HomeMy WebLinkAbout02-0985ROBEKT L. NICHOLSON,
Plaintiff,
VS.
GEORGIA J. NICHOLSON
Defendant,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - AT LAW
IN DIVORCE
NOTICE TO DEFEND AND CLAIM RIGHTS
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take prompt action. You are warned that if you fail to do so, the case
may proceed without you, and a decree of divorce, or annulment may be entered again~ you by
the court. A judgment may also be entered against you for any other claim or relief requested in
these papers by the Plaintiff. You may lose money or property or other fights important to you,
including custody or visitation of your children.
When the ground for the divorce is indignities or irretrievable breakdown of the marriage,
you may request marriage counseling. A list of marriage counselors is available in the Office of
the Prothonotary at the Cumberland County Courthouse, Carlisle, Pennsylvania.
IF YOU DO NOT FILF. 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 TI:IlS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TEI,EPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT W[rERE YOU CAN GET LEGAL
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE
CARLISLE, PA 17013
(717) 249-3166
ROBERT L. NICHOLSON,
Plaintiff,
VS.
GEORGIA J. NICHOLSON
Defendant,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
No.
CIVIL ACTION- AT LAW
IN DIVORCE
COMPLAINT IN DIVORCE UNDER SECTIONS 3301(c) or 3301(d)
OF ~ DIVORCE CODE
The Plaintiff. Robert L. Nicholson, by and through hl.q attorneys, The Law Offices ofPalrick F.
Lauer, Jr., makes the following Complaint in Divorce:
COUNT I - NO-FAULT DIVORCE
1. The Plaintiff, Robert L. Nicholson, is an adult individual whose current address is 1104
Yverdon Drive, Apt. A4, Camp Hill. Cumberland County, Pennsylvania 17011.
2. The Defep~d~nt, Georgia J. Nicholson, is an adult individual whose current address is
1012 W. FoxcroR Drive, Camp Hill. Cumberland County, Pennsylvania 17011.
3. The Parties have been bona fide residents of the Commonwealth of Pennsylvania for at
least six months mediately prior to the filing of this Complaint.
4. The Plaintiff and Defendant were manied on March 15, 1996 inl~_aami, Florida.
5. There have been no prior actions of divorce or for annulment between the parties
except for a 2001 Cameron County divorce action that was dismissed for lack of Venue.
6. The marriage is ineh-ievably broken.
7. The Plaintiff has been advised that counseling is available and that the Plaintiff may
have the right to request that the court require the parties to participate in counseling.
8. This action is not collusive.
WHEREFORE, the Plaintiff requests this Honorable Court to enter a Decree of Divorce in this
COUNT II - EQUITABLE DISTRIBUTION
9. Paragraphs one (1) through eight (8) of this Complaint are incorporated herein by
reference as if set forth speelflcal~ below.
10. The parties have legally and beneficially acquired property, both real and personal,
during their marriage.
11. The Plaintiff and the Defendant have been unable, as of the a_ote of this Complaint, to
agree as to an equitob!e division of said property.
WHI~Rg. gORE, the Plalnti~ Robert L. Nicholson, respectfully requests this Honorable
Court to equitably divide all marital property and to enjoin it from being removed, disposed of,
alienated, sold, or otherwise encumbered pending final hearing and settlement of all claims. The
Plaintiff further requests the Court to incorporate any Stipulation reached by the parties regarding
the division of marital proper~y into the divorce decree; or, should the parties fail to reach such an
agreement, to equitably divide all marital property.
Date:
Respectfully submitted,
Mm~L Marldey, Esquire
2108 Market Str~, Aztec Building
Camp I-~ Pennsylvanh 170114706
ID# 84745 Tel. (717) 763-1800
ROBERTL. NICHOLSON,
Plaintiff,
VS.
GEORGIA J. NICHOLSON
Defendant,
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: No.
:
: CIVIL ACTION - AT LAW
: IN DIVORCE
VERIFICATION
I verify that the statements made in this Complaint are true and correct. I understand that false
statements herein are made subject to the penalties of 18 Pa. C.S. § 4904, relating to unswom
falsification to authorities.
Signature: ~~~..~
ROBERTL. NICHOLSON
ROBERT L. NICHOLSON,
Plaintiff
Vo
GEORGIA J. NICHOLSON,
Defendant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: NO. 02-985 Civil
:
: CIVIL ACTION - 1N LAW
: DIVORCE
.NOTICE TO DEFEND AND CLAIM RIGHTS
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims
set forth in the following pages, you must take prompt action. You are warned that if you
fail to do so, the case may proceed without you and a decree of divorce or annulment may
be entered against you by the court. A judgment may also be entered against you for any
other relief requested in these papers by the Plaintiff. You may loose money or property
or other rights important to you, including custody or visitation of your children.
