HomeMy WebLinkAbout92-139214 - • ,
INCOME WITHHOLDING FOR SUPPORT
Q ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
Q AMENDED IWO
O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT
RE: ANDERSON. JAMES T.
Q TERMINATION OF IWO y. Date: o1/obn2
i
? Child Support Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One)
NOTE: This IWO must be reg6{t l-o4 itsftyle. Under certain circumstances you must reject this IWO and return it to the sender (see IWO
instructions http:l acf hhs gov7r%rograms/cse/newhire/employer/publication/publication htm -forms). If you receive this document from
someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached.
State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier (include w/payment): 0190000025
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket lnforma/ton)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
DAYS INN
239 W MAIN ST
WAYNESBORO PA 17268-1521
Employee/Obligor's Name (Last, First, Middle)
163-342563
Employee/Obligor's Social Security Number
(See Addendum for plaintiff names
associated with cases on attachment)
Custodial Party/Obligee's Name (Last, First,
Middle)
Employer/Income Withholder's FEIN
Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s)
NOTE: This IWO must be regular on its face.
Under certain circumstances you must reject this
IWO and return it to the sender (see IWO
instructions
D (0 DD DD A10
Ga CIUI I
C1
emplover/publication/publication.htm - forma. If
you receive this document from someone other
than a State or Tribal CSE agency or a Court, a
copy of the underlying order must be attached.
See Addendum for dependent names and birth dates associated with cases on attachment, c `
ORDER INFORMATION: This document is based on the support or withholding order from CUM AID C
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these am ounts fhe?rtp
obligor's income until further notice. -<> uo S
$ 0.00 per month in current child support i
C ..a r}
$ 0.00 per month in past-due child support - Arrears 12 weeks or greater? ye C ri>!i: 7
$ 0.00 per month in current cash medical support
$ 0.00 per month in past-due cash medical support = rv }
$ 0.00 per month in current spousal support
b.
$ 0.00 per month in past-due spousal support
$ 0.00 per month in other (must specify)
for a Total Amount to Withhold of $ 0.00 per month.
AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information.
If your pay cycle does not match the ordered payment cycle, withhold one of the following amount:
$ 0.00 per weekly pay period. $ 0.00 per semimonthly pay period (twice a month)
$ 0.00 per biweekly pay period (every two weeks) $ 0.00 per monthly pay period.
$ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is CUMBERLAND County,
Commonwealth of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that
occurs ten (10) working days after the date of this Order/Notice. Send payment within seven 7 working days of the
pay date. If you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up
to 55% of disposable income for all orders. If the employee/obligor's principal place of employment is not
CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe), obtain withholding limitations, time
requirements, and any allowable employer fees at http://www.acf.hhs.gov/programs/cse/newhire/employer/contacts/
contact map.htm for the employee/obligor's principal place of employment.
Document Tracking Identifier
Service Type M
OMB No.: 097"154
Form EN-028 11/11
Worker ID $IATT
? Return to Sender [Completed by Employerlincome Withholder]. Payment must be directed to an SDU in
accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not
directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to
the sender.
Signature of Judge/Issuing Official (if required by State or Tribal law): %
Print Name of Judge/Issuing Official: MI. i
Title of Judge/Issuing Official:
Date of Signature: _IAN n c 7(117
If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO
must be provided to the employee/obligor.
? If checked, the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered
to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of
two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and
Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER /D (shown above as
the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
htto://www.acf.hhs.aov/ roarams/cse/`newhirelemfoyer/contacts/contact map htm
Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42
§666(b)(7)). If a Federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from
more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/
obligor's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a
Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial
party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent
by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was
issued by a Tribal CSE agency, you must follow the "Remit payment to" instructions on this form.
Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the
amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if
applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement
the withholding and forward the support payments.
Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to
Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current
support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal
place of employment to determine the appropriate allocation method.
Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this
employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to
report and/or withhold lump sum payments.
Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the
employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and
any penalties set by State or Tribal law/procedure.
Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from
employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
OMB Expiration Date - 05/3112014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use.
Form EN-028 11/11
Service Type M Page 2 of 3 Worker ID $IATT
Employer's Name: DAYS INN Employer FEIN:
Employee/Obligor's Name: ANDERSON, JAMES T.
CSE Agency Case Identifier: (See Addendum for case summary) Order Identifier: (See Addendum for order/docket information
Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection
Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor's principal place of
employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such
as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal limit is 50% of
the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting
another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitted by the State
or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in
this section.
For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income
withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which
the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)).
Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in
determining disposable income and applying appropriate withholding limits.
Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the
Employer should calculate the CCPA limit using the lower percentage.
Additional Information:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you a
no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by
returning this form to the address listed in the Contact Information below:
Q This person has never worked for this employer nor received periodic income.
O This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date:
Last known address:
Final Payment Date To SDU/Tribal Payee:
New Employer's Name:
New Employer's Address:
Last known phone number:
Final Payment Amount:
CONTACT INFORMATION:
To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT (Issuer name)
by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at: www.childsupport.state.ga.us.
Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST.
P.O. BOX 320 CARLISLE PA 17013 (Issuer address).
To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT (Issuer name)
by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at www.childsupport.state. pa. us.
IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.
Service Type M
OMB No.: 0970-0154
Page 3 of 3
Form EN-028 11/11
Worker ID $IATT
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: ANDERSON, JAMES T.
PACSES Case Number 062000023 PACSES Case Number
Plaintiff Name Plaintiff Name
MARY ANDERSON
Docket Attachment Amount Docket Attachment Amount
92-1392 CIVIL $ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s):
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
DOB
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
DOB
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
DOB
Addendum Form EN-028 11 /11
Service Type M OMB No.: 0970-0154 Worker ID $IATT
In the Court of Common Pleas of CUMBERLAND County, Pennsylvania
DOMESTIC RELATIONS SECTION
13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013
Phone: (717) 240-6225 Fax: (717) 240-6248
Defendant Name: JAMES T. ANDERSON
Member ID Number: 0190000025
Please note: All correspondence must include the Member ID Number.
MODIFIED ORDER OF ATTACHMENT OF UNEMPLOYMENT BENEFITS
Financial Break Down of Multip le Cases on Attachment N
Plaintiff Name PACSES
Case Number Docket
Number 1E?i C r?t?
Attachment nt/FfTquenn r
MARY ANDERSON 062000023 92-1392 CIVIL 1 a / %34T2
--t 4
--?/
$/ Cn
t.J
TOTAL ATTACHMENT AMOUNT: $ 100.00
Now, by Order of this Court, the Department of Labor and Industry, Office of Unemployment
Compensation Benefits (OUCB), is hereby directed to attach the lesser of $23.01 per week, or 55.0%,
the Unemployment Compensation benefits otherwise payable to the Defendant, JAMES T. ANDERSOI
Social Security Number XXX-XX-2563, Member ID Number 0190000025. OUCB is ordered to remit tt
amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received
from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages.
If the Defendant's Unemployment Compensation benefits are attached by another Court or
Courts for support and/or support arrearage, DPW may reduce the amount attached under this Order sc
that the total amount attached does not exceed the maximum amount subject to garnishment pursuant t
15 U.S.C. § 1673(b)(2) and 23 Pa. C.S. § 4348(g).
This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall
remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the
Application for Benefits dated NOVEMBER 14, 2010 is exhausted, expired or deferred.
OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of thi;
Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations
Section of this Court.
BY THE COURT
Date of Order: JUL 18 2012
Service Type M
t
M..L. EbW, Jr U JUDGI
Form EN-034
Worker ID $IATT
e
r 1?
