUI~J, MARSHALL . MD. 949-559-1800 Wli [lAMS, ADELAIDA YOUR PHARMACIST RECOMMENDS P~GE QTY: 68.00 RPH: RLA Jllllllllllll 05765 211103 DAW: 0 DAYS: 030 REFILL 1 TIME WILLIAMS, ADELAIDA NORTRIPTYUNE HCL 2BMG CAF* NDC: 00093-~! 1-01 DR. CLEEREMANS, BRUCE B. IN. PAID P~EBCRIPTION$ OM PAY'. ~ 5.00 549 ~60.,4465 OEA: BT5249D62 DATE: 04/'15/01 WILLIAMS, ADELAIOA YOUR PHARMACIST RECOMMENDS QTY: 60.00 RPH: ZN1 PAY: $ 5.00 05765 216!04 ~AW: 0 I~Y~,i 030 REFILL 1 TIME WILLIAMS. ADELAIDA VIO)U( 25MG TABLET NDC: 00006-~11 D*.68 DR. CLEEREMANB, BRUCE B. IN. 949 260-4485 DBA: BT5249962 DATE: 04/15/01 949 559 1800 WILLIAMS, ADI~LAIDA YOUR PHARMACIST RECOMMENDS QTY: 30.00 RPH: ZN1 PAY: $ 17.32 05765'2133~b DAW: 0 DAYS 030 REFILL :3 TIMES WlLLIA~IDA DR. GRC~S[~RIIIARSHALL · MD. 949 25O 44~5 OEA~ST52~,~62 NtR N WIt[lAMS. AD~ LAIDA R:~comrnended OTC PrOduCtS: QTY: 30.00 RPH: DJH 1111111111111111IIII 05765 213361~ DAW: 0 DAYSt 030 REFILL 2 TIMES WILLIAMS, AriELAIDA ACTC)8 dl~dG T~A~LET NDC: 6476~l-24 DR. GROSS~N.~RSHALL . MD. PAiD ~l~ OM PAY: $ 25.00 ~1.9 260-Mel5 DEA: BT5249962 DATE: 04125/01 949 559-1800 WILLIAMS, ADEt AIDA YOUR PHARNIACIST RECOMMENDS flPH: lllllllllllllllll PAY: $ 26.00 06765 212129 DAW: 0 DAYS: 034 REFILL 1 TIME WtLLIAMS. ADELAIDA ~LUCOPHA(tl ~OM(~ TA~LIT NDC: ~87- 6 OR. GROSS~"S~ALL 949 260-4486 DEA: RT5249962 DATF: 04125/01 949-559 1800 WILLIAMS,, ADELAIDA YOUR pHARMACIST RECOMMENDS OTY; 68.00 RI~I: RLA PAY: ~ ' 15.00 ~0/02/2001 03:06 gl · 06765' 212534 DAW: 0 DAYS: 034 REFILL ~ TIME WILLIAMS, ADELAIDA 949 250-4466 DEA BT5249962 DATE: 03121101 GLYBUNDE $1d~ TAB {MI(:) ND(:: 66963-e~14-80 DR. GROSSMAM, MARSHALL . MD. WILL 1AMS, ADELAIDA Recommended OTC Producte: PAGI QTY: 68-00 RPH: DJH 05765 212529 DAW: 0 DAYS: 034 REFILL 1 TIME WILLIAMS, ADELAIDA GLUCOPHAGE ]~O~MGI TAIILET NDC: DR. GROSSMAN, MARSHALL . MO PAY: i 5.00 S4~ 25O-4465 DEA: 51'6249962 DATE: 03/21/0t 949 .559 WILLIAMS. ADELAIDA Recommended OTC Producte: OTY: ~lkO0 RPH: PAY: a 1B.O0 DEA: BT5249962 05766 212530 DATE: 03121/01 DAW: 0 DAYS: 034 REFILL 1 TIML WILLIAMS, ADELAIDA Z~iTRIL 10M~ TABLET NDC: 003104q&It~i~0RSHALL MD. DR. GROSSMAN, - WILLIAMS. ADELAIDA RecommeDded OTC Producte: QTY: 34.00 RPH: DJH PAY: t 15.00 06786 2260B0 DAW: 0 DAYS: 030 REFILL 1 TIME WILLIAMS, ,~;)ELAIDA 949 260-4446 NC)C: $~)R. G HALL MD. pAID PRE~,CRIPllaN8 OM 1800 WILLIAMS, ADELAIDA YOUR PHARMACIST RECOMMEND8 QTY: 30.00 RPH: DJH 06765 227000 WILLIAMS. ADELAIDA 91.yIURIDI MIG ?NI (MIC) NIX:: 00093-144-10 DR. GROSSNU~N, MARSHALL . MO. PAID pflE$l~qp111:)N8 GM PAY: I 28.00 949 260-440U DEA: BT6249962 DATE; 09/24/01 WI WILLIAM0. ADELAIDA YOUR PHARMACIST RECOMMEND8 SUNSCREEN QTY: 80.00 RPH: OJH IBIIIIIII 06786 2270O3 DAW: 0 D~YS: 030 REFILL I TIMIr WILLIAMS. ADELAIDA PA JD P~ESCR~ON8 GM PAY: I 6.00 048 2BO-4,40B DEA: BT5249962 DATF: 09124/01 949-5.~9-18oo WILLIAMS, ADELAIDA YOUR PHARMACIST RECOMMEND8 QTY: 111111111 PAY: ~ 16.00 05765 2161~4 DAW: 0 DAYS: 030 REFILL 1 TtMF WILUAMS, ADELAIDA VIOXX ~q;I T~IT DR. CLE~RE~, ~UCE 8- IN 949 250-4486 DEA: BT5249962 DATI=: 09/1 949 559 1800 DI!~C£IUNT<O TI ~ ~ WILLIAMS, ADELAIDA YOUR PHAR~fIACIST RECOMMEND8 Q'I~: RPH: DJM 10/02/2001 03:0B 81 'STE~EN K WILLIARS RD 1~3oo 'SAND CANYON AVE SUITE 506 IRVINE CA 92618 Return ser¥i~e Requested 12~44 33235 ILl,.,,I,l.ll,,,,,Ihh,lh.lhh,lh.,.I.II.,I,II.,,,,I,II AOELAIDA WlLLIARS 380 E YALE LOOP IRVINE CA g2614-7902 D I ~COL ]NT<01 ITL F~ ! ~ PAGF 1 1 ADELAIDA WILLIARS 819.819000045.t 07-07-01 1 3~,,. oo STEVEN K WILLIARS HD 163OO SAND CANYON AVE SUITE 506 IRVINE CA 92&18 02-15-01 02-15-01 05-22-01 15 I03&12700000081900004635800001140020 PLEASE DE[ACH AND RETURN TOP pORTIflN WITH PAYMENT ..... "AROUNT DOCTOR' CODE - D'I~SCRI PTION ~924425 CONSULT, OFC/OTHR OUPT;ROD CO 150.00 2311 INJ SINGLE SHOT LU/~B/SACRAL E 520.00 3501 UNITED HEALTHCARE Pt~T -$36.00 PLEASE CALL BET~£EN T~E HOURS O~ 9:00 AH TO ~:OO Billing questions? Call: 949/753-7421 P~ YOUR ACCOUNT IS PAST COLLECTION ACTIVITY, - TODAY! I 134.o0 OUEII TO AVOID FURTHER PLEASE HAIL PAYRENT IN FULL Tax Id 448646298 IRVIN[ CA 92&1B 94g/75~-7421 ' (81 B).508-0107 6450 Bellltlgharn Avenue, Suite C. No.th Hollywood, CA. 91606 1429 Personnl & Conpdential RETURN SFRVICE flEOUESTED #CCNgIIEKAO01471 # $06760 7 005 II,l,..,I,hlh,.,Ihh,lh,,Ihh,ll,,...hlh,lhih'"'hll WILLiAMS,GORDON 380 E Y~,LE LOOP IRVINE CA 92614 7902 The Collection Conne_ction September ] q, 2001 Accuunt #' 306'760 7 IHE COLLECTION CONNF£TiON 6450 BELLINGHAM AVFNU£, SUITE C NORTH HOLLYWOOD, CA 91e06 1429 Ihl ..... Ihll,,ll,,,,ll ..... Ihh,h,Mhh,hh,l,l,,,h,II ~ oeta~h Uppr Poffion And Re~urn With Payment Reference: Emergency Physicians Billing Account: 306760-7 Amount Due: $91.20 If yOU have any questions <:all (8181 508 0107 Our prewous demands for payment m full have been ~gnot,.d. Your failure to cooperate can ordV make matters worse If vou ~ntend to pa,/ this account, dc, ~t nowI "Protecl your Credit Rating' Visa, MasterCard, Dtscover. and Ameucar~ Express accept[ed (;all for details. This is a communication from a Debt Collector. This is a~n attempt to collec! a debt. information obtained will be used for that purpose. · (818) 508-0107 ' The Collection Connection An,/ '10/02/200~ 02: OB E1 D!~CLIL!N F</'! ~T! ! 7% ~,~Gf ~ '~ 9/6/200 ! PO BO:< 2~t B0 t'C:'---"~OLt3~aBt~$~ OHiO ~4:r~6-0t a0 PEIL~ON AND CONFID~IAL 571317 RETURN S~t'VICE REQUE~ED WILLI/I, MS, ADELAIDA C 380 E YALE LOOP IRVINI~ CA 92614-7902 Ih h,.l,l,lh,,,.Ihh',lh,,Ihh,lh.,.,hlh,hlh,,,,hll AMERISHIELD CORPORATION ICradRor: HIIII Ph~lcal Therapy Ret~,en©e No: WILADO00-1I Am~ant tRl~: ~9.29 SEND TO: Hills Physical 'Dlex apy 4330 Bartanca Pkwy., $'240 lrvine. CA 92604 Re: Hills Physical Therapy Phone: 949~'7-6558 Reference #: WILAD000-18 Amount Due: $829,29 AMERISH1ELD CORPORATION is a collection agency. This is an attempt to collect a debt. Any information obtained will be used for that purpose. Our client has asked us to contact you about the past due amount shown above Send your check or money order, payable to our client for the full amount due We have pre-addres~d the uppeT, tea~ off portton of this letter and have included a Teturn vnvelope tot your convenience When your obligation has been resolved, we will clear this record from our active collection ti[es. Unlesa you notify this office within t0 days afte~ receiving this notice tho1 you dispute the validity of this debt. or any po;lion thereof, this office will assume this debt is valid. If you notib! this office m writing within 30 days from receiving this notice that the debt. or an~, portion thereof, is disputed, this office wilt obtain verification of the debt or a copy of a judgment and mail you a copy of such judgment or verification. If you request in writing within 30 days after receiving this notice, this ottice will provide you with the name: and address al the original creditor, ii different from the current creditor Thank you. AMERISHIELD ' ' P O Box 26180 / Columbus, OH 43226 0180 OIC 1970 Central Financial Control PO BOX 14050 Orange, CA 92863 September 29, 2001 #BWNHDLV II1 II#IilI I INIlilHIIIII EIII HIII I#III Ili ~00177848431G0010~ ADELAIDA WILLIAMS 380 E YALE LOOP IRVINE, CA 92614-7902 ~DELAIDA WILLIAMS 006090195 DO177848~31 01 140 01 692.70 692.70 . O0 03/27/2001 Irvine Medical Center(PeAR) tDELAIDA WILLIAMS PAY NOW OR CALL 800)300-7192 714)431-7113 Para asistencia en sspa~ol, sirvase Ilamar al nOmero identificado. To pay by credit card, please complete this section EXPIRATION DATE MONTH YEAR [] VISA [] MASTERCARD ~ ~ []AMEX [] DISCOVER CARD NUMBER (ALL DIGITS PLEASE) Print cardholder's name: Cardhoide?s signature: Amount to Charge Ce~atral Financial Control Check here for change of address. [] Please note change of address on the reverse side. Pleass include your account number on your check or money order, payable to: Account Number ..... 0017784.8431 Responsible Party... ADELAIDA WILLIAMS Patient Name .......... ADELAIDA WILLIAMS Account Balance ..... 692.70 Payment Amount MECFR01 Please make sure the return address on the back of this form shows in the window of the envelope provided. 01 529 Unless you notify this office of your dispute within 30 days after receiving this notice, we will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice we will: obtain verification of the debt or obtain a copy of a judgment and mail you a copy of such judgment or verification. Upon receipt of your written request during this time period, we will provide you with verification and the name and address of the original creditor, if different from the current creditor. De no not,car e esta oficina su desacuerdo, dentro de 30 dias de haber recibido este aviso, asumiremos que esta deuda es vdlida. Si notOqca a esta oficina por escrito antes de los antedichos 30 dias, esta oficina: obtendrd el comprobante de la deuda y le env#ardt por correo una copia del mismo. ,~1 recibo de ~u peticidn escrita dentro de dicho plazo, ie proveeremas el comprobante y el hombre y direcci6n del acreedor original, si fuese distinto del acreedor actual. Central Financial Control PO BOX 14050 Orange, CA 92863 0910140 006090195 000069270 0 01 5)0 10/02/~001 03:0B Bi SA~A ANA TUSTIN RAD MED GROUP '~450 N TUSTIN AVE #'~32 SANTA AN'A, CA 92705 8641 FORV~ARDING SERVICE REQU£STIeD PHONE: 714 835 3709 TAX ID: 95-2316954 GORDON WILLIAMS 380 E YALE LOOP [RVINE, CA 92614-7902 D~!X}OLIN7 <OLJI LE] 5 PAGE 15 9t05/0~ i 27,60 ~ 96093801 _ PAGE: I I PAI~ H~RE $ I1,1,,,,I,I1,,,111,,,,I,1,1,,I,,11,,,I,,I,,,11,,11,,,I,1,,11,1 SANTA ANA-TUSTIN RAO MED GROUP 1450 N TuSTIN AVE //132 SANTA ANA, CA 92105,8641 DATE EXAM CODE 03129101 03/29/01 05/29101 973 05129/01 FOR SERVICE DAT! PS - PLACE (~F SERVICE I INPATIENT HOSP 3. DOCTORS OFFICE 2. OUTPATIENT HO~IP. 4. EMERGENCY ROOM STATEMENT SERVICE DESCRIPTION PREVIOUS BALANCE: NI CAROTID IMAGING CHEST 2 VIEWS 'ONTRACT PAYMENT ; 03/29101 03/29101 lllI IIIIIIIIII~IIElilII DIAGNOSIS AMOUNT ?85.9 ?66.50 OVER 80 DAYS OVER 90 DAYS CURRENT OVER 30 DAYS °° °° [ °° ,,o·.o IRVINE MEDICAL CENTER **'*'*''*''TAKE ACTION NOW****'***"*'*'* YOUR INS CARI~ER CAN NOT IDENTIFY YOU AS A MEMBER OF THEIR PLAN. PLEASE PAY BALANCE DUE ON THIS ACCOUNT IMMEDIATELY· ACCOUNT NUM~ 96093801 100.00 38.00 BALANCE DUE 27.60 DATE OF IURTH LAST PAYMENT 5/10/53 $/39/01 MPLOYER ~- GENERAL MOTORS PRIMARY INSURANCE ~ UNITED HEALTH CARE SECONDARY INSURANCE" ATTENDING PHYSICIAN m, STEIN, MARK G M.D. P.O. Box 8669 ' Calabasas,.CA 91372-8669 ADDRESS SERVICE REQUESTED Septembex 11, 2001 #BWNFTZF IIOWI0660961016~ FDS001/066096-1 / 108 - R02 ADELAIDA WILLIAMS 38O E YALtt LOOP IRVINE CA 92614 7902 Ihh.,,hhll.,,,Ihh,lh,,Ihh,ll ..... I,Ih,hlh,..hll GRANT & WEBER "A Professional Collection Coq)oratmn" (818)-871 7736 (800) 400- ! 240 For: SANTA ANA-TUSTIN RAD MED GRP Acct No.: FDS001/066096-1 / 108 Call: R. CHANCE Amount' $70 00 Interest: S4.15 T(:~al- $74 15 Ca'mt & Weber P O. BOX 8669 CAIa~,BASAS. CA 91372-8669 Ihh.,,dhdl,h,.h.hll,.h.lh.lh,hh..Ih,hh-I-II ~ Cut Or gald On Lira & P,s~m W~h Y~ Paltmmt ~< YOU HAVE APPARENTLY IGNORED OUR PREVIOUS NOTICES THE CLAIM IN QUESTION MAY BE ON ¥OU~k CREDIT RECORD FOR A NUMBER OF YEARS YOU SHOULD PAY 1N FULL NOW AND CLEAR YOUR CREDIT RECORD WITH THIS OFFICE. THIS IS AN ATTEMPT TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. ~dm~ [] VISA For the Amount of $ [] MASTERCARD DISCOVER [] CARTE BLANCE I ] DINERS CLUB If you choose to pay by credit clrd, fold on the line above and return entire letter Chant & Weber e26575 W. Agoma Road ~2alabasa$. CA 91302 e(818)-871-7736 Member of Experian (Formerly TRW Credit Data) Dewat H, Oumdhr M.D. lrss NudUK. CJ4~ 76~ IL IAfml~NlmdJ~t ~3(~J4~4 AddddB IWl~Wllmu b~m, CA ~lil4 Rmpoeslbb rmv &6~ ..... 10320 Prdmimld ~ Ibad~ad br (B)Adddda Jbim-Wlllbatn tntm: Jo I. 10~ ~ bp 2o, Idmw4~ l~,m Mmw ~0, t~ Idm~ ~. ISSO Ama. l~ imm ii, IS ArumS1, I~ Aq SI. im ~ PuidBy C3mk - ~lmk Tm I1 PuidB~ Oink - ~mk Ym nm0 cb~k ILimmd m A4mmm (-) m A4mmm(-) m A4mmm(-) - -,,¥tARK E. ANDERSON, NEUROSURGEON MrJMtrs/Ms ~f~~ 1. Make sure you are scheduled with the American Red Cross for your blood donation (800 696-1757). 2. On f~Z.~-~9? at /~,'~ a.m., you are scheduled with pre-admitting. You will complete your admission forms at this time. Once these are complete, you will be sent to the preop clinic for all lab work-up. *****'Private patients and work comp. patients:'r***** You are scheduled with D~r. Marshall Grossman ¢'or a history and physical on ~/~. _¢2.