HomeMy WebLinkAbout02-1763 NMINCOME WITHHOLDING FOR SUPPORT
C; d V Li `??z5 1
Q ORIGINAL INCOME WITHHOLDING ORDERlNOTICE FOR SUPPORT (IWO) 22 /?
Q AMENDED IWO U ?? (j J CI U I L
Q ONE-TIMEORDERMOTICE FOR LUMP SUM PAYMENT
0 TERMINATION OF IWO Date: 06/29/12
? Child Support Enforcement (CSE) Agency Z Court ? Attorney ? Private Individual/Entity (Check One)
NOTE: This 11yQLaWli try rrgtufa UnJts face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO
instructions htt[)://www acf hhs clov/programs/ese/newhire/employer/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.
State/Tribe/Territory Commonwealth of Pennsylvania Remittance wentlner tinciuae w/paymeny: iv44 wuw o
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket lnformalton)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
WILSON COLLEGE
1015 PHILADELPHIA AVE
CHAMBERSBURG PA 17201-1279
Employer/Income Withholder's FEIN 231352629 _
Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s)
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County,
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the employee/
obligor's income until further notice.
$ 0.00 per month in current child support
L
$ 0.00 per month in past-due child support - Arrears 12 weeks or greater? 0 yes a nd?; ` r
$ 0.00 per month in current cash medical support
o3 ' a'
$ 0.00 per month in past-due cash medical support =? C ! n
$ 0.00 per month in current spousal support =M r-- -vr--t
$ 0.00 per month in past-due spousal support -C> tV
$ 0.00 per month in other (must specify) <= ..0
C-) = C -rt
for a Total Amount to Withhold of $ 0.00 per month. 3
AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the r r Irkgrm0on.
If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: -< w
$ 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 within the Commonwealth
of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs n 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 within the
Commonwealth of Pennsylvania (State/Tribe), the employer can 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.
RE: KIME DONALD P.
Employee/Obligor's Name (Last, First, Middle)
209-36-5054
Employee/Obligor's Social Security Number
(See Addendum for plaintiff names
associated with cases on attachment)
Custodial Party/Obligee's Name (Last, First,
Middle)
NOTE: This IWO must be regular on its face.
Under certain circumstances you must reject
this IWO and return it to the sender (see IWO
instructions
http•//www acf hhs oov/Qroarams/cse/newhire/
em to over/publication/publication htm - form . If
you receive this document from someone other
than a State or Tribal CSE agency or a Court, a
copy of the underlying order must be attached.
2313526290
Document Tracking Identifier
Service Type M
OMB No.: 0970-0154
Form EN-028 06/12
Worker ID $IATT
? Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU ;,-,
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:
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 I WO
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 ID (shown above as
the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
http://www.acf.hhs. ov/programs/cse/`newhire/em loyer/contacts/contaclmap.ht„
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 $IATT
Employer's Name: WILSON COLLEGE Employer FEIN: 231352629
Employee/Obligor's Name: KIME, DONALD P. 1633100676
CSE Agency Case Identifier: (Se Addendum for case summarvl Order Identifier: (Spe Addendum for order/docket information)
Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit Protection
Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligor's principal place of
employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such
as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal limit is 50% of
the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not supporting
another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weeks. If permitted by the State
or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit indicated in
this section.
For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income
withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which
the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S.C. 1673 (b)).
Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in
determining disposable income and applying appropriate withholding limits.
Arrears greater than 12 weeks? If the Order Information does not indicate that the arrears are greater than 12 weeks, then the
Employer should calculate the CCPA limit using the lower percentage.
Additional Information:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you
no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by
returning this form to the address listed in the Contact Information below: 2313526290
Q This person has never worked for this employer nor received periodic income.
Q 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.pa.us.
Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST.
P .O. BOX 320, CARLISLE. PA. 17013 (Issuer address).
