HomeMy WebLinkAbout02-0598 H./28/oz
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SNYDER,
Defendant
TRANSFERRED TO CUHBERLAND COUNTY.
: IN THE COURT OF COMMON PLEAS
: CAMERON COUNTY, PENNSYLVANIA
: CIVIL ACTION - LAW
: NUMBER: 2001-6313
:
: IN DIVORCE
ORDER TO TRANSFER CA.~E
AND NOW, this/3~day of/~~001, upon consideration
the within Motion to Transfer Venue, it is hereby ORDERED a: rd! ~
DECREED that the above divorce action is transferred to the odrffbf
Common Pleas of the Coun~ of Cumberland. ~ ~ iq
~rsuant to Pa.R.C.P. No. 213(0, the Prothonota~ of the C
Common Pleas of the Coun~ of Cameron is directed to immediately-
transfer the record together with a certified copy of the docket entries to
the Prothonotary of the Court of Common Pleas of the County of
Cumberland.
True and Correct Copy
certified from the
Rec(;~,.~ o! Cameron Co.
Deputy Prothonotary
Je
IN THE COURT OF COMMON PLEAS OF CAMERON COUNTY
Fifty - Ninth Judicial District
NO: 01- 6313
RECORDED: 10/04/01
BOOK: PAGE:
KIND: DIV
DEBT: $ 0.00
SURCHARGE: 10.00
PRO: 40.50
JCP FEE: 5.00
SAT DATE: 11/28/01
<PLAINTIFF> I SNYDER
HAROLD W
<DEFENDANT> 1 SNYDER MARY L
OCTOBER 4, 2001 - Plaintiff's Complaint in Divorce filed by CHARLES E.
PETRIE, ESQ.
SAME DATE: Certified copy of Complaint with endorsement thereon to plead to
same, issued for service upon the defendant.
Verification ~nd Affidavit of Non-Military Service filed.
NOVEMBER 26, 2001 - Motion to Transfer Venue filed by attorney Charles Petrie
on behalf of Plaintiff. Entire file sent to Judge Roof.
NOVEMBER 28, 2001 - ORDER TO TRANSFER CASE - AND NOW, this 28th day of
November 2001, upon consideration of the within Motion to Transfer Venue, it
is hereby ORDERED AND DECREED that the above divorce action is transferred to
the Court of Coa,L~on Pleas of the County of Cumberland.
Pursuant to Pa.R.C.P. No. 213(f), the Prothonotary of the Court of CoL~u.on
Pleas of the County of Cameron is directed to i,,,ediately transfer the record
together with a certified copy of the docket entries to the Prothonotary of
the Court of Co,mr, on Pleas of the County of Cumberland. BY THE COURT /s/
Vernon D. Roof, P.J.
NOVEMBER 29,2001 - Copies sent to the Court of Co~,,,on Pleas of Cumberland
County, Charles E. Petrie, Attorney for Plaintiff and Mary L. Snyder,
Defendant, 15 Colonial Village, Berkeley Springs, West Virginia.
True and Correct ~ ~
certified from the '~
~:~¢cords of Cameron Co. '
Penna.
Deouty. Prothonotary
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SHYDER,
Defendant
: IN THE COURT OF COMMON PLEAS
: CAMERON COUNTY, PENNSYLVANIA
: CIVIL ACTION - LAW
NUMBER: 2001-6313
IN DIVORCE
MOTION TO TRANSFER VENUE
NOW COMES the Plaintiff, HAROLD W. SNYDER, by and through
his attorney, Charles E. Petrie, and respectfully represents as follows:
1. That Plaintiff is HAROLD W. SNYDER, who currently resides at
1 1 Pinehill Avenue, Mechanicsburg, County of Cumberland,
Pennsylvania.
2. That Defendant is MARY L. SNYDER, who currently resides at
15 Colonial Village, Berkley Springs, West Virginia.
3. That at the time of the filing of the Complaint in Divorce,
Plaintiff believed that the divorce matter would be resolved withou~
necessity of a master's hearing.
4. The Defendant through counsel has verbally objected t, fl.
jurisdiction of Cameron County.
and Correct Copy
~i"~,'! ;'rom the
:~:- of Cameron Co,
Doputy Prothbnotary
5. That Plaintiff is a resident of Cumberland County.
WHEREFORE, Plaintiff respectfully requests that Your Honorable
Court enter an Order transferring venue to the Court of Common Pleas of
Cumberland County, Pennsylvania, and directing that the Prothonotary
of Cameron County transfer the case file to the Prothonotary of
Cumberland County.
Respectfully submitted,
Charles E. Petrie
3528 Brisban Street
Harrisburg, PA 17111
(717) 561-1939
Attorney for Plaintiff
True and Correct Copy
certified from the
Records of Cameron Co.
Penna.
Deputy Prothonotary
HAROLD W. SNYDER, :
Plaintiff :
VS.
MARY L. SI,P/DER,
Defendant
IN THE COURT OF COMMON PLEAS
CAMERON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NUMBER: 2001-6313
IN DIVORCE
CERTIFICATE OF SERVICE
I certify that I sent a copy of the foregoing Motion to Transfer
Venue to the Defendant, MARY L. SNYDER, by and through her attorney,
JUDY CALKIN, ESQUIRE, at 2201 North Second Street, Ha~-~isburg,
Pennsylvania, 17110, on November 19, 2001, by U.S. First Class Mail,
postage prepaid.
True and Correct Copy
ce~ified from the
Records of Cameron Co.
Penna,
Respectfully Submitted,
Charles E. Petrie
3528 Brisban Street
Harrisburg, PA 17111
(717) 561-1939
Attorney for Plaintiff
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SNYDER,
Defendant
IN THE COURT OF COMMON PLEAS
CAMERON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
BER: 2001'-4 3/..3
IN DIVORCE
NOTICE TO DEFEND AND CLAIM RIGHTS
You have been sued in court. If you wish to defend again.~
claims set forth in the following pages, you must take prompt ac
You are warned that if you fail to do so, the case may proceed wi
you and a decree of divorce or annulment may be entered again.~
the court. A judgment may also be entered against you for any other
claim or relief requested in these papers by the plaintiff. You may lose
money or property or other rights important to you, including custody or
visitation of your children.
When the ground for the divorce is indignities or irretrievable
breakdown of the marriage, you may request marriage counseling. A list
of marriage counselors is available in the Office of the Prothonotary,
Cameron County Courthouse, Emporium, PA.
IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF
PROPERTY, LAWYER'S FEES OR EXPENSES BEFORE A DIVORCE OR
ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM ANY
OF THEM.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF
YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR
TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE
YOU CAN GET LEGAL HELP.
True and Correct Copy '
certified from the
Records of Cameron Co.
Penna.
Deputy PlolllollOmty
DAVID J. REED, PROTHONOTARY
CAMERON COUNTY COURTHOUSE
EMPORIUM, PA 15834
(814) 486-3355
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SNYDER,
Defendant
: IN THE COURT OF COMMON PLEAS
: CAMERON COUNTY, PENNSYLVANIA
: CIVIL ACTION - LAW
: NUM : 2001
:
: IN DIVORCE
COMPLAINT UNDER SECTION 3301~c) OF THE DIVORCE CODE
11 Pinehill Avenue, Mechanicsburg, County of Cumberland,
Pennsylvania, since January 2, 2000.
2. Defendant is MARY L. SNYDER, who currently reside:
15 Colonial Village, Berkley Springs, West Virginia, since 1986.
3. Plaintiff has been a bona fide resident in the
Plaintiff is HAROLD W. SNYDER, who currently resides at
Commonwealth for at least six months immediately previous to the filing
of this Complaint.
4. The plaintiff and defendant were married on June 4, 1993,
in Winchester, Virginia.
5. There have been no prior actions of divorce or for annulment
between the parties.
6. The marriage is irretrievably broken.
True and Correct Copy
certified from the
Records o! Cameron Co.
Penna.
D~u~ pm~ho~
7. Plaintiff has been advised that counseling is available and
that plaintiff may have the right to request that the court require the
parties to participate in counseling.
8. Neither party is a member of the Armed Forces of the United
States of America or any of its Allies.
9. After ninety (90) days have elapsed from the date of service
of this Complaint, plaintiff intends to file an Affidavit consenting to a
divorce. Plaintiff believes that defendant may also file such an affidavit.
WHEREFORE, if both parties file affidavits consenting to a divorce
after ninety (90) days have elapsed from the date of service of this
Complai t, plaintiff respectfully requests the Court to enter a decree o
divorce pursuant to Section 3301 (c) of the Divorce Code.
I verify that the statements made in this Complaint are true ~a~d
correct. I understand that false statements herein are made subject to
the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification
to authorities.
DATE: /~//~ /
True and Correct Copy
ce~'tii'iecl from the
Records of Cameron Co.
Penna.
