HomeMy WebLinkAbout00-03134 NM INCOME WITHHOLDING FOR SUPPORT 9 51 ()q 577
0 ORIGINAL INCOME WITHHOLDING ORDERINOTICE FOR SUPPORT(IWO) CIVIL
0 AMENDED IWO
0 ONE-TIMEORDERINOTICE FOR LUMP SUM PAYMENT
(F) TERMINATION OF IWO Date: 03/21/13
❑ Chili$Support Enforcement(CSE)Agoody N Court ❑ Attorney ❑ Private Individual/Entity(Check One)
NOTE:This IWO must be Under certain circumstances you must reject this IWO and return it to the sender(see IWO
.,-:be
, #Wo W ace,Und
instructions hUg: I - /cse/newhirete ploMpublicabon/12ublication.h-tm-forms .If you receive this document from
someone other than a State or Tribal CSE agency or a Court,a copy of the underlying order must be attached.
State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 1438100560
City/County/Dist./Tribe CUMBERLAND Order Identifier. (See Addendum for ordorldockot 1011ci►mal1on)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
SPRINGWOOD MANAGEMENT CORP RE: ELICKER,JEFFREY L.
SUITE 200 Employee/Obligor's Name(Last,First,Middle)
146 PINE GROVE CIRCLE 181.42-8188
YORK PA 17403 Employee/Obligor's Social Security Number
(See Addendum for pialnd►names
associated with cases on aftchmenQ
Custodial Party/Obligee's Name(Last,First,
Middle)
Employer/Income Withholder's FEIN 232832916
NOTE:This IWO must be regular on its face.
Under certain circumstances you must reject
Child(ren)'s Name(s)(Last,First,Middle) Child(ren)'s Birth Date(s) this IWO and return it to the sender(see IWO
instructions
M*Ibmm.ad.hhs.covipmramstcse/newhI
form$.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.
2328329160
See Addendum for dependent names and birth dates associated with cases an attachment
ORDER INFORMATION; This document is based on the support or withholding order from CUMBERLA Q r--- ,
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from tht#mP%yeeMy/
obligor's income until further notice.
$ 0.00 Per month in current child support niGO :z oil._=M 3XV
$ 0.06 per month in past-due child support-Arrears 12 weeks or greater? 0 Ygta M-9
,7
$ 0.00 per month in current cash medical support C:)
$ 0.00 per month in past-due cash medical support --i
$ 0.00 per month in current spousal support
>C- :X
$ 0.00 per month in past-due spousal support
$ 0.00 per month in other(must specify) C.-3 >
for a Total Amount to Withhold of$ 0.00 per month.
AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information.
If your pay cycle does not match the ordered payment cycle,withhold one of the following amount:
$ 0.00 per weekly pay period. $ 0.00 per semimonthly pay period(twice a month)
$ 0.00 per biweekly pay period(every two weeks) $ O.Oo 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 550 of
disposable income for all orders. If the employee/obligors 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 hftp:IAME-N.acf.hbs.go-vLprpgramskse/newhire/empIMr/contacts/contagl mal2.
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$IATT
❑ Return to jl^ a by tit must be directed to an SDU in
accordence with 42 USC b)(S)and f# }or Try f nit
directed to an SDU/Triba f i�ayee or this IWO is not regular onIts' ,you Must this box and r afn tit#om to
the sander.
IL
Signature of Judge/issuing Official{if rewired by ft
W or Trig law};
Print Name of J I oft9l: r
Title of Judga/tssuing Oftlw:
Date of Signature:
If the emploYee/~wodcs in a .pr for a TtWe,ft,,is O*MM from the State or Tribe that issued this order,a"copy of this IWO
must be provided to ft employe r.