~,~/~¢._~'~,,¢¢ . The appointment card is enclosed. No food or drinks after midnight on 3 Surgery is scheduled for /~"~"~/ at ~/'~2:~' You must arrive at the hospital no later than if you should have any questions regarding this schedule, please contact me at the above number. Kate on MARSHALL K. GROSSMAN, J. FH _? RK E. ANDERSON, M,.D. N£UROSURGEON June 15, 2001 Bruce Cleeremans, M.D. 16300 Sand Canyon Avenue, Suite 608 Irvine, CA 92618 RE: WILLIAMS, ADELAIDA Dear Dr. Cleeremans: Adelaida Williams p~ to my office today in neurosurgical follow-up visit accompanied by her . The patient has undergone MRI of the cervical spine of June 7, 2001. The fi'n~ngs are somewhat surprising. There is a prominent central disc protrusion at C4-5 compromising the spinal cord. The patient has, in addition, advanced degenerative changes at C5-6. There are changes to a lesser exter, t at C3-4, The most striking finding is that of central spinal cord impingement at C4-5 and broad based disc bulge at C5-6. On the T1 image cuts,#5 of#10, thisis best seen. The patient relates the positionality of her complaint. She states that it is a functional impairment to her. As soon as she does repetitive neck motion or bending, she gets her arm complaint and has ongoing symptomatology. I have told her that I was looking for a nerve root compression at the C6-7 level as the patient has left 08 versus ulnar numbness and tingling, which is persistent. Of course, the patient has EMG evidence of mild slowing of the ulnar nerve across the elbow on the left. There simply is not a neurological compromise at C6-,7. The findings are consistent with a disc protrusion C4-5 and C5-6. I do not fee~ that the C3-4 disc protrusion is surgical. On clinical examination, she is unchanged. IMPRESSION: CERVICAL PAIN AND LEFT UPPER EXTREMITY COMPLAINT. POSITIVE EMG OF THE LEFT ULNAR NERVE AT THE LEVEL OF THE NOTCH. HNP C4-5 AND C5-6 CENTRAL WITH CERVICAL DEGENERATIVE DISEASE C3-4. RE: WILLIAMS, ADELAIDA June 15, 2001 - Page Two PLAN; I have advised the patient that in my opinion, she is a surgical candidate. I have described to her the risks, benefits and techniques inherent in the procedure of anterior cervical discectomy and fusion C4-5 and C5-6 with donor bone graft and anterior spinal instrumentation. With the use of anatomical models as well as radiographs, charts and surgical broch[~r~'s, I have advised the patient of the risks, benefits and techniques of anterior cervical disCectomy and fusion. I have described to the patient that this involves the risks inherent in general anesthetic and the probability of a sore throat from the breathing tube postoperatively. [ have described to the patient that this involves an incision on the anterior surface of the cervical spine which therefore leaves a visible pencil mark type scar. Subsequent to this surgical approach requires displacement of the breathing tube and esophagus, as welt as great vessels and nerves of the neck, This provides access to the cervical spine. The principles of microdissection are conducted in such a manner as to remove all accessible disc material, including the posterior ligament encapsulating the disc in such a manner as to decompress the nerve roots to the arm, as well as the spinaI cord. This requires the use of meticulous technique. Thereafter, a bone graft is utilized to replace the removed disc. I have described the alternative of further conservative manageme~:t including bed rest, immobilization and use of medication. Implicit in any surgical procedure, including this procedure, are the inherent risks which include, but are not limited to infection, blood clot or neurological injury. This irqcomplete list includes paralysis of the nerve to the vocal cord with subsequently hoarse voice and difficulty singing, injury to the great vessels of the neck with stroke or sudden blood loss, injury to the airway or chest breathing system, which would need further surgical attention. There is the chance of rupture of the esophagus with subsequent need for repeat procedure and chance of infection or serious life threatening complication. There is the chance of nonfusion, graft rejection or graft extrusion. The possibiliLv of acute airway compression exists, as well as the unavoidable risk of infection to the skin or wound or bone graft or spine itself, Infection of the covering around the spinal cord - meningitis - can occur. There is the chance of penetration of the dura or water filled sac with subsequent spinal leak and need for repeat surgical procedure, although this is considered remote. Upon review of the neurosurgicai professional literature, there exists a statistical incidence of 1 in 700 of nerve root injury resulting in monoplegia, paraplegia, triplegia, quadriple9ia, spinal cord injury or death. Statistically unpredictable events such as anesthetic reaction, adverse medical reaction, blood clot formation with embolism to the lung, or heart attack cannot be discounted and are threats felt to be real in any surgical hospitalization. RE: WILLIAMS, ADELAIDA June 15, 2001 - Page Three The chance of complication occurring is 2% for injury not resolving in 30 days; 3% for injury resolving in 30 days and 10% for chance of no resolution of symptomatology; i.e., chronic cervical pain or persistent arm pain. This includes the possibility of the need for repeat surgery for inaccessible or recurrent disorder and approximately 85% chance of resolution of arm and shoulder symptomatology and decrease of neck pain, although there is no complete cure for neck pain. Approximately 10% of the patients are not helped. This is believed to be related to scarring or permanent nerve injury having already occurred prior to the surgical procedure. This would not be benefitted by rep'eAt surgical procedure. There are rare instances when an additional posterior surgical procedure is required to further enlarge the canal for the nerve root. It is possible for a recurrent fragment to occur; additionally, it is possible for a nonfusion to occur. Persistent chronic spinal pain can result even with a good fusion from an associated musculoligamentous disorder. Therefore, one can see that no promises of good result or outcome can be verbally offered, tendered, intimated, written or assured, and none are given to this patient. I have discussed with the patient the necessity for obtaining blood on a stand-by basis as a requirement for operative intervention. Since more 131ood may be necessary in an emergency-for transfusioT~ than the patient can donate in advance without compromising their medical status at the time of surgery, Blood Bank blood is required. The risks of blood banking, including non-detectable viral illnesses, or unforeseeable, untoward reactions have been discussed, although, in my opinion, these are uncommon and the benefits of Blood Bank blood utilization exceed its risks dramatically. The patient has been informed that surgical measures to limit blood loss will be attended by the operative team and that the patient will only receive transfusion in the event of reasonable medical need if a greater than expected blood loss occurs. However, in the outstanding majority of cases, transfusion is not required. Risks including death and debility, liver disease, and prolonged chronic illness can occur as an inherent risk in blood transfusion and the patient is knowledgeable in layrhan's terms that risk stilll exists, as does the need for blood transfusion on an unforeseeable basis. lilac'crest bone graft may be required which additionally requires an incision resulting in pain, delayed wound healing, possibility of infection or blood clot as well as numbness and tingling in the skin area around the right lilac crest l:emporarily. This bone wilt be utilized for replacement of the resected cervical disc and immobilization of the interspace. Donor bone graft may be substituted. I have advised the patient that at one level, range of mol:ion of the cervical spine is not restricted; however, at two or more levels, restriction does occur. However, the patient is able to functionally accommodate these by movement at other levels and movement of the eyes. RE: WILLIAMS, ADELAIDA June 15, 2001 - Page Four Videotape instructional information from Ludann and Acromed and patient handout literature has been provided and the patient has had their questions answered. I have encouraged the patient to obtain a Physician's Desk Reference (PDR) for review of their medication and familiarization with associated risks as well as benefits and to have._av_ail,~ble for f[cture_ reference, when given prescription medication. The patient has been advised to predonate one unit of autologous blood with preparation of split products for use at the time of surgery to stop blee,rling and to undergo general physical examination by an internist. Variances in the videotape and handout information and the patient's individual case have been described. Risks of spinal instrumentation including breakage, displacement, neurological, vascular or visceral compromise requiring removal, replacement, or revision have been discussed. In my experience, the benefits of instrumentation, i.e. increased fusion rate and prevention of anterior graft extrusion, outweighs its risks. I have recommended that she predonate one unit of blood with preparation of split products and undergo internist admission history and physical and have her diabetes followed closely by Dr. Grossman during the course of her hospitalization at Irvine. I have told her that at a later date, she may require address to C3-4, however I do not feel that this is appropriate to address at this time. She states that she will consider the recommendation and contact my office regarding scheduling. I will keep you advised as the patient's care plan evolves. Once again, thank you for your neurosurgical consultation request. Yours truly, Mark E. Anderson, M.D. MEA:mak .SINE R~G HOSP MED CTR PAT!E~ ........ 6207607 WILLIAMS, ADELAIDA ME~ REC NUMBER 236026 FAXED TO PH~ ... A/~DERSON, MARK ORDERING PHY ... ANDeRSOn, MARK ORDER NUMBER ..- 0524948 pRIORITY ....... TODAY PERFORM ........ 6/07/01 13:06 RESULT DATE/TIME 6/09/01 13:31 LOCATION .. ~ SEX ....... F 048Y AGE ....... BIRTHDATE 5/10/53 MRI OF THE CERVICAL SPI~E - 6/7/01: HISTORY: Severe neck pain. Syraptoms of disc disease at C6-7. shoulder!and left upper extremity radiculopa=~. Left The examination was performed on GE sign& 1,5 Tesla magnet utilizing the following pulse sequences: 1. Sagittal Ti-weighted. 2. Sagit=al fast spin echo T2. 3. Axial TI-weigh=ed Gradient echo, FINDINGS: At C4-5 extends indents cord. =here Is a 4 mm posterior disc extrusion. This lesion above and below the level of the C4-5 annulus and slightly at the anterior surface of the cervical spinal cord. At C6-7 there ~s a i-~ mm posterior annulus bulge. The CT-T! and C2-3 discs are normal. No fractures or destructive bone lesions are visible. The cervical spinal cord is normal. (CONTi~UED) ,..vINE REG HOSP MED CTR PATIE1T~ ........ 6207807 WILLIAMS, ADELAIDA M~D REC~UMBER 236026 FAXED TO PHY · 4. AUDERSON, MARK O~ERING P~ .,' ~ERSON, ~K ORDER ~ER ... 0524948 SP ~RV W/O ~ $ PRIORI~ ....... TODAY PERFO~ ........ 6/07/01 REseT DATE/TI~ 6/09/01 13:31 LOCgTION -. ~A SEX ....... F AGE ....... 048Y BIRTHDATE 5/10/53 This patient has a relatively small central api. nal canal. This =he C4-5 disc ex=fUsion. At C5-6 =here is a mild right foraminal s=enos:~$ and the foramina at other levels are normal. IMPRESSION: 1. C4-5, 4 MM cL'NTRAL POSTERIOR DISC EXTRUSION IN A PATIL'NT wITH A CONGENITALLY SMALL SPINAL CA~AL AND AP DIAMETER OF ESTIMATED 9 MM. 2. C5-6, 3 MM POSTERIOR DISC PROTRUSION AND A MILD RIGPrT FORAMINAL STF~OSi$. 3. C~°A BROAD BASED ~ ~l~ POSTERIOR DISC PROTRUSION. A. C6-7, 1-2 MM POSTERIOR ANGUS ~ULGE. THE REMAINING CERVICAL SPINE MRI IS NORMAL. END OF REPORT *~ ADELAIDA C. WILLIAMS, : 1N THE COURT O,F COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA : DOMESTIC RELATIONS SECTION GORDON S. WILLIAMS, Defendant : PACSES NO. :1 INTERIM ORDER OF COURT AND NOW, this 3rd day of January, 2002, upon consideration of the Support Master's Report and Recommendation, a copy of which is attached hereto as Exhibit "A", it is ordered and decreed as follows: A. The Defendant, Gordon S. Williams, shall pay alimony pendente lite to the Plaintiff, Adelaida C. Williams, as follows: 1. During the period of August 9, 2001, through December 5, 2001, the sum of $892.00 per month. 2. During the period of December 6, 2001, through February 13, 2002, the sum of $1,647.00 per month. 3. Commencing February 14, 2002, the sum of $892.00 per month. B. The Defendant shall be given a credit towards outstanding arrearages of $1,464.00. C. The Defendant shall pay the sum of $50.00 per month towards outstanding arrearages. D. All administrative provisions of our prior order of court dated October 16, 2001, shall remain in full force and effect. The parties are hereby advised that they may file written exceptions to the Support Master's Report and Recommendation within ten (10) days of this order. Exceptions shall conform with the requirements of Rule i[910.12(f), Pa. R.C.P. If written exceptions are filed by any party, the other party may file exceptions within ten (10) days of the date of service of the original exceptions. If no exceptions are filed within ten (10) days of this interim order, this order shall then constitute a final order. Edgar B. Bayley, J. CC: Adelaida C. Williams Gordon S. Williams James D. Flower, Jr., Esquire Melissa L. Van Eck, Esquire DRO ADELAIDA C. WILLIAMS, Plaintiff V. GORDON S. WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : DOMESTIC RELATIONS SECTION : PACSES NO. 924103734 : NO. 01-1617 CIVIL TERM SUPPORT MASTER'S REPORT AND RECOMMENDATION Following a hearing held before the undersigned Support Master on December 21, 2001, the following report and recommendation are made: FINDINGS OF FACT 1. The Plaintiff is Adelaida C. Williams, who res[des at 380 East Yale Loop, Irvine, California. 2. The Defendant is Gordon S. Williams, who resides at 9145 Joyce Lane, Hummelstown, Pennsylvania. 