When the grounds 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, First Floor, Cumberland County Courthouse,
1 Courthouse Square, Carlisle, Pennsylvania.
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.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 17013
Telephone (717) 249-3166
ROBERT L. NICHOLSON,
Plaintiff
GEORGIA J. NICHOLSON,
Defendant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: NO. 02-985 Civil
:
: CiVIL ACTION - IN LAW
: DiVORCE
COMPLAINT / PETITION FOR ALIMONY PENDENTE LITE~ COSTS~
COUNSEL FEES AND ALIMONY
AND NOW COMES the Defendant/Petitioner, Georgia J. Nicholson, by her
counsel, William L. Grubb, Esquire, and complains of the Plaintiff/Respondent, Robert L.
Nicholson, as follows:
1. The Defendant/Petitioner, Georgia J. Nicholson, is an individual residing
at 1012 West Foxcrofi Drive, Camp Hill, Cumberland County, Pennsylvania.
2. The Plaintiff/Respondent, Robert L. Nicholson, is an adult individual
residing at 1104 Yverdon Drive, Apt. A-4, Camp Hill, Cumberland County,
Pennsylvania.
Florida.
The Defendant and Plaintiff were married on March 15, 1996, in Miami,
4. The Defendant and Plaintiffare living separate and apart.
5. Plaintiff and Defendant have been residents of this Commonwealth for at
least six (6) months immediately prior to the filing of this Complaint / Petition.
6. The Plaintiff/Respondent is believed to be employed by the United States
Army and earns in excess of $5,300.00 net per month. Plalntiff/Respondent's social
security number is 011-38-7373.
7. The Defendant/Petitioner is employed by the Harrisburg Academy and
earns approximately $1,100.00 net per month. Defendant/Petitioner's social security
number is 082-40-9139.
8. The Defendant/Petitioner is not'receiving public assistance.
9. The Plaintiff/Respondent has not sufficiently provided support for the
Defendant/Petitioner and the Defendant/Petitioner has insufficient means of support for
self and is without sufficient funds to meet the costs and expenses of this litigation.
COUNT I
ALIMONY PENDENTE LITE, COUNSEL FEES, COSTS AND EXPENSES
10. Defendant/Petitioner incorporates the allegations of paragraphs one (1)
through nine (9) by reference as if set forth at length herein.
11. By reason of the divorce action filed by Plaintiff/Respondent,
Defendant/Petitioner will be put to considerable expense in the preparation of her case, in
the employment of counsel an the payment of costs.
12. The Defendant/Petitioner is without sufficient funds to support herself and
to meet the costs and expenses of this litigation, and is unable to appropriately maintain
herself during the pendency of this action.
13. Plaintiff/Respondent has adequate earnings to provide for
Defendant/Petitioner's support and to pay her counsel fees, costs and expenses.
WHEREFORE, Defendant/Petitioner requests the Court to enter an award of Alimony
Pendente Lite, costs and expenses against the Plaintiff/Respondent and in favor of
Defendant/Petitioner, as well as provide medical support for the Defendant/Petitioner, if
appropriate.
_COUNT II
ALIMONY
14. Defendant/Petitioner incorporates the allegations of paragraphs one (1)
through thirteen (13) by reference as if set forth at length herein.
15. Defendant/Petitioner lacks sufficient property to provide for her
reasonable needs.
16. Defendant/Petitioner is unable to currently sufficiently support herself
through appropriate employment.
17. Defendant/Petitioner's employment contract with Harrisburg Academy
terminates in June, 2002. Thereafter she will be without employment.
18. Plaintiff/Respondent has sufficient income and assets to provide
continuing support for the Defendant/Petitioner.
WHEREFORE, Defendant/Petitioner requests the Court to enter an alimony award in
favor of Defendant/Petitioner in as much as the law will allow.
Respectfully submitted,
William L. Grubb, Esquire
I.D. # 72661
3105 Old Gettysburg Road
Camp Hill, PA 17011
(717) 763-5580
Attorney for Defendant/Petitioner
VERIFICATION
I, GEORGIA J. NICHOLSON, verify that the statements made in this document
are true and correct. I understand that false statements herein are made subject to
penalties of 18 Pa. C.S. § 4904, relating to unswom falsification to authorities.
Georgia J. ~[chg~'on'
D~'fendant/P etitioner
CERTIFICATE OF SERVICE
I, WILLIAM L. GRUBB, Esquire, certify that I have served a copy of the
foregoing document on the individual listed below, Counsel for the Plaintiff/Respondent,
by depositing the same in the United States Mall, First Class, postage prepaid, at Camp
Hill, Pennsylvania:
Marlin L. Markley, Esquire
2108 Market Street
Camp Hill, PA 17011
William L. Grubb, Esquire
I.D. # 72661
3105 Old Gettysburg Road
Camp Hill, PA 17011
(717) 763-5580
Attorney for Defendant/Petitioner
ROBERT L. NICHOLSON,
Plaintiff
GEORGIA J. NICHOLSON,
Defendant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: NO. 02-985 Civil
.'