Deputy Prothor~,ary
'~AR~OLD W.-SliDER, '-7 - -/d]'
PLAINTIFF
CHARLES E. PETRIE
3528 Brisban Street
Harrisburg, PA 17111
(717) 561-1939
ATTORNEY FOR PLAINTIFF
N
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SNYDER,
Defendant
IN THE COURT OF COMMON PLEAS
CAMERON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
: NU R: 2001
IN DIVORCE
AFFIDAVIT OF NON-MILITARY SERVICE
I, Plaintiff herein, do hereby depose and say that I am advised and
believe that the above named Defendant is not presently in the active
military service of the United States of America and I aver that the
Defendant is not a member of the Army of the United States, United
States Navy, the Marine Corps, or the Coast Guard, and is not an officer
of the Public Health Service detailed by proper authority for duty with the
Army or Navy; nor is Defendant engaged in any military or Navy ~ nils ~
covered by the Soldiers and Sailors Civil Relief Act of 1940 and ~ ~
designated therein as military service; nor has Defendant, to the t~e~ ~
my knowledge, enhsted ~n the military service covered by this act. ~
This Affidavit is made under the provisions of the Soldiers nc ~
Sailors Civil Relief Act of 1940. ~
I verify that the statements made in this Affidavit are true and
correct. I understand that false statements herein are made subject to
the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification
to authorities.
DATE
LD W~ SN~SER~~' .v~,.. ~
PLAINTIFF
True and Correct Copy
~rtified from the
~,,~ccrds o~ Cameron Co.
Penna.
Deputy ~
HAROLD W. SNYDER, :
Plaintiff :
:
:
VS.
:
MARY L. SNYDER, :
Defendant :
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND CO., PENNSYLVANIA
NO. 02-598 civil Term
IN DIVORCE
1. A Complaint in Divorce under Section 3301(c) of the
Divorce Code was filed on October 4, 2001 in Cameron County and
than tranferred to Cumberland County.
2. The marriage of Plaintiff and Defendant is
irretrievably broken and ninety (90) days have elapsed from the
date of the filing and service of the Complaint.
3. I consent to the entry of a Final Decree in Divorce
after service of notice of intention to request entry of the
decree.
I understand that false statements herein are made
subject to the penalties of 18 Pa.C.S. Section 4904, relating to
unsworn falsification to authorities.
Date:
M~r/ L. ~nyder
ss~ Mo. ~ ~ 7 -Z d - ~ / ~
HAROLD W. SNYDER,
Plaintiff
vs.
MARY L. SNYDER,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND CO., PENNSYLVANIA
:
: NO. 02-598 Civil Term
IN DIVORCE
:
:
WAIVER OF NOTICE OF IlffElffION TO REQUEST
ENTRY OF A DIVORCE DECREE UI~DER SECTION
330! (c) OF THE DIVORCE CODE
1. I consent to entry of a final Decree of Divorce
without notice.
2. I understand that I may lose rights concerning
alimony, division of property, lawyer's fees or expenses if I do
not claim them before a divorce is granted.
3. I understand that I will not be divorced until a
Decree is entered by the Court and that a copy of the Decree will
be sent to me immediately after it is filed with the Prothonotary.
4. I verify that the statement made in this Waiver are
true and correct. I understand that false statements herein are
made subject to the penalties of 18 Pa.C.S. Section 4904, relating
to unsworn falsification to authorities.
CX
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SNYDER,
Defendant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: CIVIL ACTION - LAW
:
: NUMBER: 02-598 CIVIL TERM
:
: IN DIVORCE
AFFIDAVIT OF CONSENT
1. A complaint in divorce under Section 330 l(c) of the Divorce Code
was filed on October 4, 2001.
2. The marriage of plaintiff and defendant is irretrievably broken and
ninety days have elapsed from the date of filing and service of the Complaint.
3. I consent to the entry of a final decree of divorce after service of
notice of intention to request entry of the decree.
I verify that the statements made in this affidavit are true and correct. I
understand that false statements herein are made subject to the penalties of
18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities.
DATE:
~ARdLi~W~-Sr~YDE~R, ~--//
PLAINTIFF
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SNYDER,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NUMBER: 02-598 CIVIL TERM
IN DIVORCE
WAIVER OF NOTICE OF INTENTION TO RF-~UEST
ENTRY OF A DIVORCE DECREE UNDER
SECTION 3301[c) OF THE DIVORCE CODE
1. I consent to the entry of a final decree of divorce without notice.
2. I understand that I may lose rights concerning alimony, division of
property, lawyer's fees or expenses if I do not claim them before a divorce is
granted.
3. I understand that I will not be divorced until a divorce decree is
entered by the Court and that a copy of the decree will be sent to me
immediately after it is filed with the prothonotary.
I verify that the statements made in this affidavit are true and correct. I
understand that false statements herein are made subject to the penalties of
18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities.
DATE: C~-~/~-~/O ~-_
HAROLD W. SNYDiER', ~ -
PLAINTIFF
HAROLD W. SNYDER, :
Plaintiff :
:
VS. :
:
MARY L. SNYDER, :
Defendant :
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND CO., PENNSYLVANIA
NO. 02-598 Civil Term
IN DIVORCE
1. A Complaint in Divorce under Section 3301(c) of the
Divorce Code was filed on October 4, 2001 in Cameron County and
than tranferred to Cumberland County.
2. The marriage of Plaintiff and Defendant is
irretrievably broken and ninety (90) days have elapsed from the
date of the filing and service of the Complaint.
3. I consent to the entry of a Final Decree in Divorce
after service of notice of
decree.
I understand that
intention to request entry of the
false statements herein are made
subject to the penalties of 18 Pa.C.S. Section 4904, relating to
unsworn falsification to authorities.
Date:
M~r~ L. ~nyde~ <~
szabo. ~ o~ 7 -/~ ~ -~/~>k
HAROLD W. SNYDER, :
Plaintiff :
:
VS. :
:
MARY L. SNYDER, :
Defendant :
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND CO., PENNSYLVANIA
NO. 02-598 Civil Term
IN DIVORCE
WAIVER OF NOTICE OF INTENTION TO REQUEST
ENTRY OF A DIVORCE DECREE UNDER SECTION
3301 (c) OF THE DIVORCE CODE
1. I consent to entry of a final Decree of Divorce
without notice.
2. I understand that I may lose rights concerning
alimony, division of property, lawyer's fees or expenses if I do
not claim them before a divorce is granted.
3. I understand that I will not be divorced until a
Decree is entered by the Court and that a copy of the Decree will
be sent to me immediately after it is filed with the Prothonotary.
4. I verify that the statement made in this Waiver are
true and correct. I understand that false statements herein are
made subject to the penalties of 18 Pa.C.S. Section 4904, relating
to unsworn falsification to authorities.
CX
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SNYDER,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NUMBER: 02-598 CIVIL TERM
IN DIVORCE
AFFIDAVIT OF SERVICE
CHARLES E. PETRIE, Esquire, being duly sworn according to law,
deposes and states that he served a true and correct copy of the NOTICE TO
DEFEND, COMPLAINT UNDER SECTION 3301 (c), AND MILITARY-AFFIDAVIT,
upon MARY L. SNYDER, defendant, in the above-captioned matter, by mailing
a true and correct copy of same by U.S. Certified Mail, return receipt requested,
Article Number 70993400000717867965, postage prepaid, on October 7, 200 1, to the
following address:
Name: Mary L. Snyder
Address: 15 Colonial Village, Berkley Springs, WV 25411
Defendant personally received said documents on October 12, 2001, as
evidenced by her signature on the certified mail return receipt card which is
attached hereto and marked Exhibit "A".
I verify that the statements in the foregoing Affidavit are true and correct.
I understand that false statements herein are made subject to the penalties of
18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities.
· Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
· Pdnt your name and address on the reverse
so that we can return the card to you.
· Attach t~hl~,~ard to the Pack of the mailpiece,
or on the front if space permits.
1. ~icle A~reseed to:
Mary L. Snyder
151Colonial Village
~kley Springs, Wv 25611
C. Signature
~l/; t, Q ) []AddreSSes
O.'ls delh,le~y-a~::fl~ss dif~e~t3~c,n ~ 17 n Y~
If YES, enter deliveu add~ below: '~ No
3. Service Type [] Certified Mail
[] Registered
[] Insured Mail
[] Express Mail
[] Return Receipt for Merchandise
m C.O.D.
4. Rest~icted Delivery? (Extra Fee) [] Yes
2. Article Numper tCopy from service label)70993400000717867965
PS Form 381 1, July 1999 Domestic Return Receipt 102595-00-M-0952
PETRIE
?OR PLAINTIFF
HAROLD W. SNYDER,
Plaintiff
VS.
MARY L. SNYDER,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NUMBER: 02-598 CIVIL TERM
: IN DIVORCE
PRAECIPE TO TRANSMIT RECORD
TO THE PROTHONOTARY:
Transmit the record, together with the following information, to the court
for entry of an appropriate divorce decree:
1. Ground for divorce: Irretrievable breakdown under §3301 (c) of the
Divorce Code. (Strike out inapplicable section).
2. Date and manner of service of complaint: October 12, 2001, by
certified mail.
3. Complete either paragraph (a) or (b):
(a)(1) Date of execution of the affidavit of consent required by
3301(c) of the Divorce Code: by plaintiff: May 25, 2002; by defendant: May 3,
2002.