3. The parties were married on June 27, 1998. 4. At the time of the marriage, the Defendant resided in the State of New York. 5. At the time ofthe marriage, the Plaintiff operated a business in the State of Illinois, which she continued to operate after the marriage. 6. The Plaintiff is a licensed cosmetologist and al[so performs massage therapy. 7. The Plaintiff was involved in an automobile accident in July, 1997, and suffered a serious neck injury. 8. In May, 1999, the Defendant was transferred to Pennsylvania. 9. The parties resided together in the marital residence at 5C Richland Lane, Camp Hill, Pennsylvania, from May, 1999 through December, 1999. 10. Because of an incident involving a physical assault upon her by the Defendant, the Plaintiffleft the marital residence in December, 1999 and moved to a women's shelter. 11. In January, 2000 the Plaintiff moved to Arizona. 12. While in Arizona the Plaintiff was hired by Richard Baron as a district manager to oversee the operation of several stores which he owned. Exhibit "A" 13. The Plaintiff's annual salary as district manager was $40,000.00. 14. The Plaintiff left the position as district manager after one month because, in her opinion, she lacked the physical stamina to perform the duties of the position. 15. In December, 2000 the Plaintiff moved to a home owned by Richard Baron in California in which his elderly mother also resided. 16. The Plaintiff performed services as a caretaker for Mr. Baron's elderly mother in exchange for room and board. 17. Rent and utilities for a one-bedroom apartment would cost the Plaintiff approximately $1,425.00 per month should she leave the Baron home. 18. On December 6, 2001, the Plaintiffunderwent surgery for a cervical discectomy and fusion. She will be disabled for eight to twelve weeks as a result of the surgery. 19. The Plaintiff receives a monthly annuity of $438.75 as the result of the death of a former husband. 20. In addition to the medical problems involving her neck, the Plaintiff also suffers from diabetes. 21. The Plaintiff has not filed a federal income tax: return since 1998, the last year in which she had income from her self-employment. 22. The Defendant is employed as a sales representative for General Motors. 23. The Defendant has a gross monthly income of $6,161.15. 24. The Defendant pays $60.67 for medical insurance on himself and the Plaintiff. 25. When the Plaintiff left Pennsylvania in January, 2000, she took a 1996 Oldsmobile Bravada titled in the Defendant's name for which he was making loan payments of $488.00 per month. 26. The Bravada was used primarily by the Plaintiff's son until late October, 2001, when it was returned to the Defendant. 27. The Plaintiff filed her petition for alimony pendente lite on August 9, 2001. DISCUSSION Before a spouse is entitled to an award of alimony pendente lite, she must show entitlement. Clouse v. Clouse, 50 Cumb. L. J. 167 (2001) The party claiming alimony pendente lite must show that the award is required to adequately preserve his or her rights in the divorce litigation. Sutliffv. Sutliff, 326 Pa. Super. 496, 474 A.2d. 599 (1984), overruled on other grounds Rosen v. Rosen, 520 Pa. 19, 549 A.2d. 561 (1988) Factors to be considered in determining entitlement to an award of alimony pendente lite are the ability of the other party to pay, the separate estate and income of the party petitioning for the award, and the character, situation, and surroundings of the parties. Litmans v. Litmans, 449 Pa. Super. 209, 673 A.2d. 382 (1996) If an award of alimony pendente lite is warranted, the support guidelines as set forth in the Pennsylvania Rules of Civil Procedure are utilized to calculate the amount of the award in a similar manner as spousal support. Little v. Little, 47 Cumberland L.J. 131 (1998) Under the facts of the present case, the Plaintiff is ,entitled to an award of alimony pendente lite. Her medical condition clearly prevents her fi-om earning a sufficient amount to support herself and preserve her rights in the divorce litigation. Consequently, the support obligation of the Defendant is to be calculated pursuant to the support guidelines as contained in the Rules. The Plaintiff obtained employment after the separation in December, 2000, where she had an annual salary of $40,000.00. The Defendant contends that this income should be utilized in determining his support obligation. However, the Plaintiffargues that because of her medical condition as a result of the auto accident and injury to her neck, she was unable to fulfill the responsibilities of that employment. Plaintiff's Exhibit 5 and 6, the report from the neurosurgeon and the IVlRI results respectively, both of which predate the filing of the petition for alimony pendente lite, support the Plaintiff' s position that the $40,000.00 salary should not be utilized as her earning capacity. In determining a person's earning capacity, a Court cannot estimate what an individual might theoretically earn, but rather what that person could "realistically earn under the circumstances, considering his or her age, health, mental and physical condition and training." Goodman v. Goodman, 544 A.2d. 1033 (Pa. Super. 1988); Strawn vs. Strawn, 664 A.2d. 129 (Pa. Super. 1995) In computing the Defendant's support obligation, the Plaintiff's earning capacity will be the value of the in-kind compensation paid to her for services provided as a caretaker to Richard Baron's mother, determined to be $1,425.00 as shown on her Income and Expense Statement (Plaintiff's Exhibit No. 1), plus the monthly annuity of $438.75. This results in a gross monthly income of $1,863.75. Inasmuch as the Plaintiff has no tax liability for this income, this figure will also be utilized as her net monthly income. The parties stipulated that the Defendant's gross monthly income was $6,161.15 and that the Defendant paid a medical insurance premiurn of $60.67 per month for insurance covering himself and the Plaintiff. Utilizing the incomes as set forth above and making the adjustment for the health insurance premium paid by the Defendant, his obligation for alimony pendente lite is $892.00 per month as set forth on Exhibit A. The effective date of the order will be August 9, 2001. The Defendant will be given a credit towards arrearages for automobile payments made on the 1996 Bravada for the months of August through October, 2001, for a total credit of $1,464.00. On December 6, 2001, the Plaintiff became totally disabled as a result of the surgery performed on her neck. Consequently the Defendant's obligation for alimony pendente lite will be $1,647.00 per month for a period often weeks, the anticipated convalescent period for the Plaintiff fullowing her surgery,, and will revert to $892.00 per month thereafter. RECOMMENDATION The Defendant, Gordon S. Williams, shall pay alimony pendente lite to the Plaintiff, Adelaida C. Williams, as follows: 1. During the period of August 9, 2001, through December 5, 2001, the sum of $892.00 per month. 2. During the period of December 6, 2001, through February 13, 2002, the sum of $1,647.00 per month. 3. Commencing February 14, 2002, the sum of $892.00 per month. The Defendant shall be given a credit towards outstanding arrearages of $1,464.00. The Defendant shall pay the sum of $50.00 per month towards outstanding arrearages. All administrative provisions of our prior order of court dated October 16, 2001, shall remain in full force and effect. Michael R. Rundle Support Master In the Court of Common Pleas of Cumberland County, Pennsylvania Docket Number: PACSES Cese Number: Other Case ID Number: 01-1617 Civil 924103734 Defendant Name: Gordon S. Williams Plaintiff Name: Adelaida C. Williams 1. Number of~endents in this Case 2. Total Gross Monthl_y~_ncome 3. Less Monthly Deductions 4. Monthly Net Income $2,025.65 Line 2 minus Line 3 5 a. C~i~bined Total Monthly Net Income Amounts on Line 4 Combined 5 b. Derivative Soc. Sec. Benefits Paid to Child r_~(~ ~ted Combined Total Monthl~et Income 6 a. Child SuCtion based on A~'usted Income LIn._(~.~ 6 b. Less Derivative Soc. Sec. Benefit~ 6 c, Basic Child Support Obligation From Rule 1910.16-3 Basic Child Su~rt Schedule 7. Net Income as a Percentage of Combined Amount 8. Each Parent's Monthly Share of the Child S~ation ~ent for Shared Custod__~y. Rule 1910.16-4 c~_~# of Overnights: 10. Adjustment for Child Care Expenses Rule 1910.16-6 (a) 11. Adjus~i~u.{ for Health Insurance Premiums Rule 1910.16-6 (b) 12. Adjus{~ei~ for Unreimburaed Medical Expenses Rule 1910.16-6 (c) ,13. Adjustment for Additional Expenses Rule 1910.16-6 (d) 14. Total Obligation with Adjus~,~ei~$ Line 8 minus Line 9, plus Lines 10,11,12,13 15. Less Split Custody Counterclaim Rule 1910.16-4 (d) 16. Obligor's Support Obligation Line 14 minus Line 15 Prepared by: mrr I [)ate: $5,999.25 68.93 ~31.07 -$18.85 -$18.85 -$18.85 1/2/2002 S1. PACSES Multi~_~ Family_~_d. justment S2. Spousal Support Award S3. Adjustment for Excess Mortgage Payments (If Applicable) S4. Final Calculated Support Obligation Line 16 (or S1, if applicable) plus Line S2 and S3, if applicable $891.97 Monthly: Weekly: s8.~ustification for Deviating_from Guidelines Calculation and/or Other Case Comments: SupportCalc 2001 Exhibit "A" ADELAIDA C. WILLIAMS, Plaintiff V. GORDON S. WILLIAMS, Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : DOMESTIC RELATIONS SECTION : PASCES NO. 924103734 advised that our error, said order A. B. C. AMENDED ORDER OF COURT AND NOW, this 4th day of January, 2002, the Court being prior order of court entered January :3, 2002 contains a clerical is amended as follows: The figure of $892.00 in paragraph A (1) is amended to read $873.00; The figure of $892.00 in paragraph A (3) is amended to read $873.00; In all other respects our prior order of January 3, 2002 remains in full force and effect. Edgar B. Bayley, J. CC: Adelaida C. Williams Gordon S. Williams James D. Flower, Jr., Esquire Melissa L. Van Eck, Esquire DRO ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania CoJCity/Dist. of ~R~D Date of Order/Notice 01/14/o2 Cou~C~e Number (See Addendum ~r case summary) Emplowr/Withholder,sFedemlEIN Number GENERAL MOTORS CORP* EmployerA, Vith~lde~sName C/O ARTHUR ANDERSON BPS CENTR Emplo~rANith~lder'sAdd~ss PAYROLL SERVICES PO BOX 62650 PHOENIX AZ 85082-2650 C) Original Order/Notice (~) Amended Order/Notice C) Terminate Order/Notice RE: WILLIAMS, GORDON S. EmployeWObligo6sName(Last, First, MI) 366-40-0477 Employee/OblJgor's Social Securiiy Number 0322100482 Employee/Obligor'$ Case ~dentifier (See Addendum for p~aintfff names associated with cases on attachment) Custodial Parents Name (Last, First, 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 CUM~ERLR-ND County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named employee's/obiigor's income until further notice even if the Order/Notice is not issued by your State. $ 1,647. oo per month in current support $ 134.00 per month in past-due support ^-' 'eeks or greater? C)yes (~) no $ 0. g0 per month in medical support $ o. 00 per month for genetic test costs $ per month in other (specify) for a total of $ 1, '/81.00 per month to be ~ You do not have to vary your pay cycle to be in c the ordered support payment cycle, use the foiiow~. $ 41:L. o0 per weekly pay period. Date of Order: JAN 1 $ 2{302 Service Type M ,our pay cycle does not match ,,id: NO.: 0970-0154 Expiration Date: 12/31/00 $ 1~22. O0 per biweekly pay period (every two $ ~90.50 per semimonthly pay period (twice a $ __],.,./.Ek,_Q_Q. 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 haws governing the work state of your employee for the 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 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, PA YMENTS MUST INCLUDE THE DEFENDANT'S NAM~E AND THE PACSES MEMBER ID (shown above as the Empfoyee/Obligor's Case Identifier) OR SOCIAL SECURI~K NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. Form EN-028 Worker ID $IATT ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS [] If checked you are required to provide a copy of this form to your employee. 1. Pr ority: Withholdin§ under th s Order/Not ce has priority over any other legal process under State law a§ainst 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 fi.om more than orle employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the port:ion of the single payment that is attributable to each employee/obligor. ...................... ,,,,u r,~u~t i~,~., t t,,~a pa~ ~,at~,~a.; of ~,,L',,',,~,',d,,,e ,,', ........ d,,,~ ,',,~ ~,~ ............ R~,.,iuh~ ...... r ........................ ~' .., ',. _,u, ] .... , ....... Ynu must comoIv w th 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) $. 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. WITHHOLDER'S ID: EMPLOYEE'S/OBLIGOR'S NAME: WTt.T.]:.l~lSf GOI~.DO~T $. EMPLOYEE'S CASE IDENTIFIER: 0322:].0048~2 __ DATE OF SI-_-PARATION: LAST KNOWN HOME ADDRESS: NEW EMPLOYER'S NAME/ADDRESS: 6. Lump Sum Payments: You may be required to report and withhold fi.om 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/obli§or because of a support withholding. Pennsylvania State Jaw governs unless the obli§or is employed in another State, in which case the law oftbe 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)l; or 2) the amounts allowed by the State of the employee's/obli~or's principal place of employment. The Federal limit applies to the aggregate disposable weekly earnin§s (ADWE). ADWE is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes~ and Medicare taxes. 