To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT (Issuer name)
by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at www.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 06/12
Worker ID $IATT
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: KIME, DONALD P
PACSES Case Number 027105881 PACSES Case Number
Plaintiff Name Plaintiff Name
CATHY J. KIME
Docket Attachment Amount Docket Attachment Amount
02-1763 CIVIL $ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
PACKS Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
PACKS Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
PACKS Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
Addendum Form EN-028 06/12
Service Type M OMB No.: 0970-0154 Worker ID $IATT
INCOME WITHHOLDING FOR SUPPORT OU
O ORIGINAL INCOME WITHHOLDING ORDERMOTICE FOR SUPPORT(IWO) Q� - / C/ V/
Q AMENDEDIWO
O ONE-TIMEORDERMOTICE FOR LUMP SUM PAYMENT
O TERMINATION OF IWO Date: 05/03/13
❑ Child Support Enforcement(CSE)Agency ® Court ❑ Attorney ❑ Private Individual/Entity(Check One)
NOTE:This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender(see IWO
instructions http•//www acf hhs gov/programs/cse/newhire/employer/publication/publication htm-forms). If you receive this document from
someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached.
State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 1633100676
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket informaiton)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
RE: KIME, DONALD P.
BUREAU OF COMMONWEALTH Employee/Obligor's Name(Last, First,Middle)
209-36-5054
Sent Electronically Employee/Obligor's Social Security Number
(See Addendum for plaintiff names
DO NOT MAIL
associated with cases on attachment)
Custodial Party/Obligee's Name(Last, First,
Middle)
Employer/Income Withholder's FEIN 232172299 NOTE:This IWO must be regular on its face.
Under certain circumstances you must reject
Child(ren)'s Name(s)(Last, First,Middle) Child(mn)'s Birth Date(s) this IWO and return it to the sender(see IWO
instructions
httr)://www.acf.hhs.gov/i)rograms/cse/newhire/
employer/publication/publication.htm-formsj. 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.
2321722990
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County,
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the employee/
obligor's income until further notice. C-) r
$ 0.00 per month in current child support 3
$ 0.00 per month in past-due child support- Arrears 12 weeks or greater? p yes rng not I'T=1-
$ 0.00 per month in current cash medical support
r
$ 0.00 per month in past-due cash medical support -<> Cn c
$ 1,100.00 per month in current spousal support r`-x
C
$ 0.00 per month in past-due spousal support �� C:) .:
$ 0.00 per month in other(must specify) �CD W
for a Total Amount to Withhold of$ 1,100.00 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:
$ 253.15 per weekly pay period. $ 550.00 per semimonthly pay period (twice a month)
$ 506.30 per biweekly pay period (every two weeks) $ 1,100.00 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 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,
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 requirements,
and any allowable employer fees at http•//www act hhs aov/programs/cse/newhire/employer/contacts/contact map
htm for the employee/obligor's principal place of employment.
Document Tracking Identifier
OMB No.:0970-0154 Form EN-428 06/12
Service Type M Worker ID $IATT
❑ Return to Sender[Completed by Employer/income Withholder). Payment must be directed to an SDU in
accordance with 42 USC §666(b)(5)and(b)(6)or Tribal Payee(see Payments to SDU below). If payment is not
directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to
the sender.
Signature of Judge/Issuing Official (if required by State or Tribal law): KEVIN A HESS
Print Name of Judge/Issuing Official:
Title of Judge/Issuing Official:
Date of Signature: MAY 3,2013
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 ID(shown above as
the Employee/Obligor's Case Identirter)OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
http://www.acf.hhs.ciov/proarams/cse/`newhire/emplo-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 ta employ, or taking disciplinary action against an employee/obligor because of this IWO.
OMB Expiration Date—0513112014.The OMB Expiration Date has no bearing on the termination date of the IWO;it identifiet,the version of the form currently in use,
Form EN-428 06/12
Service Type M Page 2 of 3 Worker ID$IATT
Employees Name: BUREAU OF COMMONWEALTH Employer FEIN: 232172299
Employee/Obligor's Name: KIME, DONALD P. 1633100676
CSE Agency Case Identifier:(See Addendum for case summa Order Identifier:(See Addendum for order/docket information
Withholding Limits:You may not withhold more than the lesser of. 1)the amounts allowed by the Federal Consumer Credit Protection
Act(CCPA)(15 U.S.C. 1673(b)); or 2)the amounts allowed by the State or Tribe of the employee/obligor's principal place of
employment(see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such
as:State, Federal, local taxes; Social Security taxes;statutory pension contributions;and Medicare taxes.The Federal limit is 50%of
the disposable income if the obligor is supporting another family and 60%of the disposable income if the obligor is not supporting
another family. However,those limits increase 5%-to 55%and 65%-if the arrears are greater than 12 weeks. If permitted by the State
or Tribe,you may deduct a fee for administrative costs.The combined support amount and fee may not exceed the limit indicated in
this section.