(a)(2) Date of execution of the Waiver of Notice of Intention
required by §3301(c) of the Divorce Code: by plaintiff: May 25, 2002; by
defendant: May 3, 2002
(b)(1) Date of execution of the affidavit required by §3301(d) of the
Divorce Code:
(b)(2) Date of filing and service of the plaintiffs affidavit upon the
respondent: Filed: ; Served:
4. Related Claims Pending: No claims raised.
5. Complete either (a) or (b):
(a) Date and manner of service of the notice of intention to file
praecipe to transmit record, a copy of which is attached:
(b) Date plaintiffs Waiver of Notice in §3301(c) Divorce was filed
with the prothonotary: May 29, 2002.
(c) Date defendant's Waiver of Notice in §3301 (c) Divorce was
filed with the prothonotary: May 17, 2002.
CHARLES E. PETRIE
ATTORNEY FOR PLAINTIFF
THIS AGREEMENT, made this~day of 7~~ , 2002
by and between HAROLD W. SNYDHR of Cumberland County, Pennsylvania
(hereinafter referred to as HUSBAND), and MARY L. SNYDHR of Berkley
Springs, West Virginia (hereinafter referred to as WIFE),
WHEREAS, HUSBAND and WIFE were lawfully married on
June 4, 1994 in Winchester, Virginia.
WHEREAS, no children were born of this marriage:
WHEREAS, diverse, unhappy differences, disputes and
difficulties have arisen between the parties and it is the
intention of WIFE and HUSBAND to live separate and apart for the
rest of their natural lives, and the parties hereto are desirous of
settling fully and finally their respective financial and property
rights and obligations as between each other, including without
limitation by specification: the settling of all matters between
them relating to the ownership and equitable distribution of real
and personal property; settling of all matters between them
relating to the past, present and future support, and alimony and
in general, the settling of any and all claims by one against the
other or against their respective estates.
NOW, THEREFORE, in consideration the premises and of the
mutual promises, covenants and undertakings hereinafter set forth
hereby acknowledged by each of the parties hereto, WIFE and
HUSBAND, each intending to be legally bound, hereby covenant and
agree as follows:
1. SEPARATION: It shall be lawful for each party at all
times hereafter to live separate and apart from the other party at
such place as he or she may from time to time chose or deem fit.
The foregoing provisions shall not be taken as an admission on the
part of either party of the lawfulness or unlawfulness of the
causes leading to their living apart.
2. INTERFERENCE: Each party shall be free from
interference, authority, and contact by the other, as fully as if
he or she were single and unmarried, except as may be necessary to
carry out the provisions of this Agreement. Neither party shall
molest the other or attempt to endeavor to molest the other, nor
compel the other to cohabit with the other, or in any way harass
or malign the other, nor in any way interfere with their peaceful
existence, separate and apart.
3. SUBSEQUENT DIVORCE: The parties hereby acknowledge
that HUSBAND has filed a Complaint in Divorce in Cumberland County
to docket number 02-598 Civil Term claiming that the marriage is
irretrievably broken under the no-fault mutual consent provision of
Section 3301(c) of the Pennsylvania Divorce Code. WIFE hereby
expresses her agreement that the marriage is irretrievably broken
and expresses her intent to execute any and all affidavits or other
documents necessary for the parties to obtain an absolute divorce
pursuant to Section (c) of the Divorce Code at the same time as she
executes this agreement. The parties hereby waive all rights to
request Court-ordered counseling under the Divorce Code. It is
further specifically understood and agreed by the parties that the
provisions of this Agreement as to equitable distribution of
property of the parties are accepted by each party as a final
settlement for all purposes whatsoever, as contemplated by the
Pennsylvania Divorce Code.
Should a decree, judgment or order of separation or
divorce be obtained by either of the parties in this or any other
state, country or jurisdiction, each of the parties hereby consents
and agrees that this Agreement and all of its covenants shall be
not affected in any way by any such separation or divorce; and that
nothing in any such decree, judgment, order or further modification
or revision thereof shall alter, amend or vary any terms of this
Agreement, whether or not either or both of the parties shall
remarry. It is specifically agreed, that a copy of this Agreement
or the substance of the provisions thereof, may be incorporated by
reference but not merged into any divorce, judgment or decree. It
is the specific intent of the parties to permit this Agreement to
survive any judgment and to be forever binding and conclusive upon
the parties.
4. DATE OF EXECUTION: The "date of execution', or
"execution date" of this agreement shall be defined as the date
upon which it is executed by the parties if they have each executed
the agreement on the same date. Otherwise the "date of execution"
or "execution date" of this agreement shall be defined as the date
of execution by the party last executing this agreement.
5. DISTRIBUTION DATE: The transfer of property, funds
and/or documents provided for herein, shall only take place on the
"distribution date" which shall be defined as specified herein.
6. MUTUAL RELEASE: HUSBAND and WIFE each do hereby
mutually remise, release, quitclaim and forever discharge the other
and the estate of such other, for all time to come, and for all
purposes whatsoever, of and from any and all rights, title and
interests, or claims in or against the property (including income
and gain from property hereafter accruing) of the other or against
the estate of such other, of whatever nature and wheresoever
situation, which he or she now has or at any time hereafter may
have against the other, the estate of such other or any part
thereof, whether arising out of any former acts, contracts,
engagements or liabilities of such other or by way of dower or
curtesy, or claims in the nature of dower or curtesy or widow's or
widower's rights, family exemption or similar allowance, or under
the intestate laws, or the right to take against the spouse's will;
or the right to treat a lifetime conveyance by the other as
testamentary, or all other rights of a surviving spouse to
participate in a deceased spouse's estate, whether arising under
the laws of (a) Pennsylvania, (b) any State, Commonwealth or
territory of the United States, or (c) any country, or any rights
which either party may have or at any time hereafter shall have for
past, present or future support or maintenance, alimony, alimony
pendente lite, counsel fees, property division, costs or expenses,
whether arising as a result of the marital relations or otherwise,
except, all rights and agreements and obligations of whatsoever
nature arising or which may arise under this Agreement or for the
breach of any provisions thereof. It is the intention of HUSBAND
and WIFE to give to each other by the execution of this Agreement
a full, complete and general release with respect to any and all
property of any kind or nature, real, personal or mixed, which the
other now owns or may hereafter acquire, except and only except all
rights and agreements and obligations of whatsoever nature arising
or which may arise under this Agreement or for the breach of any
provision thereof. It is further agreed that this Agreement shall
be and constitute a full and final resolution of any and all claims
which each of the parties may have against the other for equitable
division of property, alimony, counsel fees and expenses, alimony
pendente lite or any other claims pursuant to the Pennsylvania
Divorce Code or the divorce laws of any other jurisdiction.
7. ADVICE OF COUNSEL: The provisions of this Agreement
and their legal effect have been fully explained to the parties by
JUDITH A. CALKIN, ESQUIRE, counsel for WIFE and CHARLES PETRIE,
ESQUIRE, counsel for HUSBAND.
HUSBAND and WIFE accept that this Agreement is, in the
circumstances, fair and equitable and that it is being entered into
freely and voluntarily and that execution of this Agreement is not
the result of any duress or undue influence and that it is not the
result of any collusion or improper or illegal agreement or
agreements. The parties further acknowledge that they have each
made to the other a full accounting of their respective assets,
estate, liabilities, and sources of income and that they waive any
specific enumeration thereof for the purpose of this Agreement.
Each party agrees that he and she shall not at any future time
raise as a defense or otherwise the lack of such disclosure in any
legal proceeding, involving this Agreement, with the exception of
disclosure that may have been fraudulently withheld.
8. MEDICAL DEBTS: HUSBAND agrees to be solely liable
for all medical debts which are as follows:
9. WARRANTY AS TO EXISTING OBLIGATIONS: Each party
represents that they have not heretofore incurred or contracted for
any debt or liability or obligation for which the estate of the
other party may be responsible or liable except as may be provided
for in this Agreement. Each party agrees to indemnify and hold the
other party harmless for and against any and all such debts,
liabilities or obligations of every kind which may have heretofore
been incurred by them, including those for necessities, except for
the obligations arising out of this Agreement.
10. WARRANTY AS TO FUTURE OBLIGATIONS: WIFE and HUSBAND
each covenant, warrant, represent and agree that with the exception
of obligations set forth in this Agreement, neither of them shall
hereafter incur any liability whatsoever for which the estate of
the other may be liable. Each party shall indemnify and hold
harmless the other party for and against any and all debts, charges
and liabilities incurred by the other after the execution date of
this Agreement, except as may be otherwise specifically provided
for by the terms of this Agreement.
11. PERSONAL PROPERTY: The parties hereto have divided
between themselves, to their mutual satisfaction, all items of
tangible and intangible marital property. Neither party shall make
any claim to any other such items of marital property, or to the
separate personal property of either party, which are now in the
possession and/or under the control of the other. Should it become
necessary, the parties each agree to sign, upon request, any titles
or documents necessary to give effect to this paragraph. Property
shall be deemed to be in the possession or under the control of
either party if, in the case of tangible personal property, the
item is physically in the possession or control of the party at the
time of the signing of this Agreement, and in the case of
intangible personal property, if any physical or written evidence
of ownership, such as passbook, checkbook, policy or certificate of
insurance or other similar writing is in the possession or control
of the party. HUSBAND and WIFE shall be deemed to be solely and
individually in the possession, control and ownership of any
pension or other employee benefit plans or other employee benefits
of any nature to which either party may have a vested or contingent
right or interest, apart from the provisions of the Divorce Code,
at the time of the signing of this Agreement.