10. *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. Requesting A§ency: DOMESTIC RELATIONS SECTION 1;~ N, HANOVER ST P,O. BOX 320 CARLISLE PA 1 7013 If you or your employee/obligor have any questions, contact WAGE A'rI-ACHMENT UNIT by telephone at (717) 240-6225 by FAX at ~7'L.Z)_2,_4.Q:.6.2,.~ or by Internet or Service Type Page 2 of 2 OMB NO,: 0970-0154 Form EN-028 Worker ID ADDENDUM Summary of Cases on Attachment Defendant/Obligor: WILLIAMS, GORDON S. Plaintiff Name ADEI~AIDA C. WILT.I~J4S Docket At~chment Amount 01-1617 CIVIL $ 1,781.00 Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ o.oo Child(ren)'s Name(s): DOB l-hr ~hecked yOU are required tO enroll the Child(mn) identified above in any heakh insurance coverage available through the employee's/obligor's employment. F-lif Checked ?U are required to enroii the Child(ten) identified abow. in any, health i.n, surance coverage available through the employee s/obligor s employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ o.oo Child(mn)'s Name(s): DOB PACSES Case Numbe_.___~r Plaintiff Name Docket _Attachment Amount $ o.oo Child(ren)'s Name(s): DOB I--IIfchecked you are required to enro the child(ren) identified above in any health insurance coverage avai able through the employee's/obligor's emp oyment .PACSES Case Number Plaintiff Name Docket Attachment Amount $ o.oo Child(ren)'s Name(s): DOB [] If checked, you are required to enroll the child(mn) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number P!aintiff Name Docket Attachment Amount $ o.oo Child(ren)'s Name(s): DOB I-hr checked, you are requ red to enro I the child(mn) identified above in any health nsurance coverage avai able through the emp oyee's/obligor's emp oyment. E]lf checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. Service Type M Addendum Form EN-028 Worker ID $IATT ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT Slate Commonwealth of Pennsylvania Co./Ci~/Dist o~ Date of Order/Notice 02/~/02 Cou~Case Numar (See Addendum for case summary) RE: WILT,TAMS, GORDON S. EmployerANithholder's Federal EIN Number GENERAL MOTORS CORP* E m ployer/%Nith holder's Name C/O ARTHUR Ai~DERSON BPS CENTR E m pJoye rA~/it h holder's Address PAYROLL SERVICES PO BOX 62650 PHOENIX AZ 85082-2650 O Original Order/Notice Amended Order/Notice O Terminate Order/Notice Employee/Obligor's Name (Last, First, MI) 366-40-0477 Employee/Obiigor's Social Security Number 0322100482 Employee/Obligor's Case Identifier (See Addendum fnr plaintiff names associated with cases on attachment) Custodial Parent's Name (Last, First, Mt) 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 CUMBERLAIqD County, Commonwealth of Pennsylvania. By law, you are required to deduct these amounts from the above-named emp]oyee's/obligor's income until further notice even if the Order/Notice is not issued by your State. $ 873. oo per month in current support $ 134. oo per month in past-due support Arrears 12 weeks or greater? (~)yes C) no $ o. oo per month in medical support $ 0.00 per month for genetic test costs $ per month in other (specifT) for a total of $ 1,00'7 · 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: $ 232.38 per weekly pay period. $ 464. '7'7 per biweekly pay period (every two weeks). $ 503.50 per semimonthly pay period (twice a month) $ 1.00'7. oo per monthly pay period. You must begin withholding no later than the first pay period ~fter the date of this Order/Notice. Send payment within seven (7) working days ¢. You are entitled to deduct a fee to defray the cost of withholding. Refer to the our employee for the the allowable amount. The total withheld amount, and yot :mployee's/obligor's aggregate disposable weekly earnings. For the purpose of tr,¢ .... following information is needed (See #9 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, Harrisb,urg, 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. Date of Order: FEB]., ~'[:Jg, Form EN-028 Worker ID STAT? Service Type M OMB NO.: 09704)154 -- Expiration Date: ~ ADDITIONAL ~NFORMATION TO EMPLOYERS AND OTHER W~THHOLDERS [] If checked you are required to provide a copy of this form to your employee. 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 pJease 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. · . · _ ............................................... 5. You must comply with the law of the Py 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 noti~ 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. WITHHOLDER'S iD: 3805725~.50 EMPLOYEE'S/OBLIGOR'S NAME: WI?.?.TAI~B ~ (~O~DON B · EMPLOYEE'S CASE iDENTIFIER: 0322100482 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 wh ich 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)l; or 2) the amounts allowed by the State of the empioyee'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. 10. * 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. Requesting Agency: 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 a~t (717) 240-6225 by FAX at ~717~ or by Internet ~ or Page 2 of 2 OMB NO,: 0970-0154 ExpiratTon Date: 12/31/00 Form EN-028 Service Type M Worker ID $IATT PACSES Case Number 924103734/~2~?f~/~/? Plaintiff Name / ADELAIDA C. WILLI~34S Docket Attachment Amount 01-1617 CIVIL$ 1,007.00 Child(ren)'s Name(s): ADDENDUM Summary of Cases on Attachment DefendantJObligor: WILLIAMS, GOPd~ON S. PACSES Case Number Plaintiff Name Docket Attachment Amount $ o.o0 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. [] 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 A[tachment 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. ~ACSES 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. Service Type M Addendum OMB NO.: 0970-0154 Form EN-028 Worker ID $IATT In the Court of Common Pleas of CUMBERLAND DOMESTIC RELATIONS SECTION County, Pennsylvania ADELAIDA C. WILLIAMS Plaintiff VS, GORDON S. WILLIAMS Defendant ) Docket Ntunber ) ) PACSES Case Number ) ) Other SIate ID Number 01-1617 CIVIL 924~03736///~.~ PETITION FOR MODIFICATION OF AN F, XISTING SUPPORT ORDER 1. The petition of represents that on ocT,. support of ADELAIDA CASTANEDA WILL respectfully . of Court was entered for the A tree and correct copy of the order is attached to this petition. Form OM-501 Service Type M Worker ID 21205 WILLIAMS v. WILLIAMS PACSES C~e Number: 924103734 2. Petitioner is entitled to C) increase ~) decrease C) termination C) reinstatement C) other of this Order because of the following material and substantial change(s) in circumstance: (Please complete this section by listing the reasons for your request.) Defendant. Gordon WillY.mm. reauests a decrease due to a a chanKe in circumstances. Defendant's income has decreased due to being forced into early retirement by his employer, beginning WHEREFORE, Petitioner requests that the Court modilby the existing order for support. l~etitti6ner .... 'Attorney for P~titioner [ unde~tand I verify that the statements made in this complaim are tree and/f6rre~l~ that false statements herein are made subject to the penalties of 18 Pa. C.S. §~904 rcq'~ting to unswom falsification to authorities. " Date /Petitioner Page 2 of 2 Form OM-501 Service Type M Worker ID 21205 ADELAIDA CASTANEDA WILLIAMS, Plaintiff VS. GORDON STANLEY WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE MOTION FOR APPOINTMENT OF MASTER AND NOW, Gordon Stanley Williams, Defendant, moves the court to appoint a master with respect to the following claims: ( ) Divorce (X) Distribution of Property ( ) Annulment ( ) Support (X) Alimony (X) Counsel Fees (X) Alimony Pendente Lite (X) Costs and Expenses and in support of the motion states: (1) requested. Discovery is complete as to the claim(s) for which the appointment of a master is (2) Esquire. The Defendant has appeared in the action by his attorney, Melissa L. Van Eck, (3) The statutory ground for divorce is 3301(c) and/or (d) of the Pennsylvania Divorce Code. (4) The action is contested with respect to the following claim: (i) Equitable Distribution. (ii) Alimony, Alimony Pendente Lite mad Attorneys Fees and Costs. Document #: 219683.1 CERTIFICATE OF SERVICE I, Melissa L. Van Eck, Esquire, of the law fn-m of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and correct copy of the Motion for Appointment of Divorce Master of Defendant with reference to the foregoing action by fn's.t class mail, postage prepaid, this ~xc(x. day of ~ ,2002, on the following: Carol Lindsay, Esquire Saidis, Shuff, Flower & Lindsay 26 W. High Street Carlisle, PA 17013 METZGER, WICKERSHA2vl, KNAUSS & ERB, P.C. Melissa L. Van Eck, Esquire Doentment ii: 219683.1 ADELAIDA CASTANEDA WILLIAMS, Plaintiff VS. GORDON STANLEY WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE ORDER APPOINTING MASTER. AND NOW, this ~ ,r~ ~ day of / 2002, _~fi?_ ,~,g(2/-- ~d/~t, Esquire, is appointed master with respect to the following claims: Equitable Distribution. Alimony, Alimony Pendente Lite and Attorneys Fees and Costs. By the Court: Document #.. 219683.1 ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsvlvanial /~,~ ~'~C ~ ~/~ ~=~ ~ Co./CKy/Dist. of Date of Order/Notice 05/0~/02 ~/~ Cou~Case Number (S~ Addendum for case summary) (~ Original Order/Notice O Amended Order/Notice C) Terminate Order/Notice Employer/Withholder's Federal EIN Number PENSION ADMINISTRATION CENTER E rnployerANithholder's Name PO BOX 5014 E mployerA, Vithholder's Address SOUTHFIELD MI 48086-5014 ) RE: WILLIAMS, GORDON $. Employee/Obligor's Name (Last, First, MI) 366-40-0477 Employee/Obligor's Sociar Security Number 0322100,~82 Employee/Obligor's Case Identifier (See Addendum for plaintiff names associated with cases on a{fachmPnt) Custodial Parent's Name (Last, First, M~) 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 CUMBERI~%ND Count, 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. $ 873. oo per month in current support $ 50. oo per month in past-due support Arrears '12 weeks or greater? C)yes (~) no $ 0. oo per month in medical support $ o. oo per month for genetic test costs $ per month in other (specify) for a total of $ 923.00 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: $ 23.3. oo per weekly pay period. $ 426.0O per biweekly pay period (every two weeks). $ 461.50 per semimonthly pay period (twice a month). $ 923. or) 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 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'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 SC DU, P.O. Box 69112, Harrisbu~rg, Pa 17106-9112 IN ADDITION, PA YMENTS 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: Service Type M Form EN-028 Worker ID $OINC ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS [] If checked you are required to provide a copy of this form to your employee. 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 singre payment that is attributable to each employee/obligor. ~"~Y ........................ ~ ............................................ ~,'.,~ y~% ,,o~es. You must comply with the law of the state of the employee's/obligor's principal place of employment with respect to the tim(,, 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 Agenc~ 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. WITHHOLDER'S ID: 31461001?2 EMPLOYEE'S/OBLIGOR'S NAME: WILLIES, GO~d)ON S. EMPLOYEE'S CASE IDENTIFIER: 0322].00482 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 emproyed 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 disciplinmy 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)l; 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. 