For Tribal orders,you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income
withholders who receive a State IWO,you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which
the employer/income withholder is located or the maximum amount permitted under section 303(d)of the CCPA(15 U.S.C. 1673(b)).
Depending upon applicable State or Tribal law,you may need to also consider the amounts paid for health care premiums in
determining disposable income and applying appropriate withholding limits.
Arrears greater than 12 weeks?If the Order Information does not indicate that the arrears are greater than 12 weeks,then the
Employer should calculate the CCPA limit using the lower percentage.
Additional Information:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are
no longer withholding income for this employee/obligor,an employer must promptly notify the CSE agency and/or the sender by
returning this form to the address listed in the Contact Information below: 2321722990
0 This person has never worked for this employer nor received periodic income.
0 This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date: Last known phone number:
Last known address:
Final Payment Date To SDLI/Tribal Payee: Final Payment Amount:
New Employer's Name:
New Employer's Address:
I
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.pa,us.
Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER SL
P.O. BOX 320, CARLISLE, EA. 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.
OMB No.:0970-015A Form EN-428 06/12
Service Type M Page 3 of 3 Worker ID $IATT
.J v
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: KIME, DONALD P.
PACSES Case Number 027105881 PACSES Case Number
Plaintiff Name Plaintiff Name
CATHY J. KIME
Docket Attachment Amount Docket Attachment Amount
02-1763 CIVIL $ 1,100.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
PACSES Case Number PACSES Case Number
Plaintiff Name Plaintiff Name
Docke Attachment Amount Docket Attachment Amount
$ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
PACSES Case Number PACSES Case Number
Plaintiff Name Plaintiff Name
Docket Attachment Amount Docket Attachment Amount
$ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
Addendum Form EN-428 06/12
Service Type M OMB No.:0970-0154 Worker ID $IATT
INCOME WITHHOLDING FOR SUPPORT b9-7 I DS Rs C
O ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO) _ CI VI
I
Q AMENDED IWO
Q ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT
Q TERMINATION OF IWO Date: 05106/13
❑ Child Support Enforcement(CSE)Agency ® Court ❑ Attorney ❑ Private Individual/Entity(Check One)
NOTE:This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender(see IWO
instructions http•//www acf hhs gov/programs/cse/newhire/employer/publication/publication htm forms). If you receive this document from
someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached.
State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 1633100676
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket informaiton)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
RE: KIME, DONALD P.
BUREAU OF COMMONWEALTH Employee/Obligor's Name(Last, First, Middle)
209-36-5054
Sent Electronically Employee/Obligor's Social Security Number
(See Addendum for plaintiff names
DO NOT MAIL
associated with cases on attachment)
Custodial Party/Obligee's Name(Last, First,
Middle)
Employer/Income Withholder's FEIN 232172299 NOTE:This IWO must be regular on its face.
Under certain circumstances you must reject
Child(ren)'s Name(s)(Last, First, Middle) Child(ren)'s Birth Date(s) this IWO and return it to the sender(see IWO
instructions
httr)://www.acf.hhs.gov/r)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.
2321722990
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County,
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the employee/
obligor's income until further notice. c.=
$ 0.00 per month in current child support C=
$ 0.00 per month in past-due child support- Arrears 12 weeks or greater? p yes r` r no
$ 0.00 per month in current cash medical support "M t
$ 0.00 per month in past-due cash medical support r -c 8)6
$ 0.00 per month in current spousal support _<3- �-} �C,
$ 0.00 per month in past-due spousal support .=
$ 0.00 per month in other(must specify) o = �
-- P a rte:
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 Orde°r1nformation.
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 within the Commonwealth
of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs ten 10
working days after the date of this Order/Notice. Send payment within seven 7 working days of the pay date. If
you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to 55% of
disposable income for all orders. If the employee/obligor's principal place of employment is not within the
Commonwealth of Pennsylvania (State/Tribe), the employer can obtain withholding 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
OMB No.:0970-0154 Form EN-428 06/12
Service Type M Worker ID $IATT
❑ Return to Sender[Completed by Employer/Income Withholder]. Payment must be directed to an SDU in
accordance with 42 USC§666(b)(5)and (b)(6)or Tribal Payee(see Payments to SDU below). If payment is not
directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to
the sender.