INCOME WITHHOLDING FOR SUPPORT
ORIGINAL INCOME WITHHOLDING ORDERMOTICE FOR SUPPORT (IWO)
Q AMENDED IWO rr77 (fin
O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT V/
Q TERMINATION OF IWO Date: 07/18/12
? Child Support Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One)
NOTE: This IWO mush bgf"P op ks face. Under certain circumstances you must reject this IWO and return it to the sender see IWO
instructions httD://www acf hhs gov%pmgrams/cse/newhire/employer/publication/publication htm - forms). If you receive this document from
someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached.
State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier (include w/payment): 0190000025
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for ordeddocket lnformalton)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
SOCIAL SECURITY ADMINISTRATION
STE 1
200 S SPRING GARDEN ST
CARLISLE PA 17013-2578
Employer/Income Withholder's FEIN
Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s)
RE:
Employee/Obligor's Name (Last First, Middle)
163-34-2563
Employee/Obligor's Social Secu ity Number
(See Addendum for plaintiff n mes
associated with cases on attachment)
Custodial Party/Obligee's Name (Last, First,
Middle)
NOTE: This IWO must be regular on its face.
Under certain circumstances you 1 ust reject
this IWO and return it to the send r (see IWO
instructions
http://www.acf.hhs,gov/prourams/
wh'r 1
m l r li i n i i .h m- form . If
you receive this document from s meone other
than a State or Tribal CSE agency or a Court, a
copy of the underlying order must be attached.
8384100092
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLANE
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the e
obligor's income until further notice.
$ 0.00 permonth in current child support
$ 0.00 per month in past-due child support - Arrears 12 weeks or greater? yeses
$ 0.00 per month in current cash medical support --aZ iv
$ 0.00 per month in past-due cash medical support rn
G
$ 0.00 per month in current spousal support 2r r"
$ 100.00 per month in past-due spousal support _<
$ 0.00 per month in other (must specify) r-X
for a Total Amount to Withhold of $ 100.00 per month. _
y:c t`a
AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the *dW:lrlf
If your pay cycle does not match the ordered payment cycle, withhold one of the following amount:~< w
$ 23.01 per weekly pay period. $ 50.00 per semimonthly pay period (twi(
$ 46.03 per biweekly pay period (every two weeks) $ 100.00 per monthly pay period.
$ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is within the oml
of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs en
working days after the date of this Order/Notice. Send payment within seven 7 working days of the pay d
you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to
disposable income for all orders. If the employee/obligor's principal place of employment is not within the
Commonwealth of Pennsylvania (State/Tribe), the employer can obtain withholding limitations, time require
and any allowable employer fees at http://www acf hhs gov/programs/cse/newhire/employer/contacts/conts
htm for the employee/obligor's principal place of employment.
Document Tracking Identifier
c:
? r.._
c=
`fI
a month)
If
of
OMB No.: 0970-0154 Form EN-028 0 /12
Service Type M Worker ID $OI C
? Return to Sender [Completed by Employer/income Withholder]. Payment must be directed to an SDU in
accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not
directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to
the sender. rl_ - % Ito
Signature of Judge/Issuing Official (if required by State or Tribal law):
Print Name of Judge/Issuing Official:
Title of Judge/Issuing Official:
Date of Signature:
If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO
must be provided to the employee/obligor.
? If checked, the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic - payment method if an employer is ordered
to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of
two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and
Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER /D (shown above as
the Employee/Obligor's Case /dent/t7er) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
hh tp://w v acf hhs gov/prouramsicse/`newhire/empllo_yer/contacts/contact_map htm
Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42
§666(b)(7)). If a Federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from
more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/
obligor's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a
Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial
party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent
by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1 1994 or the order was
issued by a Tribal CSE agency, you must follow the "Remit payment to" instructions on this form.
Reporting the, Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the
amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if
applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement
the withholding and forward the support payments.
Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to
Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current
support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal
place of employment to determine the appropriate allocation method.
Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this
employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to
report and/or withhold lump sum payments.
Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the
employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and
any penalties set by State or Tribal law/procedure.
Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from
employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
OMB Expiration Date - 05/31/2014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use.