10. *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. Requesting Agency: 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 by FAX at (717) 240-6248 or by Internet @ or Service Type Page 2 of 2 Form EN-028 WorkerlD $OZ~O ADDENDUM .Summary of Cases on Attachment Defendant/Obligor: WILLIAMS, GORDON S. PACSES Case Number 924103734~ .Plaint ff Name ADELAIDA C. WILLIAMS Docket Attachment Amount 01-1617 CIVIL $ 923.00 Child(ren)'s Name(s): DOB PACSES Case Number .Plaintiff Nam_e Docket Attachment Amount $ o.oo Chi[d(ren)'s Name(s): DOB I-'Ill choked y~u ~re ~equ red tO ~nroli the child(ten) identified above in any health insurance coverage available through the employee's/obligor's employment. identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name _Docket Attachment Amount $ o.o0 Child(ren)'s Name(s): DOB pACSES Case Number Plaintiff Name, _Docket Attachment Amount $ 0.00 Child(renYs Name(s): DOB [] If checked, you are required to enroll the child(ten) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSE5 Case Number .pla nt ff Name Docket Attachment Amount $ o.o0 Chi[d(ren)'s Name(s): DOB E]lf checked, you are required to enroll the child(ten) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ o.oo Child(ren)'s Name(s): DOB E]lf checked, you are required to enroll the chi[d(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. [] If checked you are requ red to enroll the child(mn) identified above in any health nsurance coverage available through the emp oyee's/obligor's employment. Service Type M Addendum OM8 NO.: 0970~)154 Expiration Date: 12/31/00 Form EN-028 Worker ID $OINC ADELAIDA CASTANEDA WILLIAMS, Plaintiff GORDON STANLEY WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS CUMBEILLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL ACTION - LAW IN DIVORCE INCOME AND EXPENSE STATEMENT OF DEFENDANT, GORDON STANLEY WILLIAMS METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: Melissa L. Van Eck, Esquire Attorney I.D. No. 85869 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Defendant Document #: 233223.1 INCOME AND EXPENSE STATEMENT OF GORDON STANLEY WILLIAMR 05/01/2002 Employer: Retired Address: Type of Work: Payroll Number: Pay Period (weekly, biweekly, etc.): Monthly GROSS PAY PER PERIOD: $3,1:36.36 Itemized Payroll Deductions: Federal Withholding: $311.47 Social Security: Medicare: Local Wage Tax: State Income Tax: Unemployment Tax: Retirement: Savings Bonds: Credit Union: Life Insurance: Health Insurance: Other: (specify) NET PAY PER PAY PERIOD: $2,824.89 Document #: 176291.1 OTHER INCOME: WEEK MONTH YEAR Interest Dividends Pension Annuity Social Security Rents Royalties Expense Account Unemployment Comp. Workmen's Comp. TOTAL OTHER INCOME: TOTAL MONTHLY NET INCOME: $2,824.89 Document #: 176291.1 WEEKLY MONTHLY YEARLY HOME: Mortgage/rent $919.00 Maintenance $50.00 Repairs $25.00 UTILITIES: Electric $60.00 Gas Oil Telephone $70.00 Water $20.00 Sewer/Garbage $30.00 EMPLOYMENT: Public Transportation Lunch TAXES: Real Estate Personal Property Income INSURANCE: Homeowners Automobile $72.00 Life Accident Health $67.00 Other Doc~ment #: 176291.1 AUTOMOBILE: Payments Fuel $90.00 Repairs $25.00 Maintenance $20.00 Licenses $12.00 Registration $8.00 Auto Club $5.00 MEDICAL: Doctor $30.00 Dentist $40.00 Orthodontist Hospital Medicine Special needs $20.00 (glasses, braces, orthopedic devices) EDUCATION: Private school Parochial school College $150.00 Religious School lunches Books/misc. $10.00 PERSONAL: Clothing $30.00 Document ti: 176291.1 Food $300.00 Barbedhairdresser $26.00 Personal care $15.00 Laundry/dry cleaning $10.00 Hobbies Memberships CREDIT PAYMENTS: Credit card $150.00 Charge account $75.00 LOANS OR DEBTS: Credit Union $288.00 MISCELLANEOUS: Household help Child care Camp Pet expense Papers/books/ magazines Entertainment $20.00 Pay TV $35.00 Vacation Gifts $50.00 Legal fees $50.00 Charitable Contributions Religious Memberships (Tithing) $200.00 Children's Document #: 17629]. ] Allowances Other Child Support Alimony $1,007.00 payments Lessons for Children OTHER: SSPP Loans $289.00 TOTAL EXPENSES $4,248.00 $20.00 Document #.. 176291.1 CERTIFICATE OF SERVICE I, Melissa L. Van Eck, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a true and exact copy of Income and Expense Statement of Defendant with reference to the foregoing action by first class mail, postage prepaid, this '~ j~ day of ~0~, 2002 upon the following: Carol Lindsay, Esquire Saidis, Shuff, Flower & Lindsay 26 W. High Street Carlisle, PA 17013 METZGER, WICKERSE[AM, KNAUSS & ERB, P.C. Melissa L. Van Eck, Esquire Document#.'233223.1 VERIFICATION I, Gordon Stanley Williams, do hereby verify that the fiacts set forth in Income and Expense Statement of Defendant, Gordon Stanley Williams, are true and correct to the best of my personal knowledge or information and belief. I understand that false sl~tements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unswom falsification to authorities. Date: ~'-[ f) -~. Gordon Stanley Williams D~cument #.- 232373.1 ADELAIDA CASTANEDA WILLIAMS Plaintiff GORDON STANLEY WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CiVIL TERM IN DIVORCE INVENTORY OF DEFENDANT Defendant files the following inventory of all property owned or possessed by either party at the time this action was commenced and all property transferred within the preceding three years. Defendant verifies that the statements made in this inventory are true and correct. · Defendant understands that false statements herein are'made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. GbRDON STANLEY( WILLIAMS ASSETS OF PARTIES Defendant marks on the list below those items applicable to the case at bar and itemizes the assets in the following pages. (x) (x) (x) () (x) (x) () () (x) ) ) ) ) ) ) (x) () (x) (x) () () () (x) (x) () 1. Real property 2. Motor vehicles 3. Stocks, bonds, securities and options 4. Certificates of deposit 5. Checking accounts, cash 6. Savings accounts, money market and savings certificates 7. Contents of safe deposit boxes 8. Trusts 9. Life insurance policies (indicate face value, cash sm:render value and current beneficiaries) 10. Annuities 11. Gifts 12. Inheritances 13. Patents, copyrights, inventions, royalties 14. Personal property outside the home 15. Business (list all owners, including percentage of ownership, and officer/director positions held by a party with company) 16. Employment termination benefits--severance pay, workmen's compensation claim/award 17. Profit sharing plans 18. Pension plans (indicate employee contribution and date plan vests) 19. Retirement plans, Individual Retirement Accounts 20. Disability payments 21. Litigation claims (matured and unmatured) 22. Military/V.A. benefits 23. Education benefits 24. Debts due, including loans, mortgages held 25. Household furnishings and personality (include as ~, total category and attach itemized list of distribution of such assets in dispute 26. Other Document ii: 230082. l MARITAL PROPERTY Defendant lists all marital property in which either or both spouses have legal or equitable interest individually or with any other person as of the date this action was commenced. Names Item Description of All No. of Property Owners 1. 3 Savings Bonds ($150.00) Husband 2. 3 75 Shares of GM (stock option) Husband 3. 19 Retirement from GM Husband Document #: 230082.1 NON-MARITAL PROPERTY Defendant lists all property in which a spouse has a legal or equitable interest which is claimed to be excluded from marital property. Names Item Description of All Reason for No. of Property Owners Exclusion 1. 1 9145 Joyce Lane Husband post-separation 2. 2 1996 Bravada Husband pre-marital 3. 3 Household Furnishings Husband pre-marital 4. 3 Household Furnishings Wife pre-marital Document it; 230082.1 Description of Property None PROPERTY TRANSFERRED Date of Transfer Consideration Person to Whom Transferred Document #: 230082.1 LIABILITIES 2. 3. 4. 5. 6. 7. 8. Item No. 1 24 24 24 24 24 24 24 Description of Property 9145 Joyce Lane Credit card Student loans Credit card School Consolidation loan 401 (k) loan Credit card Names Names of All of All Creditors Debtors GMAC Husband Discover Card Husband US Dept. of Education Joint The Bon Ton Husband School of Theology Husband Automakers Credit Union Husband SSPP Husband Hecht's Joint Document #: 230082. I CERTIFICATE OF SERVICE I, Melissa L. Van Eck, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a tree and correct copy of the Inventory of Defendant with reference to the foregoing action by first class mail, postage prepaid, this q30~ day of ~ Jo[ ,2002, on the following: Carol Lindsay, Esquire Saidis, Shuff, Flower & Lindsay 26 W. High Street Carlisle, PA 17013 METZGER, WICKERSHAM, KNAUSS & ERB Date: May ~ ,2002 Melissa L. Van Eck, Esquire Attorney Id. 85869 3211 North From Street PO Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Defendant Gordon Stanley Williams Document #: 228599.1 In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION ADELAIDA C. WILLIAMS Plaintiff VS. GORDON S. WILLIAMS Defendant ) Docket Number ) ) PACSF~~, Case Number ) ) Other State ID Number 01-1617 CIVIL 924103734/~LQ~3~? ORDER OF COURT - APPEAR AT A MODIFICATION CONFERENCE Initial Conference O Rescheduled Conference YOU, ADELAIDA CASTANEDA WILLIAMS , Respondent have been sued in Court to modify an existing Apl- order. You, ADELAIDA CASTAiNEDA WILLIAMS Respondent, and You, GORDON STANLEY WILLIAMS Petitioner, are ordered to appear in person at CUMBERLAND CO DRS 13 NORTH HANOVER STREET, CARLISLE, PA. 17013 onthe 12TH DAY OF JUNE, 2002 at lO:30AM for a conference and remain until dismissed by the Court. If the Petitioner of this action fails to appear as provided in this Order, this petition may be dismissed. If the Respondent of this action fails to appear as provided in this Order, an Order for Modification may be entered against the Respondent. You are further required to bring to the conference: 1. a true copy of your most recent Federal Income Tax Return, including W-2s, as filed, 2. your pay stubs for the preceding six (6) months, 3. the Income and Expense Statement attached to this order as r~luired by Rule 1910.11 (c). 4. verification of child care expenses, and 5. proof of medical coverage which you may have, or may have available to you, Form OM-503 Service Type M Worker ID 21205 WILLIAMS v. WILLIAMS PACSES Case Number: 924103734 THE EXISTING ORDER MAY BE MODIFIED OR TERMINATED IN ANY APPROPRIATE MANNER BASED UPON THE EVIDENCE PRESENTED. If you fail to appear for the conference/hearing or to bring the required documents, the court may issue a warrant for your arrest or enter an order in your absence. If paternity is an issue, the court may enter an order establishing paternity. An appropriate order may be entered against either party based upon the evidence presented without regard to which party initiated the ~i~/~ action. Date of Order: BY THE COURT: F~Y~C~~. ~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 TO FIND OUT WHERE YOU MAY GET LEGAL HELP: CUMBERLAND CO BAR ASSOCIATION 2 LIBERTY AVE CARLISLE PA 17013-3308-02 (717) 249-3166 AMERICANS WITH DISABILITIES ACT OF 199~ The Court of Common Pleas of Cm~Ea.tau~ County isC~requir~ by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office at: (717) 240-6225. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference. Page 2 of 2 Form OM-503 Service Type M Worker ID 21205 ORDE~NOTICE TO WITHHOLD INCOME FOR SUPPORT ~,E'/, ~oo/-/~/7 c?t ~/~_ State Commonwealth of Pennsvlva.ia Co./Ci~/Dist. of Date of Order/Notice 06/~3/02 Cou~Case Number (See Addendum for case summary) O Original Order/Notice (~ Amended Order/Notice O Terminate Order/Notice Employer/Witbholder's Federal EIN Number E m ploye r/With holder's Name PO BOX 5014 E m p~oye r/Wit h holder's Address SOUTHFIELD MI 48086-5014 ) RE: WILLIAMS, GORDON S. Employee/Obligor's Name (Last, First, MI) 366-40-0477 Employee/Obligor's Social Security Number 0322100482 Employee/Obligor's Case Identifier (See Ad~en~um for plaintiff names a~ociated w~th 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. $ 3?5.00 per month in current support $ o. oo per month in past-due support Arrears {2 weeks or greater? C)yes (~) no $ o. oo per month in medical support ' $ o. 0o per month for genetic test costs $ per month in other (specify) for a total of $ 3'/5. O0 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: $ 86.54 per weekly pay period. $ 173.08 per biweekly pay period (every two weeks). $ 187.50 per semimonthly pay period (twice a month). $ 3?5.00 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 ~!he work state of your employee for the 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 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, PA YMENTS 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. Form EN-028 Service Type M Worker ID $OTNC ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS [] If checked you are required to provide a copy of this form to your employee. 1. Priority: Withholding under this Order/Notice bas priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of th is 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/ob[igor'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. ' ' ' ' yee~s~ages. 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 wlhen 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. WITHHOLDER'S ID: 31461001?2 EMPLOYEE'S/OBLIGOR'S NAME: WTT,LTAMS, GORDON S. EMPLOYEE'S CASE IDENTIFIER: 0322100482 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)l; 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. 10. *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. Requesting Agency: 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) 240-624(I or by Intemet @ Service Type M Page 2 of 2 Form EN-028 Worker ID $OINC ADDENDUM S_ummary of Cases on Attachment Defendant/Obligor: WILLIAMS, GORDON $. PACSES Case Number 924103734/v~,~-'.