12. MOTOR VEHICLES: The parties agree that HUSBAND and
WIFE shall become the sole and exclusive owner of any motor vehicle
in their possession.
13. AFTER ACQUIRED PERSONAL PROPERTY: Each of the
parties shall hereafter own and enjoy, independently of any claims
or right of the other, all items of personal property, tangible or
intangible, hereafter acquired by him or her, with full power in
him or her to dispose of the same as fully and effectively, in all
respects and for all purposes, as though he or she were unmarried.
14. APPLICABILITY OF TAX LAW TO PROPERTY TRANSFERS:
The parties hereby agree and express their intent that any transfer
of property pursuant to this Agreement shall be within the scope
and applicability of the Deficit Reduction Act of 1984 (herein in
"Act"), specifically, the provisions of said Act pertaining to
transfers of property between spouses or former spouses. The
parties agree to sign and cause to be filed any elections or other
documents required by the Internal Revenue Service to render the
Act applicable to the transfers set forth in this Agreement without
recognition of gain on such transfer and subject to the carry-over
basis provisions of said Act.
15. WAIVER OF ALIMONY PENDENTE LITE AND LEaAL FEES:
Each party hereby waives any right to alimony pendente lite. The
parties agree to be responsible for their own attorney's fees.
16. FULL DISCLOSURE: Each party asserts that she or he
has made a full and complete disclosure of all the real and
personal property of whatsoever nature and wheresoever located
belonging in any way to each of them, of all debts and encumbrances
incurred in any manner whatsoever by each of them, of all sources
and amounts of income received or receivable by each of parties,
and of every other fact relating in any way to the subject matter
of this Agreement. These disclosures are part of the consideration
made by each party for entering into this Agreement.
17. ALIMOI~Y: HUSBAND agrees to pay WIFE alimony in the
amount of One Thousand ($1000.00) Dollars per month for eighteen
(18) months from the date of the final divorce decree. The amount
and duration of these alimony payments are not modifiable except it
will terminate should either party die or should WIFE remarry or
cohabit. This alimony amount will be entered and collected through
the Office of Domestic Relations as a continuation and modification
of the current spousal support order.
18. BAI~I~RUPTCY OR REORGANIZATION PROCEEDINGS: In the
event that either party becomes a debtor in any bankruptcy or
financial reorganization proceedings of any kind while any
obligations remain to be performed by that party for the benefit of
the other party pursuant to the provisions of this Agreement, the
debtor spouse hereby waives, releases and relinquishes any right to
claim any exemption (whether granted under State or Federal law) to
any property remaining in the debtor as a defense to any claim made
pursuant hereto by the creditor-spouse as set forth herein,
including all attorney fees and costs incurred in the enforcement
of this paragraph or any other provisions of this Agreement. No
obligation created by this Agreement shall be discharged or
dischargeable, regardless of Federal or State law to the contrary,
and each party waives any and all right to assert that obligation
hereunder is discharged or dischargeable.
The parties mutually agree that in the event of
bankruptcy or financial reorganization proceedings by either party
in the future, any monies to be paid to the other party, or to a
third party, pursuant to the terms of this Agreement shall
constitute support and maintenance and shall not be discharged in
bankruptcy.
19. INCO~ TAX PRIOR RETURNS: The parties have
heretofore filed joint federal and state tax returns. Both parties
agree that in the event any deficiency in federal, state or local
income tax is proposed, or any assessment of any such tax is made
against either of them, each will indemnify and hold harmless the
other from and against any loss or liability for any such tax
deficiency or assessment and any interest, penalty and expense
incurred in connection therewith. Such tax, interest, penalty or
expense shall be paid solely and entirely by the individual who is
finally determined to be the cause of the misrepresentations or
failures to disclose the nature and extent of his or her separate
income on the aforesaid joint returns.
20. WAIVER OR MODIFICATION TO BE IN WRITING: No
modification or waiver of any of the terms hereof shall be valid
unless in writing and signed by both parties and no waiver of any
breach hereof or default hereunder shall be deemed a waiver of any
subsequent default of the same or similar nature.
21. MUTUAL COOPERATION: Each party shall, at any time
and from time to time hereafter, take any and all steps and
execute, acknowledge and deliver to the other party any and all
further instruments and/or documents that the other party may
reasonably require for the purpose of giving full force and effect
10
to the provisions of this Agreement.
22. APPLICABLE LAW: This Agreement shall be construed
in accordance with the laws of the Commonwealth of Pennsylvania
which are in effect as of the date of execution of this Agreement.
23. AGREEMENT BINDING ON HEIRS: This Agreement shall be
binding and shall inure to the benefit of the parties hereto and
their respective heirs, executors, administrators, successors and
assigns.
24. INTEGRATION: This Agreement constitutes the entire
understanding of the parties and supersedes any and all prior
agreements and negotiations between them. There are no
representations or warranties other than those expressly set forth
herein.
25. OTHER DOCUMENTATION:
agree that they will forthwith
WIFE and HUSBAND covenant and
execute any and all written
instruments, assignments, releases, satisfactions, deeds, notes or
such other writings as may be necessary or desirable for the proper
effectuation of this Agreement.
26. NO WAIVER ON DEFAULT: This Agreement shall remain
in full force and effect unless and until terminated under and
pursuant to the terms of this Agreement. The failure of either
party to insist upon strict performance of any of the provisions of
this Agreement shall in no way affect the right of such party
hereafter to enforce the same, nor shall the waiver of any default
or breach of any provisions hereof be construed as a waiver of any
subsequent default or breach of the same or similar nature, nor
11
shall it be construed as a waiver of strict performance of any
other obligations herein.
27. B~VERABILI?¥: If any term, condition, clause or
provision of this Agreement shall be determined or declared to be
void or invalid in law or otherwise, then only that term,
condition, clause or provision shall be stricken from this
Agreement and in all other respects this Agreement shall be valid
and continue in full force, effect and operation. Likewise, the
failure of any party to meet her or his obligation under any one or
more of the paragraphs herein, with the exception of the
satisfaction of the conditions precedent, shall in no way avoid or
alter the remaining obligations of the parties.
28. BR~ACH: If either party breaches any provisions of
this Agreement, the other party shall have the right, at his or her
election, to sue for damages for such breach or seek such other
remedies or relief as may be available to him or her, and the party
breaching this contract shall be responsible for payment of
reasonable legal fees and costs incurred by the other in enforcing
their rights under this agreement.
29. HEADINGS NOT PART OF AGREEMENT: Any heading
preceding the text of the several paragraphs and subparagraphs
hereof are inserted solely for convenience of reference and shall
not affect its meaning, construction or effect.
12
IN WITNESS WHEREOF, the parties hereto have set their
hands and seals this day and year first above written.
Witness
J~itness ' '
13
Memomal
HOSPITAL
MARCH 12, 1999
Guarantor #: 8015567
SNYDER, MARY
15 COLONIAL VILLAGE
BERKELEY SPGS, WV 25411 0000
Patient #: 8015567 Date of Last Payment: 0/00/00
SAP/DER, MARY Balance Due: 261.70
Date of Service: 11/16/98
A review of our records indicates an outstanding balance for
services provided. This letter is a FINAL REMINDER of this out-
standing obligation. Unless this debt is paid in full within
five (5) days, or suitable payment arrangements made, we shall
have no choice but to take whatever action is necessary to
collect this debt which could result in additional costs for you.
This letter is an attempt to collect a debt and any information
obtained will be used for that purpose. If you have any questions
please, do not hesitate to contact me at 800-337-9164, Monday
thru Friday, 8:30 a.m to 5:00 p.m.
Sincerely,
Lisa Watson
FINAL NOTICE
Collection Associate
1124 FairfaxStreet, Berkeley Springs, WestVirginia 25411
504-258-1254
~. 8015567
SNYDER, MARY
15 COLONIAL UILL. AGE
BE~KEL. EY SF:'GS, WV
I='at lent..-.'"-' 801556'?
SNYDEI::~, MARY
2,5411 0000
F'E:BRUAIqIY 9:, ,11.999
Date of I..ast F'aymen%~
Bm Lance
0/00/00
261, ?0
]Dat*e of Service: .1.1/16/98
NOT:i:CE OF:' INTEN'F TO F':[LE SUIT.
Your delin.iuent account is schedul, ed for suit, which means that
judgment wi I.L be sought and when obtmined~ gar'nishalent's and/or'
Levies wi LI. be imposed against you.
Way' Memorial I--Iompi'taL never cle.~ires to tal-,'e such measures and
considers this our final option when those who have rec:eived
services from us refuse to pay. However-~ you can ~s%J I.L avoid
Legal action if you contact us immediately ~o arrange settlement
o'f your account balance, ~em~mbet", raj I.~r'e ~o pay %hies obLiga--
tion wi LL permanently affec'[ your c¥'edit ~tandJng and wi LL cause
you ~he added expense of at~ornew*s 'fee~ and cour'~ co~t~,
*Fo arrange, roi" immediate e~ettLemen'[', ¥o[! may contact
8-6~=~2'?. We mum~ hear from you within 'five
Si ncere Ly,
Or'ecl i t I:fel:>ar tfllent
[Ion*t forget, you cmn use Visa or Master'car'd for payment, *¥o do
· this, please 'fi [L in the re.iuemted information and r'et[n"n to ctso
Visa Mastercard (circle one)
Account Numbe~ ....