Form EN-028 06/12
Service Type M Page 2 of 3 Worker ID $OINC
Employer's Name: SOCIAL SECURITY ADMINISTRATION Employer FEIN:
Employee/Obligor's Name: ANDERSON JAMES T. 0190000025
CSE Agency Case Identifier: [See Addendum for case s„ Marv) Order Identifier: Addendum for order
/doc et info atio
Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection
Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor's principal plac of
employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory ded ctions such
as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal li it is 50% of
the disposable income if the obligor is supporting another, family and 60% of the disposable income if the obligor is not su portin
another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitt d by the State
or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit i dicated in
this section.
For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal emp oyers/income
withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdicti n in which
the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S. . 1673 (b)).
Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premium in
determining disposable income and applying appropriate withholding limits.
Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the
Employer should calculate the CCPA limit using the lower percentage.
Additional Information:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for yo or you
no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sen er by
returning this form to the address listed in the Contact Information below: 838 100092
Q This person has never worked for this employer nor received periodic income.
O This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date: Last known phone number:
Last known address:
Final Payment Date To SDU/Tribal Payee:
New Employer's Name:
New Employer's Address:
CONTACT INFORMATION:
Final Payment Amount:
To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT (Issuer name)
by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at: www.childsupportstate. pa us.
Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SFCTION, 1 N. Hi
P.O. BOX 320, ARLISLE PA 17013 (Issuer address).
To Em looyee/Obligor• If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT (Issuer name)
by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at www childsupport state oa us.
IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.
Service Type M
OMB No.: 0970-0154
Page 3 of 3
Form EN-028 06/1
Worker ID $OINC
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: ANDERSON, JAMES T.
PACSES Case Number 062000023
Plaintiff Name
MARY ANDERSON
92-1392 CIVIL $ 100.00
Child(ren)'s Name(s): DOB
PACSES Case Number
Plaintiff Name
pocket A=hment Amount
$ 0.00
Child(ren)'s Name(s): DOB
PACSES Case Number
Plain iff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
Service Type M
PACSES Case Number
Plaintiff Name
Docket Attach neaAmQuM
$ 0.00
Child(ren)'s Name(s): DOB
PACSES Case Number
Plaintiff Name
Docket Attachment Amour
$ 0.00
Child(ren)'s Name(s): DOB
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
Addendum
OMB No.: 0970-0154
Form EN-028 06/12
Worker ID $OINC
INCOME WITHHOLDING FOR SUPPORT n
O ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
O AMENDEDIWO
O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT Cw ?4?j C1 U'1 l
O TERMINATION OF IWO
Date: 07/24/12
? Child Support Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One)
NOTE: This IWO mL@t ",Miuilar omits face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO
instructions h :// ov/programs/cse/newhire/emDloyer/Dublication/publication htm forms). If you receive this doc ment from
someone other than a S ate or Tribal CSE agency or a Court, a copy of the underlying order must be attached-
State/Tribe/Territory Commonwealth of Pennsylvania
City/County/Dist./Tribe CUMBERLAND
Private Individual/Entity
SOCIAL SECURITY ADMINISTRATION
STE 1
200 S SPRING GARDEN ST
CARLISLE PA 17013-2578
Employer/Income Withholder's FEIN
Child(ren)'s Name(s) (Last, First, Middle)
Remittance Identifier (include w/payment): 0190000025
Order Identifier: (See Addendum for order/docket informaiton)
CSE Agency Case Identifier: (See Addendum for case summary)
Child(ren)'s Birth Date(s)
RE: ANDERSON JAMES T.
Employee/Obligor's Name (Last, First, Middle)
163-342563
Employee/Obligor's Social Secu ity Number
(See Addendum for plaintiff names
associated with cases on atta hment)
Custodial Party/Obligee's Name Last, First,
Middle)
NOTE: This IWO must be regular n
face.
Under certain circumstances you n
this IWO and return it to the sende
instructions ;
h f. h v r r m
employ r ublication/D li ' n h If
you receive this document from so er
than a State or Tribal CSE agency or a Court, a
copy of the underlying order must a attached.