~) Plaint ff Name ADELAIDA C. WILLIAMS Docket Attachment Amount 01-1617 CIVIL$- 375.00 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(ten) identified above in any health insurance coverage available through the employee's/obligor's employment. l--Jif checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket .Attachment Amount $ o.o0 Child(ren)'s Name(s): DOB PACSES Case Number .plaint ff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB [] If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ o.oo Child(ren)'s Name(s): DOB [] If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. PACSES Case Number Plaintiff Name Docket Attachment Amount $ o.oo Child(ren)'s Name(s): DOB []If checked, you are required to enroll the child(ren) identified above in any health insurance coverage available through the employee's/obligor's employment. []If checked, you are required to enroll the child(mn) identified above in any health insurance coverage available through the employee's/obligor's employment. Service Type M Addendum OM8 NO.: 097C~0154 Expiration Date: 12/31/00 Form EN-028 Worker ID $OINC ADELAIDA WILLIAMS, Plaintiff/Petitioner IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA VS. : CIVIL ACTION - DIVORCE : : NO. 2001-1617 CIVIL TERM GORDON S. WILLIAMS, : IN DIVORCE Defendant/Respondent : DR# 30930 : Pacses# 924103734 ORDER OF COURT AND NOW, this 13th day of June, 2002, based upon the Court's determination that Petitioner's monthly net income/earning capacity is $1,863.75 and Respondent's monthly net income/earning capacity is $2,941.39, it is hereby Ordered that the Respondent pay' to the Pennsylvania State Collection and Disbursement Unit, $375.00 per month payable monthiy as follows; $375.00 for alimony pendente lite and $0.00 on arrears. First payment due OhO or before the 5th day of each month, commencing in July, 2002. Arrears set at $695.67 as of June 13, 2002. The effective date of the order is April 1, 2002. This Order is based upon the fact that Defendant has retired, effective April 1, 2002. Consideration is given for the medical insurance costs paid by Husband. The balance of $695.67 is to be paid in full within ten days upon receipt of this Order. 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: Adelaida Williams. Payments must be made by check or money order. All checks and money orders must be made payable to PA SCDU and marled tO: PA SCDU P.O. Box 69110 Harrisburg, PA 17106-9110 Payments must include the defendant's PACSES l~lember Number or Social Security Number in order to be processed. Do not send cash by mail. Unreimbursed medical expenses that exceed $250.00 annually are to be paid 0% by the respondent and 100% by petitioner. The petitioner is responsible to pay the first $250.00 annually in unreimbursed medical expenses. Respondent to provide medical insurance coverage. Within thirty (30) days after the entry of this order, the 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 ofobtaihing 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 shall become final ten days 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 heating de novo before the Court. DRO:R.J. Shad~y Mail~mp~son 6-14~2 W: Petitioner Responsent Carol Lindsay, Esquire Melissa Van Eck, Esquire BY THE COURT, ADELAIDA WILLIAMS, Plaintiff/Petitioner VS. GORDON S. WILLIAMS, Defendant/Respondent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTIOI~T - DIVORCE NO. 2001-1617 CIVIL TERM IN DIVORCE DR~ 30930 Pacses~ 924103734 NOTICE OF RIGHT TO REQUEST A HEARINC The parties are hereby advised that they have until June 24~ 2002 to request a hearing do novo before the Court. File request in person or mail to: Office of the Prothonotary 1 Courthouse Square Carlisle, PA 1 7013 ADELAIDA WILLIAMS, Plaintiff/Petitioner VS. GORDON S. WILLIAMS, DefcndantfRespondent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - DIVORCE NO. 2001-1617 CIVIL TERM IN DIVORCE DRg 30930 Pacaes~ 924103734 DATE OF ORDER: June 13, 2002 AMOUNT: 375.00 per month FOR: Alimony Pendente Lite REASON(S): ADELAIDA WILLIAMS, PlaintifffPetitioner VS. GORDON S. WILLIAMS, Defendanv~espondent IN THE COURT OF COMMON PLEAS OF CUMBERLA~FD COUNTY, PENNSYLVANIA CIVIL ACTION - DIVORCE NO. 2001-1617 CIVIL TERM IN DIVORCE DR~ 30930 Pacses0 924103734 NOTICE OF RIGHT TO REQUEST A HEARINC The parMes are hereby advised that they have unlil .[une 24, 2002 to request a hearing do novo before the Court File request in person or mail to: Office of the Prothonotary 1 Courthouse Square Carlisle, PA 17013 ADELAIDA WILLIAMS, Plainfi.ff/Petifioner VS. GORDON S. WILLIAMS, Defendant/Respondent IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -DIVORCE NO. 2001-1617 CIVIL TERM 1~ DIVORCE DR~ 30930 PacsesO 924103734 DATE OF ORDER: June 13, 2002 AMOUNT: 375.00 per month FOR: Alimony Pendente Lite DEMAND FOR HEAl,LNG REASON(S): P~M ~G DE~ FOR ~G: , / In the Court of Common Pleas of CUMBERLAND, County, Pennsylvania DOMESTIC RELATIONS SECT]ION ADELAIDA C. WILLIAMS Plaintiff VS. GORDON S. WILLIAMS Defendant ) Docket Number ) ) PACSI:',S Case Number ) ) Other State ID Number 01-1617 CIVIL 924103734 ORDER OF COURT YOU, ADELAIDA CASTANEDA WILLIAMS 260 S LAVEEN DR, CHANDLER, AZ. 85226-3883-60 plaintiff/defendant of are ordered to appear at DOMESTIC RELATIONS HEARING RM DOMESTIC RELATIONS OFC, 13 N HANOVER ST, CARLISLE, PA. 17013-3014-13 before a hearing officer of the Domestic Relations Section, on the NOVEMBER 7, 2002 at i:30PM for a hearing. You are further required to bring to the hearing: 1. a tree copy of your most recent Federal Income Tax Remm ;.,-h,a;.,. 3. verification of child care expenses, and 4'y ur pay stubs f°r the preceding slx (6) m°nths' proof of medical coverage which you may have, or may have available 5. information relating to professional licenses 6. other: Form CM-509 Service Type M Worker ID 21302 WILLIAMS v. WILLIAMS PACSES Case Number: 924103734 If you fail to appear for the conference/hearing or to bring the required documents, the court may issue a warrant for your arrest or enter an order in your absence. If paternity is an issue, the court may enter an order establishing paternity. The appropriate court officer may enter an order agair, st either party based upon the evidence presented without regard to which party initiated the support action. Date of Order: BY THE COURT: YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATFEND THE HEARING 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 CO BAR ASSOCIATION 2 LIBERTY AVE CARLISLE PA 17013-3308-02 (717) 249-3166 AMERICANS WITH DISABILITIES ACT OF 1990 The Court of Common Pleas of CU~]ZRraU,~D County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office at: (717) 240-6225 . ./~Lll arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled hearing. Page 2 of 2 Form CM-509 Service Type M Worker ID 21302 In the Court of Common Pleas of CUMBERLAN~ County, Pennsylvania DOMESTIC RELATIONS SECTION ADELAIDA C. WILLIAMS Plaimiff VS. GORDON S. WILLIAMS Defendant ) Docket Nuraber ) ) PACSES Case Number ) ) Other State ID Number 01-1617 CIVIL 924103734 ORDER OF COURT You, SO~ON STANLEY WILLIAMS 9145 JOYCE LN, HIYMMELSTOWN, PA. 17036-8629-45 plaintiff/defendam of are ordered tO appear at DOMESTIC RELATIONS HEARING RM DOMESTIC RELATIONS OFC, 13 N HANOVER ST, CARLISLE, PA. 17013-3014-13 before a hearing officer of the Domestic Relations Section, on the NOVENBER 7, 2002 at 1:30PM for a hearing. You are further required to bring to the hearing: ~- 1. a tree copy of your most recent Federal Income Tax Return, including W-2s, ~, 2. your pay stubs for the preceding six (6) months, u~r%x/~ 3. verification of child care expenses, and 4. proof of medical coverage which you may have, or may haw, available to you~ ~ ~% 5. information relating to professional licenses 6. other: ~'::' " Form CM-509 Service Type M Worker ID 21302 WILLIAMS V. WILLIAMS PACSES Case Number: 924103734 If you fail to appear for the conference/hearing or to bring the required documents, the court may issue a warrant for your arrest or enter an order in your absence. If paternity is an issue, the court may enter an order establishing paternity. The appropriate court officer may enter an order against either party based upon the evidence presented without regard to which party initiated the support action. Date of Order: BY THE COURT: YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE HEARING AND REPRESENT YOU. IF YOU DO NOT HAVE A LAW3(ER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU MAY GET LEGAL HELP: CUMBERLAND CO BAR ASSOCIATION 2 LIBERTY AVE CARLISLE PA 17013-3308-02 (717) 249-3166 AMERICANS WITH DISABILITIES ACt OF 1990 The Court of Common Pleas of CUMBERk~'~D County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office at: (717) 240-62:!5 . All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled hearing. Page 2 of 2 Service Type M Form CM-509 Worker ID 2:1.302 ADELAIDA C. WILLIAMS, IN THE COURT OF COMMON PLEAS OF Plaintiff/Petitioner CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - DIVORCE GORDON S. WILLIAMS, Defendant/Respondent : PACSES NO. 924103734 : NO. 01-1617 CIVILTERM ORDER OF COURT AND NOW, this 8th day of November, 2002, the Court being advised that the Plaintiff has withdrawn her request for a hearing de novo to our order of June 13, 2002, and that the Defendant consents to the withdrawal, said order of June 13, 2002, is affirmed as a final order. Edgar B. Bayley, J. CC: Adelaida C. Williams Gordon S. Williams Carol J. Lindsay, Esquire For the Plaintiff Andrew C. Spears, Esquire For the Defendant DRO ADELAIDA CASTANEDA WILLIAMS, Plaintiff GORDAN STANLEY WILLIAMS, Defendant : COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : : NO. 01 - 1617 CIVIL : IN DIVORCE PRAECIPE TO WITHDRAW APPEARANCE Kindly withdraw the appearance of Melissa L. Van Eck, Esquire, on behalf of Defendant, Gordon Stanley Williams. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Dated: By Mehssa L. Van Eck, Esquire Attorney I.D. No. 85869 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 PRAECIPE TO ENTER APPEARANCE Kindly enter the appearance of Andrew Spears, Esquire, on behalf of Defendant, Gordon Stanley Williams. METZGER, WICKERSHAM, KNAUSS & ERB, P.C By Andrew ~ears~Esquire P.O. Box 5300 Harrisburg, PA 17110 (717) 238-8187 Document#247794.1 ADELAIDA CASTANEDA WILLIAMS,:IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA vs. : NO. 01 - 1617 CIVIL GORDAN STANLEY WILLIAMS, : Defendant : IN DIVORCE TO: Carol J. Lindsay Melissa L. Van Eck , Attorney for Plaintiff , Attorney for Defendant DATE: Friday, May 17, 2002 CERTIFICATION I certify that discovery is complete as for which the Master has been appointed. to the claims (a) OR IF DISCOVERY IS NOT COMPLETE: Outline what information is required that is not complete in order to prepare the case for trial and indicate whether there are any outstanding interrogatories or discovery motions. (b) Provide approximate date when discovery will be complete and indicate what action is being taken to complete discovery. DATE COUI~S~I~ /OR) PLAINT~/( COUNSEL ~ DEFENDANT~ ( NOTE: PRETRIAL DIRECTIVES WILL NOT BE ISSUED FOR THE FILING OF PRETRIAL STATEMENTS UNTIL COUNSEL HAVE CERTIFIED THAT DISCOVERY IS COMPLETE, OR OTHERWISE AT THE MASTER'S DISCRETION. AFTER RECEIVING THIS DOCUMENT FROM BOTH COUNSEL OR A PARTY TO THE ACTION, IF NOT REPRESENTED BY COUNSEL, INDICATING THAT DISCOVERY IS NOT COMPLETE, THE DIRECTIVE FOR FILING OF PRETRIAL STATEMENTS WILL BE ISSUED AT THE MASTER'S DISCRETION. HOWEVER, IF BOTH COUNSEL, OR A PARTY NOT REPRESENTED, CERTIFY THAT DISCOVERY IS COMPLETE, A DIRECTIVE TO FILE PRETRIAL STATEMENTS WILL BE ISSUED IMMEDIATELY. THE CERTIFICATION DOCUMENT SHOULD BE RETURNED TO THE MASTER'S OFFICE WITHIN TWO (2) WEEKS OF THE DATE SHOWN ON THE DOCUMENT. ADELAIDA CASTANEDA WILLIAMS, Plaintiff, VS. GORDON STANLEY WILLIAMS, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA :NO. 2001- 1617 ClVILTERM :IN DIVORCE CERTIFICATION OF DISCOVERY (a) (b) See attached letter to counsel. As soon as counsel responds to our 6/20/02 letter. JAMES D. FLOWER JOHN E. SLIKE ROBERT C. SAIDIS GEOFFREY S. SHUFF JAMES D. FLOWER, JR. CAROL J. LINDSAY JOHNNA J. KOPECKY KARL M. LEDEBOHM JOSEPH L. HITCHINGS THOMAS E. FLOWER FORREST N. TROUTMAN, II LAW OFFICES SAIDIS, SHUFF, FLOWER & LINDSAY A PROFESSIONAL CORPORATION 26 WEST HIGH STREET CARLISLE, PENNSYLVANIA 17013 TELEPHONE: (717) 240-6222 - FACSIMILE: (717) 243-6510 EMAIL: attorney@ssfl-law.com WEST SHORE OFFICE: 2109 MARKET STREET CAMP HILL, PA 17011 TELEPHONE: (717)737-3405 FACSIMILE: (717)737-3407 REPLY TO CARLISLE June 20,2002 Melissa L. Van Eck, Esquire Metzger, Wickersham, Knauss & Erb 3211 North Front Street Harrisburg, PA 17109 RE: WILLIAMS v. WILLIAMS YOUR FILE NO. 86-41 Dear Metissa: I am enclosing a copy of my Certification of Discovery to the Court. I have had an opportunity to review all of the discovery provided, and it is deficient in the following manners: There are seven bank accounts for Mr. Williams, but none of the statements provided for December 11, 1999, or for the date of the marriage, June 27, 1998. We need those statements so that we can determine the marital value of those accounts. There is no information in the file regarding the General Motors salaried retirement program; only information regarding the stock option/savings program. Can you provide me a plan booklet so I can have the pension valued? In discovery, you reveal that Mr. Williams has the option to purchase 75 shares of GM stock. I enclose the May 14, 1999 letter that you provided. The check marks in the left hand column indicate documents which would help us value that option. For instance, I do not know how long the option period is. Would you please provide the special edition of the Total Compensation Bulletin, the 1999 GM stock option prospectus and plain language version, and the additional stock option information that Mr. Williams was to have received in the Fall of 1999 with