ZJudge/Issuing Official (if required by State or Tribal law): KEVINA HESS
of Judge/Issuing Official:
e/Issuing Official:
ature: MAY 6,2013
If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order,a copy of this IWO
must be provided to the employee/obligor.
❑ If checked,the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
Pennsylvania law(23 PA C.S.§4374(b))requires remittance by an electronic payment method if an employer is ordered
to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of
two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and
Disbursement Unit(PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER/D(shown above as
the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
http://www.acf.hhs.00v/programs/cse/newhire/employer/contacts/contact map.htm
Priority: Withholding for support has priority over any other legal process under State law against the same income(USC 42
§666(b)(7)). If a Federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from
more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/
obligor's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a
Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial
party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent
by a Court,Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was
issued by a Tribal CSE agency, you must follow the"Remit payment to" instructions on this form.
Reporting the Pay Date: You must report the pay date when sending the payment.The pay date is the date on which the
amount was withheld from the employee/obligor's wages.You must comply with the law of the State(or Tribal law if
applicable)of the employee/obligor's principal place of employment regarding time periods within which you must implement
the withholding and forward the support payments.
Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to
Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current
support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal
place of employment to determine the appropriate allocation method.
Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this
employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to
report and/or withhold lump sum payments.
Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the
employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and
any penalties set by State or Tribal law/procedure.
Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from
employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
OMB Expiration Date—05/31/2014.The OMB Expiration Date has no bearing on the termination date of the IWO;it identifies the version of the form currently in use.
Form EN-428 06/12
Service Type M Page 2 of 3 Worker ID$IATT
Employer's Name: BUREAU OF COMMONWEALTH Employer FEIN: 232172299
Employee/Obligor's Name: KIME, DONALD P. 1633100676
CSE Agency Case Identifier:(See Addendum for case summary Order Identifier:(See Addendum for order/docket information)
Withholding Limits:You may not withhold more than the lesser of: 1)the amounts allowed by the Federal Consumer Credit Protection
Act(CCPA)(15 U.S.C. 1673(b));or 2)the amounts allowed by the State or Tribe of the employee/obligor's principal place of
employment(see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such
as: State, Federal, local taxes; Social Security taxes;statutory pension contributions;and Medicare taxes.The Federal limit is 50%of
the disposable income if the obligor is supporting another family and 60%of the disposable income if the obligor is not supporting
another family. However,those limits increase 5%-to 55%and 65%-if the arrears are greater than 12 weeks. If permitted by the State
or Tribe,you may deduct a fee for administrative costs.The combined support amount and fee may not exceed the limit indicated in
this section.
For Tribal orders,you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income
withholders who receive a State IWO,you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which
the employer/income withholder is located or the maximum amount permitted under section 303(d)of the CCPA(15 U.S.C. 1673(b)).
Depending upon applicable State or Tribal law,you may need to also consider the amounts paid for health care premiums in
determining disposable income and applying appropriate withholding limits.
Arrears greater than 12 weeks?If the Order Information does not indicate that the arrears are greater than 12 weeks,then the
Employer should calculate the CCPA limit using the lower percentage.
Additional Information:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are
no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by
returning this form to the address listed in the Contact Information below: 2321722990
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: Final Payment Amount:
New Employer's Name:
New Employer's Address:
CONTACT INFORMATION:
To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT(Issuer name)
by phone at(717)240-6225, by fax at(717)240-6248, by email or website at:www.chiIdsupport.state.pa.us.
Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST.
P.O. BOX 320, CARLISLE, PA. 17013(Issuer address).
To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT(Issuer name)
by phone at(717)240-6225, by fax at(717)240-6248, by email or website at www.chi ldsupport.state.pa.us,
IMPORTANT:The person completing this form is advised that the information may be shared with the employee/obligor.
OMB No.:0970-0154 Form EN-428 06/12
Service Type M Page 3 of 3 Worker ID $IATT
. ty
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: KIME, DONALD P.