.............................................................. F...X p ~ Date: ........................................
Guarantor #: 1001257
SNYDER, MARY
15 COLONIAL VILLAGE
BERKELEY SPGS, WV
war- ·
morlal
HOSPITAL
FEBRUARY 20 2002
25411 0000
Patient #: 1001257 Date of Last Payment: 1/28/02
~NYDER, MARY ~alance Due: 154.42
Date of Service: 12/17/01
Although we have made previous request for payment, the balance
shown above remains unpaid and is now considered past due. We
need your cooperation in making full payment within the next ten
days.
If you can not make full payment,, please contact us now at 304-
258-6531/6557/6527 to make arrangements as soon as possible. If
payment in full has been made, please disregard this notice.
Sincerely,
Credit Department
Don't forget, you can use Visa or Mastercard for payment. To do
this, please fill in the requested information and return to us.
Visa Mastercard (circle one)
Account Number:
Exp. Date:
Signature
124 Fairfax Street, Berkeley Springs, West Virginia 254 ] l
304-258~1234
EI UIFAX
Please address all future
'° correspondence to:
Equifax Credit Information Services
P O Box 740256
Atlanta, GA 30374
I (877) 299-5616
M - F 9:00am to 5:00pm in your time zone.
CREDIT FILE. Confirmation Number: 205631513
Please have a copy of this file, which displays a confirmation number, when calling Consumer Services for
assistance. As information is updated regularly, please call us within 60 days from the date of this credit file.
Personal Identification Information February 25, 2002
Mary Lee Snyder
15 Colonial VIg
Berkeley Springs, WV 25411
Previous Address(es):
RR I Box 369, Berkeley Springs, WV 25411
Social Secudty -~. 227-60-2183
Date of Birth: January 18, 1945
Formerly Known As: Mary Lee Chambers
Last Reported Employment: Na
Previous Employment(s): NIGHT Counselor, LEARY Education, Winc, VA
None
Public Record Information
Judgment Filed 10/97; Morgan County Courthouse; Case or Other ID Number - 9-6276463
Defendant - SNYDER Mary; Amount - $650; Plaintiff - War Memorial Hosp
Judgment Filed 02/97; Morgan County Courthouse; Case or Other ID Number - 9-1752685
Defendant - SNYDER Mary Lee; Amount - $181; Plaintiff - War Memorial Hospital
Judgment Filed 05/95; Morgan County Courthouse; Case or Other ID Number - 4804
Defendant - Subject; Amount - $827; Plaintiff - War Mere Hosp
Collection Agency Account Information
Collection Reported 11/01; Assigned 09/98 to NCO Financial Systems Inc. (800) 709-8613
Client - NCO Safelite GL; Amount - $136; Unpaid; Balance - $151
Date of Last Activity 07/98; Individual Account; Account Number 547372016
Credit Account Information (For your security, the last 4 digits of your account number(s) have been replaced by *)
Company Name Account Number opDeanteed R /~ L;reait Terms Balance I Past Due JStatuslReported
Allegheny Power 2310753533* I 01/87 32 01/02 $269 $269 01 02/02
Previous Payment History: 1 Time 30 days late
Previous Status: 09/00 - 02
UTILITY
Addres;: 800 Cabin Hill Dr Green;burg, PA 15601-1650 Phone #: (724) 838-6988
Companies that Requested your Credit File
02/25/02 Equifax- Disclosure 02/22/02
Conseco Finance Corp
02/22/02 SLM Financial Corporation
02/19/02 Conseco Finance Corp
11/24/01 Swiss Colony, Inc
09/28/01 PRM-Providian Bancorp
09/10/01 PRM-Providian Bancorp
07/24/01 American Express TRS Co,inc
06/15/01 PRM-Providian Bancorp
*000138 - 2 OF 5 *
02/22/02
12/19/01
10/30/01
09/17/01
08/06/01
07/11/01
05/22/01
Citifinancial Retail Services
Valley Health System
PRM-Infibank
Valley Health System
PRM-Providian Bancorp
PRM-Providian Bancorp
PRM-Providian Bancorp
(Continued on reverse)
Page I of 2
205631513-183-000309209.6084 - *CNTVC* S
MIRA MC~EOD, MD
P 0 BOX 5q8
BERKELEY SPRINGS
WV 25411
I,,I,l,l,l,,I,,I,,,ll,,,ll,,ll,l,,I,II,,,ll,,,,,,Ihl,l,ll,,,I
SHARON ARMSTRONG
15 COLONIAL VILLAGE
Berkeley Springs WV 25411-3800
CARD NUMBER
SIGNATURE
04/23/02
SELF PAY
71.00
MIRA MCLEOD, MD
P 0 BOX 508
BERKELEY SPRINGS WV 25411
AMOUNT
EXP DATE
4726
FOR BILLING INQUIRIES CALL:
1-800-335-1444 OR 1-800-523-3214
E~ Please check box if address or insurance information
is incorrec nd cate changes on the reverse side, then
detach and return this top portion with your payment.
71.00
71.00
04/23/02
4726 EHARONARMSTRONG
THIS IS THE RADIOLOGIST CHARGE FOR READING YOUR X-RAYS
MDSS
IF ANY OF THE FOLLOWING HAS CHANGED SI .NCE YOUR LAST STATEMENT, PLEASE INDICATE
ABOUT YOU ABOUT YOUR INSURANCE
YOUR NAME (Last, First, Middle Initial) YOUR PRIMARY INSURANCE COMPANY'S NAME
MAILING ADDRESS
CITY, STATE, ZIP CODE
HOME TELEPHONE
EMPLOYER'SNAME EMPLOYER'STELEPHONE
MPLOYER'SADDRESS
MARITAL STATUS [] [] [] [] []
SINGLE MARRIED SEPARATED DIVORCED WIDOWED
PRIMARY INSURANCE COMPANY'S ADDRESS
CITY, STATE, ZIP CODE
POLICY HOLDER'S ID NUMBER GROUP PLAN NUMBER
YOUR SECONDARY INSURANCE COMPANY'S NAME
SECONDARY INSURANCE COMPANY'S ADDRESS
CITY, STATE, ZIP CODE
POLICY HOLDER'S ID NUMBER
GROUP PLAN NUMBER
FAMILY MED OF BERKELEY SPRINGS
412 NORTH WASHINGTON ST.
BERKELEY SPRING WV 2541
h,hl,l,l,,h,h,,Ih,,Ih,,llh,h,,,Ihh,h,,Ih,hlll,,,I
12547/1--S 62--B 0
h,hhhh,h,h,,Ih,,ll,,ll,h,hlh,,Ih,,,,,Ihhhll,,,I
MARY L SNYDER
15 COLONIAL VLG
BERKELEY SPRINGS WV 25411-3800
I-- ACCOUNT NUMBER : ( AMOUNT ENCL~ED
40
PLEASE DETACH AND RETURN TOP SECTION WITH YOUR !PAYMENT.
MAKE PAYMENT TO:
FAMILY MED OF BERKELEY SPRINGS
DIAGNOSIS
CODE
466.0
DATE
PROCEDURAL~
REFERENCE
NAME
01/22/02 99214
INS
'HE BAI
02/26/02 I COMBI
*Your ~ccount i
call ii there i
get
a p
CHARGES / PAYMENTS /ADJUSTMENTS
9214
PAID =its PORTION.
y past due. Please
you have any questions,
10'; O0 .... ~0-
105.00
-6.90
-88.10
.00 ~ 10.00 ~
i 10.00, .00 j
OVER60DAYS I ~R90DAYS i
CURRENT ~L OVER 30 DAYS
'--~~- --7 ........ ~.00 i 40
THE AMOUNT SHOWN i 20.00 .00
·00 ,i IN THE PATIENT COLUMN i
OVER 120 DAYS !~ IS DUE NOW. :
~ ..... PATIENT INS. PENDING
Thla bill Is due upo. receipt. The patient is responsible to pay any and all ch;rges si~(~wn'~l ....
the "Patient" column. The charges shown in the "Insurance Pending" column have been filed with
the patient's insurance company on the patient's behalf. The patient is always responsible for the
payment of any and all services rendered which are not paid by insurance. Until further notice,
pay only the amount shown in the "Patienl" column.
YOUR NAME
STREET
CITY
If any of the following has.changed, please indicate...-
EMPLOYER
EMPLOYER ADDRESS
INSURANCE COMPANY
INS. COMPANY ADDRESS
STATE
MARITAL STATUS
HOME PHONE
ZIP CODE
BUSINESS PHONE
SOCIAL SECURITY
CONTRACT NO.
INS. POLICY NO.
OTHER INFORMATION
MA'<~ ~AyM~R'~ -O:
' ' FAMILY MED OF BERKELEY SPRINGS
DIAGNOSIS DATE PROCEDURAL NAME L~
CODE REFERENCE CHARGES/~YMENTS/ADJUSTMENTS
.......... ~;~L-~A~ FORWK~ -A~-'O~- 0~1'~0'-I0~ .00 1'1~.