specifics on how to exercise the option. June 20, 2002 Page 2 of 2 With regard to the savings stock purchase program, we need the value of that program on the date of the parties' marriage. I note that all of the loans against the program have been taken subsequent to separation and possibly impair the ability of that entitlement to be alienated. Apparently Mr. Williams, post- separation, borrowed nearly the entire value of the savings stock option plan. Please provide the cash value of the State Farm Life Insurance policy, both as of the date of the marriage and as of the date of separation. Please advise whether Mr. Williams has retained his GM Life Insurance policy and whether it, too, has a cash value or is term life. Not until we receive this information will we be in a position to negotiate or litigate this case. I look forward to your soonest response. Very truly yours, SAIDIS, SHUFF, FLOWER & LINDSAY, P.C. CJL/tib Enclosure cc: Adelaida C. Williams E. Robert Elicker, II, Esquire (Div Mast) Gordon S Williams 5C Richland Ln Apt T12 Camp Hill, PA 17011-2476 Ma3, 14, 1999 Dear Salaried Employee: Congratulations! ' ' ' rformance in 1998 we are nleased to provide stock options once again to eligible U.S. and Based on General Motors business pe . . , . r ,. . · ,, ~. --a ~'~fits rein~rce GM's Canadian classified employees. Stock opnons, combmed w?h ~rour~ir~c.t pay~ ~aname pay cas, n, commi~nent to rovide a total compensation package that is aligneo wire business success ann continues to De compeuuve with premier indPutstfial compames of the Fomme 50. GM remains the only automonve manufacturer to offer broadbased stock options to its salasied workfotce. S . . -, :.u .u ..... mini'-, to "umhase GM's $1-2/3 nar value common stock at a pre-established price over a de~ period of time. GM provides ,to~k opnon, so you at3d y. our family. ?n .m~ctly ~sn,~eJ~./~t~a~eC~2~ [,~e~screate. Provided below is a histo~ of the stock option grants you recmve~ as part ot me lvvo anu· Grant Date Number of Stock Option~ January 11, 1999 75 Januar~ 12, 1998 75 Stock Option 1Mce $85.97 U.S. $56.00 U.S. Please note that in connection with the complete separation of Delphi ,A, utomofve Systems, the number of shares ~nd .the stock option orice, associated with both giants, will be adlusted to reflect GM s lower stock price. Although the stock price ts expected to be ldwer, the value of your options will be preserved when a formula, prescribed by the Generally Accepted Accounting Principles, is used to adlust bqth the numbe~ of shares .c.o.ve~d~ b.~o~u~t~tanding 9.P, nO~ _a_n_ ~ctt~.ue~e3re..r~c~s~eS~saT~fi;sni~3fu°llennfian~°n will be cornmumcated, following the sepasanon aate or ~ay ~, ~v'~v, m a specmt emu,m Enclosed is the 1999 GM Stock Option Prospectus and Plan Language which have been re-written in a style that is easy to read. Refer to these documents for complete information conce.mi?' .gyour stocl5 option, grant. Als? incl?ed i~, ygur packet,~s a Benefici Desi anon Form. If you have not completed this form or w~sh t9 cnange your ~enenc]? 9es~gn.a.tton, {~e?e . complete~d re~n~ the form as soon as possible. If you completed a beneficiary form last year ano the oenenoary aestgnaaon remains the same, you do not need to complete another form. This Fall you will receive additional stock option information, insludi~g specifics on how. t(? exe,rcise yo.u.r 9ptip~s. If you ha~v~e an questions on the Stock Option Plan, your individual grant or destgnanon of your beneficiaries, p~ease cmt me ronowmg numoers based on your country ass~gnmetu: U.S. Employeea GM Investment Service Center 1-800489-GMGM (4646) Canadian Employees Fidelity Emplo..~ Service Centre 1-800-945.-GMGM (4646) Remember, when your actions support GM meeting its business objectives, you influence the long-term success of GM---an important element m determining the ultimate v.al. ue of your stock opngns. You~an h~e_{l~ GM m~t_ t~ts?~u~.m~SoSr~e~c~Tf~lSvbmYd improving the quality of your daily work, exceeding customer expectaaons, speemg uenvery, for salaried employees. You will be heanng more about mas lmnatav.e anna now y,our.mmre cash and/or stock opnons, can be enhanced when you help GM achieve greater ousmess success. Kathleen S. Barclay Vice President, Global Human Resources L,GM-STOCK-599 74541.001 SAIDIS SHUFF, FLOWER & LINDSAY Adelaida Castaneda Williams, Plaintiff, PENNSYLVANIA VS. Gordon Stanley Williams, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, : NO. 2001 -1617 .. : IN DIVORCE CIVIL TERM .P. LAINTIFF'S AFFIDAVIT OF CONSENT UNDER .~3301(c) OF THE DIVORCE CODI' .AND WAIVER OF COUNSELINR A Complaint in Divorce under §3301 (c) of the Divorce Code was filed March 21, 2001 The marriage of plaintiff and defendant is irretrievably broken and ninety 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. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unsworn falsification to authorities. PLAINTIFF'S WAIVER OF NOTICE OF INTENTION TO REQUE$ i ENTRY OF A DIVORCE DECREE UNDEFt .~ 3301 (c) OF THE DIVORCE COD~ 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 to the best of my knowledge, information and belief. I understand that false statement herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to uD,~,voF~ falsification to aut~'~rities ADELAIDA CASTANEDA WILLIAMS,: Plaintiff : : GORDON STANLEY WILLIAMS, : Defendant : THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 01 - 1~17 CIVIL IN DIVORCE ORDER OF COURT AND NOW, this JO 7~ ~ day of , 2004, the economic claims raised in the proceedings having been resolved in accordance with a marital settlement agreement dated March 30, 2004, the appointment of the Master is vacated and counsel can file a praecipe transmitting the record to the Court requesting a final decree in divorce. BY THE COURT, CC: ~<~rol J. Lindsay Attorney for Plaintiff ~/Andrew C. Spears Attorney for Defendant THIS AGREEMENT, made this ~ day of~/?~~,2004, by and between Gordon Stanley Williams (hereinafter "Husband") of Kentucky, :md Adelaida Castaneda Williams (hereinafter "Wife") of Arizona. WITNESSETH: WHEREAS, the parties are Husband and Wife, married on June 27, 1998, in Buffalo, NY; WHEREAS, no ch/ldren were bom of the marriage; WHEREAS, unhappy differences and difficulties have arisen between the parties, in consequence of which the parties intend to live separate and apa]:t for the rest of their natural lives; WHEREAS, Wife filed for divorce on March 20, 2001 which action is docketed to Cumberland County Docket No. 01-1617; WHEREAS, notwithstanding the filing of said divome complaint, Husband and Wife have been living separate and apart effectively since December 11, 1999; WHEREAS, the parties desire to settle fully and finally their respective financial and property rights and obligations as between each other, including, but not limited to, the ownership and equitable distribution of real and personal property; past, present and future support, alimony and/or maintenance; and any and all claims which either party has, or may have, against the other or the other's estate; and Document #: 243327 NOW, THEREFORE, in consideration of the mutual promises, covenants, and undertakings hereinafter set forth and for other good and valuable consideration, receipt of which the parties acknowledge, Husband and Wife, each intending to be legally bound, hereby covenant and agree as follows: 1. SEPARATION Each party shall have the right to live separate and apart from the other party, flee fi.om the other party's interference, authority, and control. Neither party shall interfere with the other or attempt to interfere with the other, nor compel the parties' cohabitation. 2. HUSBAND'S AND WIFE'S DEBTS Except as otherwise set forth in this Agreement, the parties represent and warrant to each other that they have not incurred and will not contract or incur arty debt or liability for which the other or the other's estate might be responsible. Each party shall indemrfify and save harmless the other party from any and all claims or demands made against the other by reason of debts or obligations incurred by that party. 3. WAIVER OF RIGHTS AND MUTUAL RELEASES Except as provided in this Agreement, both parties absolutely and unconditionally release and forever discharge each other and their heirs, executors, administrators, assigns, property, and estate from any and all rights, claims, demands, or obligations arising out of or by virtue of the marital relationship, whether such claims exist now or arise in ti're future. This release shall be effective regardless of whether such claims arise out of fonmer or future acts, contracts, engagements, or liabilities of the parties or by way of dower, curtesy, widow's rights, family 296138-1 exemption or similar allowance, or under the intestate laws, or the tight to take against the spouse's will, or the tight to treat a lifetime conveyance by the other as testamentary, or all other rights of a surviving spouse to participate in a deceased spouse's estate, whether arising under the laws of Pennsylvania, any state, commonwealth, or territory of the United States, or other country. Except for any cause of action for divorce which either pan~ may have or claim to have, and except for the obligations of the parties contained in this Agreement, each party gives to the other an absolute and unconditional release and discharge fi:om ail causes of action, claims, rights, or demands whatsoever, in law or in equity, which either party ever had or now has against the other, including, but not limited to, alimony, alimonypendente lite, spousal support, equitable distribution of marital property, counsel fees or expenses. 4. DIVISION OF PERSONAL PROPERTY Ali personal property currently in Husband's possession shall be the sole and separate property of Husband. All personal property currently in Wife's possession shall be the sole and separate property of Wife. It is acknowledged that Husband has been keeping Wife's furniture and personal items in storage at his home located at 9345 Joyce Lane, ttummelstown, Dauphin County, Pennsylvania. Wife has ninety (90) days fi.om the date of t. tfis Agreement to remove the furniture fi.om said home. Attached as Exhibit "A" and incorporated by reference is a list of personal property of Wife which Husband has been storing. Husband has not seen all of the items that are listed, but to the best of his ability warrants that the property is in the same condition as it was when removed fi.om a private storage facility. The only items known to be damaged are the wicker 296138-1 fumiture which due to space constraints had to be placed on the front porch and has been deter/orated by the weather. Provided Wife gives Husband 5 days notice, Husband will make the personal property on Exhibit "A" available to wife or her designated agent for pick up. 5. JOINT DEBTS The parties acknowledge that they have no debts which were jointly incurred during their marriage with the exception of the following: (a) Approximate Account Student loans to Direct Loans (Amount consolidated on March 22, 1999) $ 21,105.98 Amount owed after repayment by 9/21//23: $ 36,232.02 Amount paid so far: $ 4,844.50 Balance owed: $ 31,387.52 Balance Due Husband shall be solely responsible for 54% or $16,949.26 of the student loans. Wife shall be solely responsible for 46% or $14,438.26 of the Direct Loan account. Commencing February 2004, the monthly payment due on the Direct Loans will be $145.31. Husband will be responsible for 54% of this payment or the amount of $78.47. Wife will be responsible for 46% of this payment in the amount of $66.84. Wife shall make the monthly payment directly to Husband. In the event, Wife can pay offher balance owed in a lump sum prior to 9/21/23, she will be discharged from paying the monthly amount to Husband. 296138-1 For the purposes of this paragraph only, Husband and Wife agree to keep each other aware of their respective addresses so payment of this debt can be made. Wife's current address is 260 South Laveen Drive, Chandler, Arizona 85226. Husband's ctrrrent address is Box 2134, 2825 Lexington Road, Louisville, Kentucky 40280. Any debts or obligations incurred by either party in his/her individual name, other than those specified herein, whether incurred before or after separation, are the sole responsibility of the party in whose name the debt or obligation was incurred. 6. RETIREMENT BENEFITS During the marriage Husband had a savings stock purchase plan with General Motors Corporation through his prior employment with General Motors. Husband agrees to pay Wife the sum of Seven Thousand Five Hundred Dollars ($7,500.00) in settlement of Wife's claims for the marital portion of the savings stock purchase plan. Husband agree~ to pay this amount within thirty (30) days of the date of signing of this agreement. Husband also owns 75 shares of General Motors stock. V~rife specifically waives, releases, renounces and forever abandons all of her right, title, interest or claim, whatever it may be, in any stocks, whether acquired through Husband's employment or otherwise, and hereinafter said shares of stock shall become the sole and separate property of Husband. 