PACSES Case Number 027105881 PACSES Case Number
Plaintiff Name Plaintiff Name
CATHY J. KIME
Docke Attachment Amount Docke Attachment Amount
02-1763 CIVIL $ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
PACSES Case Number PACSES Case Number
Plaintiff Name Plaintiff Name
Docket Attachment Amount Docke Attachment Amount
$ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
PACSES Case Number PACSES Case Number
Plaintiff Name Plaintiff Name
Docket Attachment Amount Docket Attachment Amount
$ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
Addendum Form EN-428 06/12
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
C—
Defendant Name: DONALD P. KIME -,::o
Member ID Number: 1633100676 r-z
Please note:All correspondence must include the Member ID Number.
1
ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSAVO BISNEL
-r
Financial Break Down of Multiple Cases on Attachment
PACSES Docket Attachment AmounUFrequency
Plaintiff Name Case Number Number
CATHY J.KIME 027105881 02-1763 CIVIL 1,100.00 MONTH
TOTAL ATTACHMENT AMOUNT: $ 1,100.00
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$253.15 per week, or 5p%, of
the Unemployment Compensation benefits otherwise payable to the Defendant, DONALD P. KIME
Social Security Number XXX-XX-5054, Member ID Number 1633100676. OUCB is ordered to remit the
amount attached to the Department of Public Welfare (DPW). DPW shall forward the amount received
from OUCB to the Domestic Relations Section of this Court for support and/or support arrearages.
If the Defendant's Unemployment Compensation benefits are attached by another Court or
Courts for support and/or support arrearages, DPW may reduce the amount attached under this Order so
that the total amount attached does not exceed the maximum amount subject to garnishment pursuant to
15 U.S.C. § 1673(b)(2)and 23 Pa. C.S.A. §4348(g).
This Order shall be effective upon receipt of the notice of the Order by the OUCB and shall
remain in effect until the Defendant's entitlement to Unemployment Compensation benefits, under the
Application for Benefits dated JUNE 16, 2013 is exhausted, expired or deferred.
OUCB shall comply with this Order, unless it is amended or vacated by subsequent Order of this
Court. All questions, challenges or obligations to this Order shall be directed to the Domestic Relations
Section of this Court.
BY THE COURT
Date of Order: JUN 2 5 2013
Albert H. Maslaand JUDGE
Form EN-530
Service Type M Worker ID $IATT
INCOME WITHHOLDING FOR SUPPORT
0A-11D5Rsi
® ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO)
O AMENDED IWO I-) , I I {_j I
O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT (� lL l�
Q TERMINATION OF IWO
Date: 07/26/13
❑ Child Support Enforcement(CSE)Agency ® Court ❑ Attorney ❑ Private Individual/Entity(Check One)
NOTE:This IWO must,be.regu*tort stfp9 1LAnder certain circumstances you must reject this IWO and return it to the sender(see IWO
instructions http://ww)Wacf.hhs.gov/programs/cse/newhire/employer/publication/publication.htm-forms). If you receive this document from
someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached.
State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 1633100676
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket informalton)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
ALZHEIMER'S ASSOCIATION RE: KIME, DONALD P.
STE 205 Employee/Obligor's Name(Last, First, Middle)
3544 N PROGRESS AVE 209-36-5054
HARRISBURG PA 17110-9638 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 251510692 NOTE:This IWO must be regular on its face.
Under certain circumstances you must reject
Child(ren)'s Name(s)(Last, First, Middle) Child(ren)'s Birth Date(s) this IWO and return it to the sender(see IWO
instructions
htta://www.acf.hhs.gov/programs/cse/newhire/
employer/publication/publication.htm-forms). If
you receive this document from someone other
than a State or Tribal CSE agency or a Court,a
copy of the underlying order must be attached.
2515106920
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County,
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the employee/
obligor's income until further notice. —'
$ 0.00 per month in current child support
$ 0.00 per month in past-due child support- Arrears 12 weeks or greater? 0 ye r
$ 0.00 per month in current cash medical support
$ 0.00 per month in past-due cash medical support
$ 1,100.00 per month in current spousal support
$ 0.00 per month in past-due spousal support ' )
$ 0.00 per month in other(must specify)
T
fora Total Amount to Withhold of$ 1,100.00 per month. zn
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:
$
253.'3.5 per weekly pay period. $ 550.00 per semimonthly pay
$ 507,E per biweekly y p period (twice a month)
q p y pay period (every two weeks) $ 1,100.00 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 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 within the
Commonwealth of Pennsylvania (State/Tribe), the employer can 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
OMB No.:0970-0154 Form EN-028 06/12
Service Type M Worker ID $IATT
❑ Return to Sender[Completed by Employer/Income Withholder]. Payment must be directed to an SDU in
accordance with 42 USC §666(b)(5) and (b)(6)or Tribal Payee (see Payments to SDU below). If payment is not
directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to
the sender.