8384100092
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAP
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the
obligor's income until further notice.
$ 0.00 per month in current child support
'"''
$ 0.00 per month in past-due child support - Arrears 12 weeks or greater? O yes C= C_J
$ 0.00 per month in current cash medical support MW w
$ 0.00 per month in past-due cash medical support =M f-
$ 0.00 per month in current spousal support c ,r N
$ 0.00 per month in past-due spousal support r-;r--
$ 0.00 per month in other (must specify)
for a Total Amount to Withhold of $
0.00 per month. ?o
S},? tV
AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the CVer ?or
If your pay cycle does not match the ordered payment cycle, withhold one of the following amount:
$ 0.00 per weekly pay period. $ 0.00 per semimonthly
$ 0.00 per biweekly pay period (every two weeks) $ Pa period (twice
) 0.00 per monthly pay period.
$ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is within the Commor
of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs ten 10
working days after the date of this Order/Notice. Send payment within even 7 working days of the pay date
you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to 5,7
disposable income for all orders. If the employee/obligor's principal place of employment is not within the
Commonwealth of Pennsylvania (State/Tribe), the employer can obtain withholding limitations, time requiremel
and any allowable employer fees at http: /www act hhs aov/programs/cse/newhire/empl yDr/contacts/contact
htm for the employee/obligor's principal place of employment.
Document Tracking Identifier
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OMB No.: 0970-0154
Form EN-028 061 2
Service Type M Worker ID $OINC
? Return to Sender [Completed by Employerlincome Withholder]. Payment must be directed to an SDU in
accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not
directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to
the sender. DDA
Signature of Judge/Issuing Official (if required by State or Tribal law):
Print Name of Judge/Issuing Official:
Title of Judge/issuing Official:
Date of Signature: 7 - 24 - /.L-
If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO
must be provided to the employee/obligor.
? If checked, the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic oaayM2nt hod if an employer is ordered
to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of
two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and
Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as
the Employse?0bligor's Case Iclentitler) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
n4tn /l?aatiti?? acf hhs,g0?program4rese/ne hire el 2, (11 r/ contacts/contact man.htm
Priority: Withholding for support has priority over any other legal process under State law against the same income (USG 42
§666(b)(7)). If a Federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from
more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/
obligor's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a
Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial
party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent
by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was
issued by a Tribal CSE agency, you must follow the "Remit payment to" instructions on this form.
Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the
amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if
applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement
the withholding and forward the support payments.
Multiple IWOs If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to
Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current
support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal
place of employment to determine the appropriate allocation method.
Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this
employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to
report and/or withhold lump sum payments.
Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the
employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and
any penalties set by State or Tribal law/procedure.
Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from
employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
OMB Expiration Date - 05/31/2014. The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use.
Form EN-028 06/12
Service Type M Page 2 of 3 Worker ID $OINC
Employer's Name: SOCIAL SECURITY ADMINISTRATION Employer FEIN:
Employee/Obligor's Name: ANDERSON JAMES T.
0190000025
CSE Agency Case Identifier: (See Addendum for case cummarv) Order Identifier: (See A mfr r r k i f i
Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection
Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor's principal place of
employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory de uctions such
as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal I mit is 50% of
the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not s pportin
another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permi ed by the State
or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit ndicated in
this section.
For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal em loyers/incor
withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdic ion in which
the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S. . 1673 (b)).
Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in
determining disposable income and applying appropriate withholding limits.
Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the
Employer should calculate the CCPA limit using the lower percentage.
Additional Information:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you
no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the se der by
returning this form to the address listed in the Contact Information below:
83 41
00092
O This person has never worked for this employer nor received periodic income.
O This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date: Last known phone number:
Last known address:
Final Payment Date To SDU/Tribal Payee:
New Employer's Name:
New Employer's Address:
Final Payment Amount:
CONTACT INFORMATION:
To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT (Issuer name)
by phone at 717 240-6225, by fax at f717) 240-6248, by email or website at: www.childsupport state pa us.
Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 1 N. Hj
P.O. BOX 320-.CARLISLE- PA 17013 (Issuer address).
To E111I210Y99 Obliges If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT (Issuer name)
by phone at 717) 240-6225, by fax at (717) 40-6248, by email or website at www.chil s 1 stateoa us.
ci ?RDort
IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.
OMB No.: 0970-0154 Form EN-028 06/
Service Type M Page 3 of 3 Worker ID $OINC
AlaDE M M
De#en1E/Obligor: ANDERSON, JAMES T.
PACSES Case Number 062000023 PACSES Case Number
Plaintiff Name Plaintiff Name
MARY ANDERSON
M
QDGM-t Attachment A
cket Aachment Amount O
$ .00
92-1392 CIVIL $ 0.00 DOB Child(ren)'s Name(s): DOB
Child(ren)'s Name(s):
PACSES Case Number
PACSES Case Number
Plaintiff Name
Plaintiff Name
Docket AUc:hment amount
Docket Atta_ chment. Amount $ 0.00
$ 0.00 DOB Child(ren)'s Name(s): DOB
Child(ren)'s Name(s):
PACSES ase Number
PACSES base Number
aintiff Name
Pl
ntiff Name
Plai
Docket Atta hment Amount
Docket A achment Amount $ 0.00
$ 0.00 DOB Child(ren)'s Name(s): DOB
Child(ren)'s Name(s):
Service Type M
Addendum
OMB No.: 0970-0154
Form EN-028 06112
Worker ID $OINC
JAMES T. ANDERSON,
Plaintiff/Respondent
VS.
MARY ANDERSON,
Defendant/Petitioner
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - DIVORCE
NO. 92-1392 CIVIL TERM
IN DIVORCE
PACSES Case No: 062000023
ORDER OF COURT
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AND NOW to wit, this 24th day of July, 2012, it is hereby Ordered that
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Cumberland County Domestic Relations Section dismiss their interest in=?,.
-s
the above captioned alimony matter pursuant to the obligation ending and the -<
Petitioner remitting all arrears.
There is no balance due.
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This Order shall become final twenty (20) days after the mailing of the notices
the entry of the Order to the parties unless either party files a written demand with the
Office of the Prothonotary for a hearing de novo before the Court.
BY THE COURT:
N t ?" ?/
M. L. Ebert, Jr., J.
DRO: R.J. Shadday
xc: Petitioner
Respondent
Gary L. Kelley, Esq.
F
o -n
r?
Form OE-001
Service Type: M Worker: 21005
r, r
JUL 2 4 2012
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ob,
In the Court of Common Pleas of CUMBERLAND County, Pennsylvania
DOMESTIC RELATIONS SECTION
13 N. HANOVER ST, P.O. BOX 320, CARLISLE, PA. 17013
Phone: (717) 240-6225
Fax: (717) 240-6248
Defendant Name: JAMES T. ANDERSON
Member ID Number: 0190000025
Please note: All correspondence must include the Member ID Number.
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PACSES Docket Attachment Amount/Frequency
Plaintiff Name Case Number Number
MARY ANDERSON 062000023 92-1392 CIVIL 100.00 MONTH
TOTAL ATTACHMENT AMOUNT: $ 1uu.uu
The prior Order of this Court directing the Department of Labor and Industry, Office of
Unemployment Compensation Benefits (OUCB), to attach $23.01 or 50% per week of
Unemployment Compensation benefits of JAMES T. ANDERSON, Social Security
Number XXX-XX-2563, Member ID Number 0190000025 is hereby vacated.
This Order to Vacate shall be effective upon receipt of the notice of the Order by the
Department and shall remain in effect until a further Order of the Court is filed.
BY THE COURT
Date of Order: JUL 2 5 2012
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ne
M.L.'Ebett,.#f: 0 JIUD?E
Form EN-035
Service Type M Worker ID $IA
Financial Break Down of Multiple Cases on Attachment