❑ If checked,the empioyertincome withholder must provide a copy of this form to the employee/obligor,
.NF T! 0,R x G NC ° %*T
Pennsovania low(, PA C.& 43,740))r ilres #y an it an'"-lo-ye �
two or more re ra t 1cs d r a c y . P *W P10"syl^0e- ",
13ie t+ tl rt t� ►A ..': .r, lawyer Cu tlet" alV !` nWu ., -
Make < to. PA SCQU
Swid ch*O to:Pem , P.O. ib , Pa 171 1 '
ytiiel�"rM � 't �' i
State specific contact and wW ftkhng information can be found on the federal Employer Services weOsite,locatadlat
Priority: Withholding;for support has priority"Duet sny_
x7)). If a l talc levy is in eft,} Mider
Cofnmnhw Per : WhtEtn ream tti payments to an or T cYk. u�
mor , 1# a
er aIlr's e a :R '
obligor's portion of*p payment.
Payn» To,$ must send child support iaaYments by in „ding to-tt apptr SPU or to a
Tribal any.'If -two ins '16l atn lii f€r titer el
party,court, orittori),You must check fire box ate �atr"°� sr►t
by a Court,AttQtney;.ott�tivate Individuantityatd"� �i i,
issued by a Tribal D�agency,you must folkww the td" �.
Rem tlwe Pay,At: You must report the pay date when sooKi A tat Tkt pay. ttae on which the
amount was , m the employe+e%t�r's You if
applicable)of the errlployee/obligor's principal t'f i fItrt ew t
the withholding and forward the support payments.
Mu 1*#W0*: If there is more than one IWO agairWA Ns N , a!tad-you are un, to qty honor ail 1WOs due to
Federal, Smote,orTribeilwu�ithkdingiir ,you #'. re � ,. ��-
support bew**ppy w,t of•any pasWue s .F0 0.4 or
place of employment to de4minline the app�_Akddlatlon_0-1i 010d.
Lump Sum Pa : You maybe requires to tt fy a, or Tr I rVy of a t l ,. pa ts to this
employee%bligor such as bonuses,comrnissions, or wm, ayY ". tl to s �i4r+ . " to
repart.ar0or wlthhbW lumpsum payments.
Liabliitty: If you have any doubts about the v d}tY of dit WO 4* If you held in ;�e
employ goes income as the it F
any penalties set by State or TrIbal 4w�p ure:
A :You are subject to a fine rw T !far d ftn"
employment,refusing to employ,or taking
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
Corm EN-028 06/12
Service Type M Page 2 of 3 Worker iii 1ATT
Employer's Name: SPRINGWOOD MANAGEMENT CORP Employer FEIN: 232832916
Employee/Obligor's Name: ELICKER JEFFREY L. 1438100560
CSE Agency Case Identifier:(See Addendum for case surnmarvl 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: 2328329160
O This person has never worked for this employer nor received periodic income.
O This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date: Last known phone number:
Last known address:
Final Payment Date To SDU/Tribal Payee: 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.childsupoort.state.12a.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 Employes/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.ga.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
195104577
Plaintiff Name Putt
COWN L.SUCKER
00-31 L $ kl . 8' $
v r...
Child(renys Non*s): DOB Child(ren)"s Name(s): DOB
PACSU CM NUMWr PAC s l tr t�et
Plaintiff bw= i:'wlitEi113
QW.M S A%QhMftM
Child(ren)'s Name(s): DOB Chiid(ron)'s Narnd(s): DOB
PA"ES QM
Ewan N me
Docke Machment 40 nt
Child(ren)'s Name(s): DOB Child(ron)'s Naffs): DOB
Addendum Form EN-028 06/12'
Service Type M OMS Rio.:097"154 Wori r 044ATT
In the Court of Common Pleas of CUMBERLAND County, Pennsylvania
DOMESTIC RELATIONS SECTION
13 N.HANOVER ST, P.O.BOX 320,CARLISLE,PA. 17013
Defendant Name: JEFFREY L. ELICKER
Member ID Number: 1438100560
Please note:All correspondence must include the Member ID Number.
ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSATION BENEFITS
Financial Break Down of Multiple Cases on Attachment
PACSES Docket
Plaintiff Name Case Num Numb pr Attachment Amount/E!Igueq
-0
CONNIE L ELICKER 195104577 00-3134 CIVIL 500.00
TOTAL ATTACHMENT AMOUNT: $ 500.00
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$ 115.07 per week, or 50%, of
the Unemployment Compensation benefits otherwise payable to the Defendant, JEFFREY L FLICKER
Social Security Number XXX-XX-8188, Member ID Number 1438100560 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 MARCH 17, 2013 is exhausted, expired or deferred.