Signature of Judge/Issuing Official (if required by State or Tribal law):
Print Name of Judge/Issuing Official:
Title of Judge/Issuing Official:
Date of Signature: JUL 2 6 2013
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 ID(shown above as
the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
http://www.acf.hhs.gov/programs/cse/newhi re/employer/contacts/contact map.htm
Priority: Withholding for support has priority over any other legal process under State law against the same income(USC 42
§666(b)(7)). If a Federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from
more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/
obligor's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a
Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial
party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent
by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was
issued by a Tribal CSE agency, you must follow the"Remit payment to" instructions on this form.
Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the
amount was withheld from the employee/obligor's wages. You must comply with the law of the State(or Tribal law if
applicable)of the employee/obligor's principal place of employment regarding time periods within which you must implement
the withholding and forward the support payments.
Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to
Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current
support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal
place of employment to determine the appropriate allocation method.
Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this
employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to
report and/or withhold lump sum payments.
Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the
employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and
any penalties set by State or Tribal law/procedure.
Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from
employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
0MB 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 $IATT
Employer's Name: ALZHEIMER'S ASSOCIATION Employer FEIN: 251510692
Employee/Obligor's Name: KIME, DONALD P. 1633100676
CSE Agency Case Identifier:(See Addendum for case summary) Order Identifier:(See Addendum for order/docket information)
Withholding Limits:You may not withhold more than the lesser of: 1)the amounts allowed by the Federal Consumer Credit Protection
Act(CCPA)(15 U.S.C. 1673(b)); or 2)the amounts allowed by the State or Tribe of the employee/obligor's principal place of
employment(see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such
as:State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes.The Federal limit is 50%of
the disposable income if the obligor is supporting another family and 60%of the disposable income if the obligor is not supporting
another family. However,those limits increase 5%-to 55%and 65%-if the arrears are greater than 12 weeks. If permitted by the State
or Tribe, you may deduct a fee for administrative costs.The combined support amount and fee may not exceed the limit indicated in
this section.
For Tribal orders,you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income
withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which
the employer/income withholder is located or the maximum amount permitted under section 303(d)of the CCPA(15 U.S.C. 1673(b)).
Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premiums in
determining disposable income and applying appropriate withholding limits.
Arrears greater than 12 weeks?If the Order Information does not indicate that the arrears are greater than 12 weeks,then the
Employer should calculate the CCPA limit using the lower percentage.
Additional Information:
NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are
no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sender by
returning this form to the address listed in the Contact Information below: 2515106920
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: Final Payment Amount:
New Employer's Name:
New Employer's Address:
CONTACT INFORMATION:
To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT(Issuer name)
by phone at(717)240-6225, by fax at(717)240-6248, by email or website at:www.childsupport.state.pa.us.
Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST,
P.O. BOX 320, CARLISLE. PA. 17013(Issuer address).
To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT(Issuer name)
by phone at(717)240-6225, by fax at(717)240-6248, by email or website at www.childsupoort.state.pa.us.
IMPORTANT:The person completing this form is advised that the information may be shared with the employee/obligor.
OMB No.:0970-0154 Form EN-028 06/12
Service Type M Page 3 of 3 Worker ID $IATT
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: KIME, DONALD P.
PACSES Case Number 027105881 PACSES Case Number
Plaintiff Name Plaintiff Name
CATHY J. KIME
Docket Attachment Amount Docket Attachment Amount
02-1763 CIVIL $ 1,100.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
PACSES Case Number PACSES Case Number
Plaintiff Name Plaintiff Name
Docket Attachment Amount Docket Attachment Amount
$ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
PACSES Case Number PACSES Case Number
Plaintiff Name Plaintiff Name
Docket Attachment Amount Docket Attachment Amount
$ 0.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
Addendum Form EN-028 06/12
Service Type M OMB No.:0970-0154 Worker ID $IATT