COMBINED INSURANCE
10129101 COMBINED! CROSS PAYMENT -12.00
311 11/13/01 99213 -83.00
'YOUR ID ITS PORT ON. 71.00
'THE 1LITY.
466.0 01/22/02
105.00
INSURANCE -12.00
12/24101 PAYMENT -49.00
*Your account is now 30 d s~ past due.
nOW,
Please remit
10.00 20.00 .00 .00 .00 THE AMOUNT SHOWN
.................. ~ ............. IN THE PATIENT COLUMN i 30.00 105.00
CURRENT OV_ER 30 ~AYS QV_ER 60 DAYS OVER 90 DAYS ..~'O~ E R 120 D-,~ySTM IS DUE NnW
.......................... ,__~ ----, PATIENT INS. PENDING
01 ~30~02 .00 40
STATEMENT DATE ~T.D. PATIENT PAYMENTs' -~,C(~L]NT NuM~E-F~' ' ~, This bill Is due upoll receipt. The pat,em JS responsible to pay any and all charges shown in
the "Patient" column The charges snown m the "insurance Pending" column have been filed with
~AM~ILY MED OF BErKeLEY' ~ING$ ....... ' the oatient's insurance company on me Datient's behalf. The patient is always responsible for the
payment of any and all services rendered which are not pa~d by insurance. Until furl'her notice,
pay only the amount shown in the "Patient" column.
· · ' MIRA MCLEOD, MD
P 0 BOX 508
il B~RKE~EY SPRINGS WV 25411
AddressSe~ice Requested
MARY SNYDER
15 COLONIAL VILLAGE
BERKELEY SPRINGS , WV 25411
MIR
Billing Questions: (800) 335 -1444
Please detach and return top portion with payment
Patient Name
MARY SNYDER
Account# Statement Date
988 11/20/00
Amount Due AmountPaid
151.60
Account # Patient Name Statement Date
988 MARY SNYDER 11/20/00
DATE DOCTOR CODE DESCRIPTION AMOUNT BALANCE
02/15/00 MCLEOD 75820 VENOGARPGHY EXTREM 158.00
04/14/00 COMMERCIAL PAYMENT 6.40-
AMOUNT APPLIED TO DEDUCTIBLE
TOTAL DUE THIS CHARGE 151.60
IF YOU HAVE INSURANCE, PLEASE CALL OUR OFFICE·
PLEASE PAY IMMEDIATELY.
THIS IS THE RADIOLOGIST CHARGE FOR READING YOUR X-RAYS
CURRENT 30 DAYS 60 DAYS 90+ DAYS Pcndin§Insurance Current
· 00 .00 .00 151.60 __ ~(DoNotPay)~
Past Due
.00 151·60
[~ 151.60
Pay This ,aunount
:ks payable to: MIRA. MCLEOD, MD Location of Service
LOCATION OF SERVICE:WAR MEMORIAL HOSPITAL
MORGAN COUNTY
MEMORIAL HOSPITAI
BERKELEY SPRINGS WV 25411
SI&Y:FRO#-TO
ROCKVILLE MD 20850 OOOO
i-~.o*
~ TZN[ [] DICTATED
usT : S~E. :
TETANUS: WEIGHT:
X-RAY
MEDICA~ON$/TREATMENT PRESCRIPTIONS GIVEN
DISPOSITION
[] HOME [] ADMIT
[] WORK [] NH
[] AMA [] POLICE
[] OTHER
DISCHARGE CONDITION
[] IMPROVED D'
[] SAME [] EXPIRED
E D PHYSICIAN SIGNATURE PRIVATE PHYSICIAN SIGNATURE REFERRAL PHYSICIAN lltPI; l/fl
IN
THE COURT OF COMMON
OF CUMBERLAND COUNTY
STATE OF ~ PENNA.
PLEAS
.HAROLD._W_....SNYDER, ..........................................
...................................... ~_!~!~.g ......................
Versus
.~R~..~,....~., .............................................
D.ef~ndant
DECREE IN
DIVORCE
AND NOW ..... '~ .~,,,..6 ..............20..0.~ .... it is ordered and
decreed that ...... t~OLD..W,. $~YDE~ ........................ plaintiff,
and ................ ~..~.~ .%:. ~.¥.D.~ ......................... defendant,
are divorced from the bonds of matrimony.
The court retains jurisdiction of the following claims which have
been raised of record in this action for which a final order has not yet
been entered;
Agreement date May 25, 2002, shall be incorporated into, but riot
~ergad. with,, t-his. D. ecre~ .in. D. ivor~e ............................. ...
State Commonwealth of Pennsylvania
Co./City/Dist. of CU~.RZ~'CD
Date of Order/Notice lO/16/02
Tribunal/Case Number (See Addendum for case summary)
ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT
EmployerANithholder's Federal EIN Number
SHAFFER TRUCKING INC
PO BOX 418
NEW KINGSTOWN PA 17072-0418
C) Original Order/Notice
(~) Amended Order/Notice
C) Terminate Order/Notice
Employee/Obligor's Name (Last, First, MI)
301-52-67'76
Employee/Obligor's Social Security Number
2422100883
Employee/Obligor's Case Identifier
(See Addendum for plaintiff names
associated with cases on attachment)
Custodial Parent's Name (Last, First, MI)
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support
from CUMBERLAND County, Commonwealth of Pennsylvania. By law, you are required to deduct these
amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not
issued by your State.
$ 1,000.00 per month in current support
$ 0. o0 per month in past-due support Arrears 12 weeks or greater? Oyes (~) no
$ 0.00 per month in medical support
0.00 per month for genetic test costs
per month in other (specify)
for a total of $ 1., 000 00 per month to be forwarded to payee below. . / . ,
You do not have to vary your~ay cycle t° be in Comp ance with the support order If your pay~:ycle d[~/f~ot match
the ordered support payment cycle, use the following to determine how much to w~thhold:'~.:
$ 230.77 per weekly pay period.
$ 461.54 per biweekly pay period (every two weeks). ;.~ ~.~
$ 500.00 per semimonthly pay period (twice a month).
$ 1,000.00 per monthly pay period. /
You must be in w thho ding no later than the first pay period occurring ten (10) working oays ar[er~ne oare~ [n~
Order/Notic~ Send payment within seven (7) working days of the paydate/date of withholding. ¥?~ are eh~.~led to
deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your ~ployee for the
allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/obligor's
aggregate disposable weekly earnings. For tbe purpose of the limitation on withholding, the following information is
needed (See #10 on pg. 2).
If remitting by £FT/[DI, please call Pennsylvania State cOllections and Disbursement Unit (SCDU) Fmpl0yer
Customer Service at 1-g77-676-9580 for instructions.
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. 8ox 69112, Harrisburg, Pa 17106-91
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.
Order:OCT1 ? .v THE COUR
Date
of
~'IOCOZV49"~.~'~ (~ Form EN-028
OMB No.: 0970q)154 Worker ID $IATT
Service Type M
ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
[] IfcheckqJ you are required to prpvide a copy of this form to youreml~loyee f your employee works in a state that is
different trom the state that issuL~t this order, a copy must be provided to your empJoyee even if the box is not checked.
1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned
businesses located on a reservation that choose to withhold in accordance with this notice.
2. Priority: Withholding under this Order/Notice has priority over any other legal process under State law against the same income.
Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting
agency listed below.
3. Combining Payments: You can combine withheld amounts from more than one employee/obligOr's income in a single payment to
each agency requesting withholding. You must, however, separately identify the portion of.the single payment that is attributable to each
employee/obligor.
......... -~ ................................... '- .................. '--'-~ ......................... st comply ith the la ofth
state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the
withholding order and forward the support payments.
5.* Employee/Obligor with Multiple Support Holdings: If them is more than one Order/Notice to Withhold Income for Support against
this employee/obligor and You am Unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow
the law of the state of employee's/oblJgor's principal place ofemployment You must honor all Orders/Notices tothe greatest extent
possible. (See #10 below)
6. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you.
Please provide the information requested and return a copy of this Order/Notice to the Agency identified below.
WlTHHOLDER'S ID: 231&397640 -
EMPLOYEE'S/OBLIGOR'S NAME: SNYDER, HAROLD W.
EMPLOYEE'S CASE IDENTIFIER: 2422'100883 DATE OF SEPARATION:
LAST KNOWN HOME ADDRESS:
NEW EMPLOYER'S NAME/ADDRESS:
7. Lump Sum Payments: yOu may be required to report and w thho d from lump sum payments such as bonuses, commissions, or
severance pay. If you have any questions about lump sum payments, contact the person or authority below.
8. Liability: If you fail to Withhold income as the Order/Notice directs, you am liable for both the accumulated amount you should have
withheld from the employee/obligor's income and other penalties set by Pennsylvania State law. Pennsylvania state law governs unless
the obligor is employed in another State, in which case the law of the State in which he or she is employed governs.
9. Anti-discrimination: You are subject to a fine determined under State laTM for discharging an employee/obligor from employment,
refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law
governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs.