,3UCB 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: M4 2 6 2013
M.L. Ebert, Jr. IJUDGE
Form EN-530
Service Type M Worker ID $IATT
In the Court of Common Pleas of CUMBERLAND County, Pennsylvania
DOMESTIC RELATIONS SECTION
13 N.HANOVER ST,P.O.BOX 320,CARLISLE,PA.17013
Phone: (717) 240-6225 Fax: (717)240-6248
,yam
Defendant Name: JEFFREY L. ELICKER :; ._.
Member ID Number: 1438100560r
Please note:All correspondence must include the Member ID Number. Nom'" I
ORDER TO VACATE ATTACHMENT OF UNEMPLOYMENT BENEEP N•
•Financial Break Down of Multiple Cases on Attachment
Plaintiff Name Case Number Number Attachment Amount/Frequency
CONNIE L.ELICKER 195104577 500.00 MONTH
TOTAL ATTACHMENT AMOUNT: $ 500.00
The prior Order of this Court directing the Department of Labor and Industry, Office of
Unemployment Compensation Benefits (OUCB), to attach$115.06 or 50% per week of
the Unemployment Compensation benefits of JEFFREY L. ELICKER, Social Security
Number XXX-XX-8188, Member ID Number 1438100560 is hereby vacated.
This Order to Vacate shall be effective upon receipt of the notice of the Order by the
Department and shall remain in effect until a further Order of the Court is filed.
BY THE COURT
Date of Order: 'r S 21 -t.
M.L. Ebert, Jt: JUIGE
Form EN-035
Service Type M Worker ID $IATT
In the Court of Common Pleas of CUMBERLAND County, Pennsylvania
DOMESTIC RELATIONS SECTION
13 N.HANOVER ST,P.Q.BOX 320,CARLISLE,PA.17013
Defendant Name: JEFFREY L. ELICKER
Member ID Number: 1438100560
Please note:All correspondence must include the Member ID Number.
ORDER OF ATTACHMENT OF UNEMPLOYMENT COMPENSATION BENEFITS
Financial Break Down of Multiple Cases on Attachment
=,r7 t r
Plaintiff Name C PA N ms r Numb r Attachment Amorreauency -'
CONNIE L.ELICKER 500.0 MoNTh!
T.,
"C3
"
$ /
TOTAL ATTACHMENT AMOUNT: $ 500.00
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$ 115.07 per week, or 50%, of
the Unemployment Compensation benefits otherwise payable to the Defendant, JEFFREY L. ELICKER
Social Security Number XXX-XX-8188, Member ID Number 1438100560. 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 MARCH 17, 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: OCT 1 5 2013
M.L.Eberk, JUDGE
Form EN-530
Service Type M Worker ID $IATT
INCOME WITHHOLDING FOR SUPPORT /9511)4577
® ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO)
Q AMENDED IWO
Q ONE-TIMEORDERINOTICE FOR LUMP SUM PAYMENT
Q TERMINATION OF IWO Date: 01/31/14
❑ Child Support Enfgrcement(CSE)Agency IX] 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/forms/OMB-0970-0154 instructions.odf). 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): 1438100560
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket information)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
P JOHN SOPENSKY RE: ELICKER,JEFFREY L.
1300 MARKET ST Employee/Obligor's Name(Last, First,Middle)
LEMOYNE PA 17043-1420 181-42-8188
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 251859273 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
http://www.acf.hh s.ggv/grogram s/cse/forms/
OMB-0970-0154 instructions.odl). 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.
2518592730
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 froth emplgyee/
obligor's income until further notice. 3 ---
$ 0.00 per month in current child support fi
$ 0.00 per month in past-due child support- Arrears 12 weeks or greater? 0 y s J t '
f t.:
$ 0.00 per month in current cash medical support _„‹
$ 0.00 per month in past-due cash medical support Ca _
$ 500,00 per month in current spousal support r, -32
$ 0.00 per month in past-due spousal support z
$ 0.00 per month in other(must specify) 23;
for a Total Amount to Withhold of$ 500.00 per month. `< tv
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:
$ 115.39 per weekly pay period. $ 250.00 per semimonthly pay period (twice a month)
$ 230.71 per biweekly pay period(every two weeks) $ 500.00 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 11/13
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: FEB-0_4_2 014
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.h hs.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.