7. DIVISION OF BANK ACCOUNTS Husband and Wife acknowledge that all joint bank accounts have been closed or divided to their mutual satisfaction prior to the execution of this Agreement. 296138-1 8. AFTER-ACQUIRED PROPERTY Each of the parties shall own and enjoy, independently of any claims or rights of the other, all real property and all items of personal property, tangible or intangible, hereaftcn' acquired, with full power to dispose of the same as fully and effectively as though he or she were unmarried. Any property so acquired shall be owned solely by that party and the other party shall have no claim to that property. 9. SPOUSAL SUPPORT, ALIMONY PENDENTE LITE, AND ALIMONY Husband and Wife waive and relinquish all rights, if may, to spousal support, alimony pendente lite, and alimony. Any transfer of monies between the parties pursuant to any term of this Agreement shall not constitute alimony, but is made as part of the parties' equitable distribution. 10. TAX MATTERS The parties have negotiated this Agreement with the understanding and intention to divide their marital property. The parties have determined that such division conforms to a right and just standard with regard to the rights of each party. The division of existing marital property is not, except as may be otherwise expressly provided herein, intended by the parties to constitute in any way a sale or exchange of assets. It is understood that the property transfers described in this Agreement fall within the provisions of Section 1041 of the Internal Revenue Code, and as such will not result in the recognition of any gain or loss upon the transfer by the transferor or transferee. 296138-1 11. COUNSEL FEES AND EXPENSES Except as otherwise specified herein, each party shall be responsible for payment of his/her own counsel fees and expenses. 12. ADVICE OF COUNSEL The parties acknowledge that each has received or has had the oppommity to receive independent legal advice fi.om counsel of their selection and that they have been informed fully as to their legal rights and obligations, including all rights available to them under the Pennsylvania Divome Code of 1980, as amended, and other applicable laws. Each party confirms that he/she understands fully the terms, conditions, and provisions of this Agreement and believes them to be fair, just, adequate, and reasonable under the existing cimumstances. The parties further confirm that each is entering into this Agreement freely and voluntarily and that the execution of th/s Agreement is not the result of any duress, undue influence, collusion, or improper or illegal agreement. 13. AFFIDAViTS OF CONSENT Each party agrees to execute an Affidavit of Consent for the obtaining of a no-fault divorce under the provisions of the Divome Code of 1980, as amended. 14. EFFECT OF DIVORCE DECREE ON AGREEMENT Either party may enfome this Agreement as provided in Section 3105(a) of the Divorce Code, as amended. 296138-1 As provided in Section 3105(c), provisions of this Agreement regarding equitable distribution, alimony, alimony pendente lite, counsel fees or expenses shall no_3t be subject to modification by the court. 15. DATE OF EXECUTION The" ' "" ' " date of execution , date of this agreement , or "execution date" of this Agreement is the date upon which it is signed by the parties if they sign the Agreement on the same date. Otherwise, the "date of execution", "date of this agreement", or "execution date" shall be the date on which the last party signed this Agreement. 16. HEADINGS NOT PART OF AGREEMENT The descriptive headings preceding the paragraphs are for convenience and shall not affect the meaning, construction, or effect of this Agreement. 17. SEVERAB1LITY AND INDEPENDENT AN~ SEPARATE COVENANTS Each separate obligation shall be deemed to be a separate: and independent covenant and agreement. If any term, condition, clause, or provision of this Agreement shall be determined or declared to be void or invalid in law or otherwise, then only 'that term, condition, clause, or provision shall be stricken from this Agreement and in all other respects this Agreement shall be valid and continue in full force, effect, and operation. 18. AGREEMENT BINDING ON HEIR S This Agreement shall be binding on and shall enure to the benefit of the parties and their respective heirs, executors, administrators, successors, and assigns. 296138-1 19. INTEGRATION This Agreement constitutes the entire understanding of the parties and supersedes any and all prior agreements and negotiations between them. There are no representations, warranties, covenants, or promises other than those expressly set forth in this Agreement. 20. MODIFICATION OR WAIVER TO BE IN WRITING No modification or waiver of any term of this Agreement shall be valid unless in writing and signed by both parties. 21. NO WAIVER OF DEFAULT The failure of either party to insist upon sthct performance of any term of this Agreement shall in no way affect the fight of such party hereafter to enforce th{.' term. 22. VOLUNTARY EXECUTION The parties acknowledge that this Agreement is fair and equitable, and that they have reached this Agreement freely and voluntarily, without any dures~, undue influence, collusion, or improper or illegal agreements. 23. APPLICABLE LAW This Agreement shall be construed under the laws of the Commonwealth of Pennsylvania and more specifically under the Divome Code of 1980, as amended. 24. ATTORNEYS' FEES FOR ENFORCEMENT If either party breaches any provision of this Agreement, the breaching party shall pay all reasonable legal fees and costs incurred by the other in enfoming tlz[s Agreement, providing that the enforcing party is successful in establishing that a breach has occurred. 296138-1 IN WITNESS WHEREOF, the parties have set their hands and seals the day and year first written above. WITNESS: Gordon Sttmley WilliamsC/ ~~~el'air~a Cas~eneda William[ ~'' -- 296138-1 In the Court of Connnon Pleas of CUMBERLAND DOMESTIC RELATIONS SECTION County, Pennsylvania ADELAIDA C. WILLIAMS Plaimiff vs. GORDON S. WILLIAMS Defendant ) Docket Number ) ) PACSES Case Number ) ) Other State ID Number 01-1617 CIVIL 924103734 ORDER AND NOW, to wit, on this 9TH DAY OF JUNE, 2004 IT IS HEREBY ORDERED that the support order in this case be O Vacated or OSuspended or ~) Terminated without prejudice or O Terminated and Vacated, effective Jim-uaa¥ l, 20o4 , due to: AN AGREEMENT OF THE PARTIES. THERE IS NO BALANCE :DUE THE PLAINTIFF. DRO: RJ Shadday xc: plaintiff defendant ~ Carol Lindsay, Esquire Andrew Spears, Esquire · ~ ;~?~.;~ Edgar Bi-Bhyley t \, Service Type M JUDGE Form OE-504 Worker ID 21005 ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT State Commonwealth of Pennsylvania Co./City/Dist. of CU~mER~¢~ Date of Order/Notice o6/o9/04 Tribunal/Case Number (See Addendum for case summary) RE: WILLIAMS, GORDON $. EmployerA, Vithholder's Federal EIN Number PENSION ADMINISTRATION CENTER PO BOX 5014 SOUTHFIELD MI 48086-5014 C) Original Order/Notice C) Amended Orde#Notice Terminate Order/Notice Employee/Obli§or's Name (Last, First, MI) 366-40-0477 Employee/Obligor's Social Security Number 0322'100482 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 CUM~ER.~'ffD 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. $ o. o0 per month in current support $ 0.00 per month in past-due support Arrears 12 weeks or greater? C)yes (~) no $ o. 0o per month in medical support $ o. oo per month for genetic test costs $ per month in other (specify) for a total of $ 0.00 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: $ o. 00 per weekly pay period. $ o. oo per biweekly pay period (every two weeks). $ o. 0o per semimonthly pay period (twice a month). $ o. 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 paydateJdate 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. Date of Order: '~ ]' 0 ~I]~]!! Form EN-028 Service Type M OMB No.: 097~0154 WorkerID $OINC ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS [~ Ifcheckedyouarerequiredtoprovideacopyofthisformtoyour m oyee. Ifyo remployee o sinastatetha is different trom the state that issued this order, a copy must be prov c~e~:f°~o your emp~Joryee even if tv~grl~ox is not che~ctked. 1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned businesses located on a reservation that choose to withhold in accordance with this notice. 2. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income. Federal tax levies in effect before receipt of th is order have priority. If there are Federal tax levies in effect please contact the requesting agency listed below. 3. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each employee/obligor. pay ..................... ~ ............. ~h;,~h ............... ~ ............ ~ ............ ~ "'~ ,°y ............ ...................................... p,c,~e~'$ wages. You must comply with the law of the state of the employee's/obi gor's pr nc~pa p ace of employment w~th respect to the t~me penods w~thm 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 #t0 below) 6. 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. W THHOLDER'S ID. 3146100172 EMPLOYEE'S/OBLIGOR'S NAME: WILLI.~J~S, GORDON S. EMPLOYEE'S CASE IDENTIFIER:. 0322:1.00482 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 Y°U 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. 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 lin 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 (t 5 U.S.C. § 1673 (b)l; 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 1~ 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 (7'~ or by FAX at (Z1 7) 240-6248 or by internet www.childsupport.state.pa.us Service Type M Page 2 of 2 Form EN-028 OMB NO.: 0970-0154 Worker ID $OINC ADELAIDA CASTANEDA WILLIAMS, Plaintiff GORDON STANLEY WILLIAMS, Defendant COURT OF COMMON PLEAS OF CUMBERLA2qD COUNTY, PENNSYLV.)~qlA NO. 2001-1617 CIVIL TERM IN DIVORCE ACCEPTANCE OF SERV~ICE_ I, Andrew C. Spears, Esquire, accepted service of the Complaint in Divorce on behalf of Defendant Gordan Stanley Williams on March 25, 2001, and certify that I was authorized to do so in accordance with Pa. R.C.P. 402. Dated: July 2, 2004 308138-1 ADELAIDA CASTANEDA WILLIAMS, Plaintiff GORDON STANLEY WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE AFFIDAVIT OF CONSENT 1. A Complaint in Divorce under § 3301(c) of the Divorce Code was filed on March 21, 2001 and served upon Defendant on March 25, 2001. 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. 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 tree and correct. I understand that any false statements herein are made subject to the penalties of 18 Pa.C.S., § 4904, relating to unswom falsification to authorities. Dated: 280208-1 ADELAIDA CASTANEDA WILLIAMS, Plaintiff GORDON STANLEY WILLIAMS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COLrNTY, PENNSYLVANIA NO. 2001-1617 CIVIL TERM IN DIVORCE WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE UNDER § 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 ifI 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 unswom falsification to authorities. Dated: ~lon ~dtanley Williams 280208-1 SAIDIS SHUFF, FLOWER & LINDSAY 26 W. High Street Carlisle, PA Adelaida Castaneda Williams, Plaintiff, vs. Gordon Stanley Williams, Defendant. To the Prothonotary: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2001 ..1517 CIVIL IERM .. : : IN DIVORCE Transmit the record, together with the followiing information, to the court for entry of a divorce decree: 1. Ground for divome: irretrievable breakdown under Section 3301(c) 3301(~)(1) of the Divorce Code. (Strike out inapplicable section). 2. Date and manner of service of the complaint: Acceptance of Service on Mamh 25, 2001 signed by Andrew C. Spears, Attorney for the Defendant and filed with Prothonotary on July 10, 2004. (copy enclosed) 3. (Complete either paragraph (a) or (b)). (a) Date of execution of the affidavit of consent required by Section 3301(c) of the Divome Code: by the Plaintiff Mamh 30, 2004; by the Defendant July ].6, 2004. Related claims pending: Nonn: Rn.~olv~.d by MArital Property Settl~.ment and Sep~rntion Agre~.ment dat~.d March 30: 2004, Complete either (a) or (b). (a) Date and manner of service of the notice of intention to file praecipe to transmit record, a copy of which is attached: (b) Date Plaintiffs Waiver of Not,ice in 3301(c) Divorce was filed with the Prothonotary: April 2g, 2004. Date Defendant's Waiver of Hotice in 3301(c) Divorce was filed with the Prothonotary: July21, 04 - Caror J~ Cin~lCa~, Eqq uire Suprem,~ Cc(.~rt I~,A4693 Saidis, Shuff,-FTower & Lindsay 26 West High Street Carlisle IPA 17013 Phone: 717.243.6222 Attorney for Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY STATE OF PENNA. ADELAIDA CASTANEDA WILLIAMS Plaintiff VERSUS GORDON STANLEY WILLIA~ Defendant N o. 2001-1617 DECREE IN DIVORCE '?~1:~, IT IS ORDERED AND AND NOW, AND Gordon Stanley Williams ARE DIVORCED FROM THE BONBS OF MATRIMONY. , PLAINTIFF, , DEFENDANT, THE COURT RETAINS JURISDICTION OF THE FOLLOWING CLAIMS WHICH HAVE BEEN RAISED OF RECORD IN THIS ACTION FOR WHICH A FINAL ORDER HAS NOT YET BEEN ENTERED; None: The terms of the marital settlememt agreement dated March 30, 2004 are incorporated but not merged into the Decree in Divorce. BY THE COURT: ATTEST: PROTHONOTARY