10.* Withholding Limit~: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit
Protection Act (15 U.S.C. § 1673 (b)l; or 2) the amounts allowed by the State of the emp!oyee's/obligor's pr!ncipal place of employment.
The Eederal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory
deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes.
11. Additional Info:
*NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the
law of the state that issued this order with respect to these items.
Submitted By:
DOMESTI.C RELATIONS SECTION
13 N. HANOVER ST
P,O. BOX 320
CARLISLE PA 1 7013
If you or your employee/obligor have any questions,
contact WAGE A-fiFACHMENT UNIT
by telephone at (717) 240-6225 or
by FAX at LZJ~)~:~_ or
by internet www.childsupport.state.pa, us
Page 2 of 2 Form EN-028
Service Type M OMB No.: 09Z0-0,S4 Worker ID $IATT
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: S~YDrR, ~a. ROt.D W.
PACSES Case Number 731104007
Plaintiff Name
MARY L. SNYDER
Docket Attachment Amount
00957 S 2001 $ 1,000.00
Child(ren)'s Name(s): DOB
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ o.oo
Child(ren)'s Name(s): DOB
[] If checked, you are required to enroll the child(ren)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
[] If checkedi you are required tO enroll the child(ren)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ o .-oo
Child(ren)'s Name(s): DOB
[]If checked, you are required to enroll the child(ten)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ o.oo
Child(ren)'s Name(s): DOB
[]If checked, you are required to enroll the child(rea)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ o.oo
Child(ren)'s Name(s): DOB
[] If checked, you are required to enroll the child(ten)
identified above in any health insurance coverage availab e
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
DOB
[] If checked, you are required to enroll the child(ren)
identified above in any health insurance coverage available
through the employee's/obligor'S employment.
Addendum
OM[~ NO.: 0970~0154
Form EN-028
Service Type M Worker ID $IATT
ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT
State Commonwealth of Pennsylvania
Co./City/Dist. of ¢Ot, U3ERZ~TD
Date of Order/Notice 12/08/03
Tribunal/Case Number (See Addendum for case summary)
O Original Order/Notice
(~ Amendecl Order/Notice
O Terminate Order/Notice
EmployerANithholder's Federal EIN Number
S~AFFER TRUCKING INC
PO BOX 418
NEW KINGSTOWN PA 17072-0418
RE:SNYDER, HAROLD W.
Employee/Obligor's Name (Last, First, MI)
301-52-6776
Employee/Obligor's Social Securib/Number
2422100883
Employee/Obligor's Case Identifier
(See Addendum for plaintiff names
associated with cases on attachment)
Custodial Parent's Name (Last, First, MI)
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support
from CUMBERI~ND County, Commonwealth of Pennsylvania. By law, you are required to deduct these
amounts from the above-named employee's/obligor's income until further notice even if the Order/Notice is not
issued by your State.
$ 1,000.00 per month in current support
$ 122. oo per month in past-due support Arrears 12 weeks or greater? C)yes (~) no
$ o. oo per month in medical support
$ 0, oo per month for genetic test costs
$ per month in other (specify)
for a total of $ !, 122.00 per month to be forwarded to payee below.
You do not have to vary your pay cycle to be in compliance with the support order. If your pay cycle does not match
the ordered support payment cycle, use the following to determine how much to withhold:
$ 258.92 per weekly pay period.
$ 517.85 per biweekly pay period (every two weeks).
$ 561. oo per semimonthly pay period (twice a month).
$ 1. 122. oo per monthly pay period.
REMITTANCE INFORMATION:
You must begin withholding no later than the first pay period occurring ten (10) working days after the date of this
Order/Notice. Send payment within seven (7) working days of the paydate/date of withholding. You are entitled to
deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the
allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/obligor's
aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is
needed (See #10 on pg. 2).
If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer
Customer Service at 1-877-676-9580 for instructions.
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown
above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED.
DO NOT SEND CASH BY MALL.
:~Z.:~~ THE COURT
_~_
Date of Order: , Eg -
Form EN-028
SewiceType M OM~No.:097~lS4 WorkerlD $IATT
ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
[] I~hecke~d you are required to provide a ~:opy of th s form to youremp oyee f yogr employee worlds in a state tha~ is
di~Terent trom the state that issued this oreer, a copy must be provided to you r employee even if the nox is not checKed.
1. We appreciate the voluntary compliance of Federally recognized Indian tribes, tribally-owned businesses, and Indian-owned
businesses located on a reservation that choose to withhold in accordance with this notice.
2. Priority: Withholding under this Order/Notice has priority over any other Je§al process under State law against the same income.
Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting
agency listed below.
3. Combining Payments: You can combine withheld amounts from more than one employee/obligor's income in a single payment to
each agency requesting withholding. You must, however, separately identify the portion of the single payment that is attributable to each
employee/obligor.
~,*r,,,,,~,,~o,~ ,, ............... ~ ...... ,,o,~ ,~ ................................ ,, .............. v,,'y~ * '"'"~*. You must comply with the law of the
state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the
withholding order and forward the support payments.
5.* Employee/Obligor with Multiple Support Holdings: If there is more than one Order/Notice to Withhold Income for Support against
this employee/obligor and you are unable to honor all support Order/Notices due to Federal or State withholding limits, you must follow
the law of the state of employee's/obligor's principal place of employment. You must honor all Orders/Notices to the greatest extent
possible. (See #10 below)
6. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you.
Please provide the information requested and return a copy of this Order/Notice to the Agency identified below.
WITHHOLDER'S ID: 2314397640
EMPLOYEE'S/OBLIGOR'S NAME: SNYDER, HAROLD W.
EMPLOYEE'S CASE IDENTIFIER: 2422100883 DATE OF SEPARATION:
LAST KNOWN HOME ADDRESS:
NEW EMPLOYER'S NAME/ADDRESS:
7. Lump Sum Payments: You may be required to report and withhold from lump sum payments such as bonuses, commissions, or
severance pay. If you have any questions about lump sum payments, contact the person or authority below.
8. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have
withheld from the employee./obligor's income and other penalties set by Pennsylvania State law. Pennsylvania State law governs unless
the obligor is employed in another State, in which case the law of the State in which he or she is employed governs.
9. Anti-discrimination: You are subject to a fine determined under State law for discharging an employee/obligor from employment,
refusing to employ, or taking disciplinary action against any employee/obligor because of a support withholding. Pennsylvania State law
governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs.
10.* Withholding Limits: You may not withhold more than the lesser of.' 1) the amounts allowed by the Federal Consumer Credit
Protection Act (15 U.S.C. § 1673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment.
The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory
deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes.
11. Additional Info:
*NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the
law of the state that issued this order with respect to these items.
Submitted By:
pOMESTIC RELATIONS SECTION
13 N. HANOVER ST
P.O. BOX 320
CARLISLE PA 1 7013
If you or your employee/obligor have any questions,
contact WAGE ATTACHMENT UNIT
by telephone at (717) 240-6225 or
by FAX at ~ or
by internet www.childsupport.state.pa, us
Page 2 of 2 Form EN-028
Service Type M OMB No.:0970~154 Worker ID $IATT
ADDENDUM
Summary of Cases on Attachment
Defendant]Obligor: SN~DER, m~,~OT.D W.
PACSES Case Number 731104007
Plaintiff Name
MARY L. SNYDER
Docket Attachment Amount
02-598 CV $ 1,122.00
Child(ren)'s Name(s): DOB
:.
[] f checked, you are required to enroll the child(ten)
identified above in any health insurance coverage avai ab e
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
; : :
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i ii i i il ii iiiiiiiiiiiii!iiiii!iiiii!iiiii!iiiiiiiii?iiiiiiiiiii!?ii!ilili!iiiii!ii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiii!iiiii i iiiiiiiiiiiiiiii!ii?iiiiiiiiiiiiiiiiiiiiiiiiiii il iii iii iii iii iii iii iii i!i i il iii i il i iiiiiiiiiiiiiiiiiii!iiiiiiiiiiii!i~iiii
[] If checked, you are required to enroll the child(ten)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.oo
Child(ren)'s Name(s): DOB
[] If checked you are required to enroll the child(ren)
identified above in any health insurance coverage avai ab e
throu§h the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
:.
:
i iiiiiiiii!iiii!iii!!!ii i!iiiiiiiiliiiiiii!ili!!!iiii!iii?iiii!iiii?iiii?iiiii~iil i i iii! !iiii!!iiii! iii ii!iii iii iii ? iii i il iii !ii i il iii iii iii iii i li i!! iii i~i iii i!i iii iii ~i~ii~iiiii~i~!i!~i~ii!~i!i!iiiiiiiiii!iiiiiiiiiii!iii~i~iii~i~iii~i~i~~i~!~i~i~ii!~~
[] If checked, you are required to enroll the child(ren)
identified above in any health insurance coverage available
through the employee's/obli§or's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ o.oo
Child(ren)'s Name(s): DOB
~ :.
il ii iii iii iii iii iii iii ili iii iii iii iil iii i!i iil iii iil iii iii iii ili iii iil iii i!i iii iii iii iii iii iii iil iii iii iil !ii iil iii iil iii ill iii ili iii iii iii iii iii iii iil iil i!i iii iii iil iil iii iii iil iii ill iii iii iii iii ili iii ili iii iii iii iii iii i!i ili iii iii iii iii iii
[] If checked, you are required to enroll the child(ren)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ o.0o
Child(ren)'s Name(s): DOB
il i i i ii iii i li iii i li iii ill iii ill iii i il iii i!iiiii!iii?i i i~iiii~iiiii!iiiii!iiiiiiiiiii~iii~i~ii~i~iii?~iii~iii~iiii~iiiii!ii~iiiii~iii~iiiii~iiiii~i~i!i~i~iii~i~i~iii~iii~i~iiii ii iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiliiiiiii!ii?iiiilil
[] If checked, you are required to enroll the child(ten)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
Addendum Form EN-028
Worker ID STATT
Service Type M OMB No.; 0970~154
ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT
Slate Commonwealth of Pennsylvania -'L_.~ ~ I C~L~
Co./City/Dist of CUMBEILT~,lq~
Date of Order/Notice 01/26/o4 [~2_-
Tribunal/Case Number (See Addendum for case summary)
RE: SNYDER, HAROLD W.