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 11/13
Service Type M Page 2 of 3 Worker ID $IATT
Employer's Name: P JOHN SOPENSKY Employer FEIN: 251859273
Employee/Obligor's Name: ELICKER,JEFFREY L. 1438100560
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: 2518592730
O This person has never worked for this employer nor received periodic income.
O This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date: Last known phone number:
Last known address:
Final Payment Date To SDU/Tribal Payee: 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. BOX320. CARLISLE. PA. 17013(Issuer address).
To EmployeelObligor: 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.:0970-0154 Form EN-028 11/13
Service Type M Page 3 of 3 Worker ID $IATT
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: ELICKER, JEFFREY L.
PACSES Case Number 195104577 PACSES Case Number
Plaintiff Name Plaintiff Name
CONNIE L. ELICKER
Docket Attachment Amount Docket Attachment Amount
00-3134 CIVIL $ 500.00 $ 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 11/13
Service Type M OMB No.:0970-0154 Worker ID $IATT
Y INCOME WITHHOLDING FOR SUPPORT i S i D 45--77
Q ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO) OD-3132 +
Q AMENDED IWO
Civil
Q ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT
Q TERMI TION OF IWO Date: 02107114
❑ Child 9upp6rt 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/forms/OMB-0970-0154 instructions.pdf). 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): 1438100560
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket information)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
P JOHN SOPENSKY RE: ELICKER,JEFFREY L.
1300 MARKET ST Employee/Obligor's Name(Last,First,Middle)
LEMOYNE PA 17043-1420 181-42-8188
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 251859273 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
htti)://www.acf.hhs.gov/12rograms/cse/forms/
OMB-0970-0154 instructions.pdf..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.
2518592730
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. r-)
$ 0.00 per month in current child support -T;3 - -�
$ 0.00 per month in past-due child support- Arrears 12 weeks or greater? O yQ (D*- o
$ 0.00 per month in current cash medical support M �y
$ 0.00 per month in past-due cash medical support Z;
$ 0.00 per month in current spousal support
$ 0.00 per month in past-due spousal support < -o -�-r
$ 0.00 per month in other(must specify) k--)
for a Total Amount to Withhold of$ 0.00 per month. S>
AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Infor-mation.
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 5510 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 mao
htm for the employee/obligor's principal place of employment.
Document Tracking Identifier
OMB No.:0970-0154 Form EN-028 11/13
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: M.L. Ebert, Jr.
Title of Judge/Issuing Official:
Date of Signature: UB 1 `) 1 I
If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order,a copy of this IWO
must be provided to the employee/obligor.
❑ If checked,the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
Pennsylvania law(23 PA C.S. §4374(b))requires remittance by an electronic payment method if an employer is ordered
to withhold income from more than one employee and employs 15 or more persons,or if an employer has a history of
two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and
Disbursement Unit(PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER/D(shown above as
the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State-specific contact and withholding information can be found on the Federal Employer Services website located at:
http://www acf hhs gov/programs/cse/newhire/employer/contacts/contact_map htm
Priority: Withholding for support has priority over any other legal process under State law against the same income(USC 42
§666(b)(7)). If a Federal tax levy is in effect, please notify the sender.
Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine withheld amounts from
more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/
obligor's portion of the payment.
Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a
Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial
party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent
by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was
issued by a Tribal CSE agency, you must follow the"Remit payment to"instructions on this form.
Reporting the Pay Date: You must report the pay date when sending the payment.The pay date is the date on which the
amount was withheld from the employee/obligor's wages.You must comply with the law of the State(or Tribal law if
applicable)of the employee/obligor's principal place of employment regarding time periods within which you must implement
the withholding and forward the support payments.
Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to
Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current
support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal
place of employment to determine the appropriate allocation method.
Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this
employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to
report and/or withhold lump sum payments.
Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the
employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and
any penalties set by State or Tribal law/procedure.
Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from
employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
OMB Expiration Date-05/31/2014.The OMB Expiration Date has no bearing on the termination date of the IWO;it identifies the version of the form currently in use.
Form EN-028 11/13
Service Type M Page 2 of 3 Worker ID $IATT
Employer's Name: P JOHN SOPENSKY Employer FEIN: 251859273
Employee/Obligor's Name: ELICKER,JEFFREY L. 1438100560
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: 2518592730
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.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-028-11/13
Service Type M Page 3 of 3 Worker ID $IATT
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: ELICKER, JEFFREY L.
PACSES Case Number 195104577 PACSES Case Number
Plaintiff Name Plaintiff Name
CONNIE L. ELICKER
Docket Attachment Amount Docket Attachment Amount
00-3134 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 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 11/13
Service Type M OMB No.:0970-0154 Worker ID $IATT
INCOME WITHHOLDING FOR SUPPORT I q5 10 45-77
C
(2) ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO) o o , S is 1 _ C)\)
0 AMENDED IWO "�
0 ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT Date: 02111/14
0 TERMINATION OF IWO
El 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 http7//www.acf.hhs.aov/programs/cse/forms/OMB-0970-0154 instructions.pdf). 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): 1438100560
City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket information)
Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary)
RE: ELICKER JEFFREY L.
JLD PROPERTY MANAGEMENT GROUP Employee/Obligor's Name(Last,First,Middle)
PO BOX 384 181-42-8188
HUMMELSTOWN PA 17036-0384 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 272945534 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
htti)://www acf hhs oov/programs/cse/forms/
OMB-0970-0154 instructions.pdt).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.
2729455340
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 t�emR,oye`e/
obligor's income until further notice.
$ 0.00 per month in current child support
$ 0.00 per month in past-due child support- Arrears 12 weeks or greater? O yes 110 ';
$ 0.00 per month in current cash medical support er N
r-: C� c>
$ 0.00 per month in past-due cash medical support r
$ 500.00 per month in current spousal support
$ 0.00 per month in past-due spousal support �,cz r
$ 0.00 per month in other(must specify)
for a Total Amount to Withhold of$ 500.00 per month. r-
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 eingamount:
$ 115. 9 per weekly pay period. $ one
50 00 per sm mt
$ 230.7"1 )er biweekly pay period (every two weeks) $ 500.00 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 (StateFrribe), 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 551/6 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/proarams/cse/newh re/employer/contacts/contact map.
htm for the employee/obligor's principal place of employment.
Document Tracking Identifier
OMB No.:0970-0154 Form EN-028 11/13
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: Ebert Jr.
Date of Signature:
If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO
must be provided to the employee/obligor.
❑ If checked,the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
Pennsylvania law(23 PA C.S.§4374(b))requires remittance by an electronic payment method if an employer is ordered
to withhold income from more than one employee and employs 15 or more persons,or if an employer has a history of
two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and
Disbursement Unit(PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00
Make Remittance Payable to: PA SCDU .
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PA CSES 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:
hftp:Hwww.acf.hhs.gov/proarams lcse/newhireZomployer/coEtactsLcontact-nap.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
party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO wastsentl
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.
Service Type M Form EN-028 11/13
Page 2 of 3 Worker ID$IATT
Employer's Name: JLD PROPERTY MANAGEMENT GROUP Employer FEIN: 272945534
Employee/Obligor's Name: ELICKER,JEFFREY L. 1438100560
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: 2729455340
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 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 childsupport state pa us.
IMPORTANT:The person completing this form is advised that the information may be shared with the employee/obligor.
OMB No.:0970-0154 Form EN-028 11/13
Service Type M Page 3 of 3 Worker ID$IATT
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: ELICKER, JEFFREY L.
PACSES Case Number 195104577 PACSES Case Number
Plaintiff Name Plaintiff Name
CONNIE L. ELICKER
Docke Attachment Amount Docket Attachment Amount
00-3134 CIVIL $ 500.00 $ 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 11/13
Service Type M OMB No.:0970-0154 Worker ID$IATT