EmployerANithholder's Federal EIN Number
SHAFFER TRUCKING INC
PO BOX 418
NEW KINGSTOWN PA 17072-0418
O Original OrdedNotice
O Amended Order/Notice
(~) lerminate Order/Notice
Employee/Obligor's Name (Last, First, MI)
30:1-52-6776
Employee/Obligor's Social Security Number
2422100883
Employee/Obligor's Case Identifier
(See Addendum for plaintiff names
associated with cases on attachment)
Custodial Parent's Name (Last, First, MI)
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMATION: This is an Order/Notice to Withhold Income for Support based upon an order for support
from CUMBERI~%ATD Count/, Commonwealth of Pennsylvania. By law, you are required to deduct these
amounts from the above-named employee's/obligor's income until further notice even if the OrdedNotice is not
issued by your State.
$ 0.00 per month in current support
$ 0.00 per month in past-due support Arrears 12 weeks or greater? Oyes {~) no
$ 0. oo per month in medical support
$ 0,00 per month for genetic test costs
$ per month in other (specify)
for a total of $ 0.00 per month to be forwarded to payee below,
You do not have to vary your pay cycle to be in compliance with the suppoFt order, if your pay cycle does not match
the ordered support payment cycle, use the following to determine how much to withhold:
$ o. oo per weekly pay period.
$ 0.00 per biweekly pay period (every two weeks).
$ 0. oo per semimonthly pay period (twice a month).
$ 0. oo per monthly pay period.
REMITTANCE INFORMATION:
You must begin withholding no later than the first pay period occurring ten I10) working days after the date of this
Order/Notice. Send payment within seven (7) working days of the paydate/clate of withholding. You are entitled to
deduct a fee to defray the cost of withholding. Refer to the laws governing the work state of your employee for the
allowable amount. The total withheld amount, and your fee, cannot exceed 55% of the employee's/obligor's
aggregate disposable weekly earnings. For the purpose of the limitation on withholding, the following information is
needed (See #10 on pg. 2).
If remitting by EFT/EDI, please call Pennsylvania State Collections and Disbursement Unit (SCDU) Employer
Customer Service at 1-877-676-9580 for instructions.
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown
above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED.
DO NOT SEND CASH BY MAIL.
OMB NO,: 0970~1B4
Date of Order: JAN 7 7 EOt]&
Service Type M
Form EN-028
Worker ID $~.TT
ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
J--il heck y°u are required to provide a °Pyofthisformtoyour m Ioyee. Ifyo remploye~ orksin.astatetha is
~if~e~ren[e~r~m the state that issued this o~dCe(r, a copy must be provio~e~t°to your emp~(~yee even if tV~e box ,s not che~tked.
businesses located on a reservation that choose to withhold in accordance with this notice.
We appreciate the voluntary compliance of Federally recognized indian tribes, tribally-owned businesses, and Indian-owned
2. Priority: Withholding under this Order/Notice has priority OVer any other legal process under State law against the same income.
Federal tax levies in effect before receipt of this order have priority. If there are Federal tax levies in effect please contact the requesting
agency listed below.
3. Combining Payments: You can combine w thhe d amounts from more than one emplo ee/o ' ,
each agency .?qu.esting withholding. You must, however, separately identify the portion o~the ~igg~er~;~nm~tln a single payment to
employee/obhgorYhat ~s attributable to each
You must comply w~th the law of th
~, o,,~, ,~.u rorwam the support payments ...... p nods within whirl' __ e
· ,, yuu must ~mplement the
.5.* Employee/Obligor with Multiple Su ort · .
this employee/obligor and ~'o ........ ,PP..Holdings. If there is more tha ~-^ r~., .... e .,.,~, you must follow
' u~':un'~u~e[ononora/Isunnort ~..~,~.. n~."~'-'roer/r~ot~cetoWithhodlnc ,~,,~.c
the law of the state of employee's/obligor,s principal place of employment. You must honor all Orders/Notices to the greatest extent
'-'- O"~=,,,,uuces oue to Federal or State withholdin~'~'~i~' ouppor[ against
possible. (See #10 below)
6. Termination Notification: You must promptly notify the Requesting Agency when the employee/obligor is no longer working for you.
Please provide the information requested and return a copy of this Order/Notice to the Agency identified below.
WITHHOLDER,S ID: 2314397640
EMPLOYEE'S/OBLIGOR,s NAME- SNYDE ,
EMPLO , · -- R ~L~Ro
YEE S CASE IDENTIFIER: 24~nn~~-~'
LAST KNOWN HOME ADDRESS. - ...... aa DATE OF S .
NEW EMPLOYER'S NAME/AD~'ESS..-~-~ EPARATION._______________~ --
7. Lump Sum Payments: You may be required to report and withhold
severance pay. if you have any questions about lump sum from lump sum payments such as bonuses, commissions, or
payments, contact the person or authority below.
8. Liability: If you fail to withhold income as the Order/Notice directs, you are liable for both the accumulated amount you should have
withheld from the emp/oyee/obligor,s income and other penalties set by Pennsylvania State law. Pennsy vania State law governs unless
the obligor is employed in another State, in which case the law of the State in wh ch he or she is employed governs.
9. Anti'discriminatiom You are subject to a fine determined under State law for discharging an employee/obligor from employment,
refusingt~empi~y~rtakingd~scip~inaryacti~naga~nstan~emp~yee/~b~g~rbecause~fasupp~rtwthh~ding~ Pennsylvania State law
governs unless the obligor is employed in another State, in which case the law of the State in which he or she is employed governs.
10.* Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit
Protection Act (I 5 U.S.C. §1673 (b) l; or 2) the amounts allowed by the State of the empJoyee's/obligor's principal place of employment·
The Federal limit applies to the aggregate disposable weekly earnings (^DWE). ADWE is rise net income left after making mandatory
deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes.
1 I. Additional Info:
*NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the
law of the state that issued this order with respect to these items.
Submitted By:
P.O. BOX 320
CARLISLE PA 17013
If you or your employee/obligor have any questions,
contact
by telephone at LT;~ or
by FAX at ~..[Z) 2~ or '
by intemet Www.~~us
Service Type M
Page 2 of 2
OM8 NO.: 0970-0154 Form EN-028
Worker
ADDENDUM
Summary of Cases on AttacF~ent
Defendant/Obligor: SNYDER, HAROLD W.
P_ACSES Case Number 731104007
Pl~aintiff Name
MARy L. SNYDER
Docket
02-$98 CV ~~
0.00
Child(ren)'s Name(s):
DOB
PACSES Case Number
Plaintiff Name
Att._~achment Amount
$ o.oo
Child(ren)'s Name(s):
DOB
~if ch~ck~ ~od a~ ~ClU r~ tO enroii the Chikl(ren)
identified above in any hea;th insurance coverage available
through the employee's/obligor,s emp;oyment
P..~ACSE$ Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.o0
Child(ren)'s Name(s):
DOB
identified above in an,, h~,k - 'Id ren)
~ .~,~,L. Insurance COVerage avalbble
through the employee's/obligor,s employment.
PACSES Case~Number
Plaintiff Nan'le
Do~cket Attachment Amount
$ o.00
Child(ren)'s Name(s):
DOB
yo; ;re r quir; tO ;nroii ih;
identif ed above in a",, k_~,.~_ · hdd(ren)
-y ..~mt. Insurance coverage available
through the employee's/obligor,s employment.
PA_~CSE5 Case Nu_mbe~r
Plaintiff Name
Doc.__~ket A~chment Amount
$ o.oo
Child(ren)'s Name(s):
DOB
identified above in a",, ~---~-'- · hdd(ren)
through the employee's/obligor,s employment.
PACSES Case Number
Plaintiff Name
D.~ocket $.~Attac.__~h m en_t Amoun]
0.00
Child(ren)% Name(s):
DOB
IfJentlhed above in any health ins" e chlld(ren)
r , urance coverage available
th ough the employee s/obligor s employment.
~dent~fled above ~;n any h ,,k ;.., chdd(ren.)
through . ea ..... *urance coverage avadable
the employee's/obligor,s employment.
Service Type M
Addendum
Form EN-028
OMBN°';09?0~)]S4 Worker ID $IATT