: CIVIL ACTION - IN LAW
: DIVORCE
PLAINTIFF'S FIRST REQUEST FOR PRODUCTION AND INSPECTION OF
DOCUMENTS
To:
Robert L. Nicholson
C/O Marlin L. Markley, Esquire
Law Office of Patrick Lauer
2108 Market Street
Camp Hill, PA 17011
PLEASE TAKE NOTICE that you are hereby, pursuant to Pennsylvania Rules of
Civil Procedure No. 4001, et seq., to serve upon the undersigned, within thirty (30) days
after service of this Notice, your Responses in writing under oath to the Following
Document Requests.
,2002
By:
William L. Grubb, Esquire
3105 Old Gettysburg Road
Camp Hill, PA 17011
(717) 763-5580
Attorney for Defendant
INSTRUCTIONS
If you object to the production of any document on the grounds that the attorney-client,
attorney work-product or any other privilege is applicable thereto, you shall, with respect
to that document:
(a) State its date;
Co) Identify its author;
(c) Identify each person from whom the document was received;
(d) Identify each person who received it;
(e) Identify each person to whom the document was sent;
(f) State the present location of the document and ail cOpies thereof;
(g) Identify each person who has ever had possession, custody or control of it
or a copy thereof; and
(h) Provide sufficient information concerning the document and the
circumstances thereof to explain the claim of privilege and to permit the
adjudication of the propriety of that claim.
As referred to herein, "document" includes written, printed, typed, recorded, or
graphic matter, however produced or reproduced, including correspondence, telegrams,
other written communications, data processing storage units, tapes, contracts, agreements,
notes, memoranda, analyses, projections, diagrams, drawings, minUtes of meetings, or any
other writing (including copies of any of the foregoing) regardless of whether you, your
former or present counsel, agents, employees, officers, insurers; or any other person
acting on your behaif, are now in possession, custody, or control.
The purpose of the inspection is to aid plaintiff in the preparation of the trial of
this case. The items to be produced for inspection and photocopying are the following:
1. The settlement statement, known as the HUD-l, foim the sale of the
marital property at 15276 Waterwheel Terrace, Woodbridge, VA.
2. The settlement statement, known as the HUD-l, form the purchase of the
property at 15276 Waterwheel Terrace, Woodbridge, VA
CERTIFICATE OF SERVICE
I hereby certify that on this __ day of June, 2002, a true and correct copy of the
foregoing PLAINTIFF'S FIRST REQUEST FOR PRODUCTION AND INSPECTION
OF DOCUMENTS was served upon the following by depositing same into the US Mail,
first class, postage pre-paid to:
Marlin L. Markley, Esquire
Law Office of Patrick Lauer
2108 Market Street
Camp Hill, PA 17011
Date:
,2002
William L. Grubb, Esquire
3105 Old Gettysburg Road
Camp Hill, PA 17011
(717) 763-5580
Attorney for Defendant
ROBERT L. NICHOLSON,
Plaintiff
VS.
GEORGIA J. NICHOLSON,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
No. 02-985 CIVIL
:
: CIVIL ACTION - LAW
: IN DIVORCE
NOTICE TO THE DEFENDANT
IF YOU WISH TO DENY ANY OF THE STATEMENTS SET FORTH IN THIS
AFFIDAVIT, YOU MUST FILE A COUNTERAFFIDAVIT WITHIN TWENTY (20)
DAYS AFTER THIS AFFIDAVIT HAS BEEN SERVED ON YOU OR THE STATEMENTS
WILL BE ADMITTED.
2001,
of at least two years.
2. The marriage is
3. I understand
division of property,
them before a divorce
AFFIDAVIT UNDER SECTION 3301(d) OF THE DIVORCE CODE
1. The parties to this action separated on or about September
and have continued to live separate and apart for a period
irretrievably broken.
that I may lose rights concerning alimony,
lawyer's fees or expenses if I do not claim
is granted.
I verify that the statements made in this affidavit
and correct. I understand that false statements herein
subject to the penalties of 18 Pa. C.S.
falsification to authorities.
are true
are made
§ 4904 relating to unsworn
Sworn to and subscribed to
before me this day
of , 2003
Notary Public
ROBERT L. NICHOLSON,
Plaintiff
VS.
GEORGIA J.NICHOLSON,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 02- 985 CIVIL
IN DIVORCE
A~FIDAVIT OF CONSENT
1. A Complaint in Divorce under Section 330 l(c) ,of the Divorce Code was
filed on March 1, 2002.
2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety
(90) days have elapsed from the date of the filing of the Complaint.
3. I consent to the entry of the final Decree in Divorce after service of notice
of intention to request entry of the decree.
I VERIFY THAT THE STATEMENTS MADE 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
AUTHORTIES.
D~TE: J
GEORGIA~J. NI~HO~/~ON
ROBERT L. NICHOLSON,
Plaintiff
VS.
GEORGIA J.NICHOLSON,
Defendant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: NO. 02-985CIVIL
: IN DIVORCE
AFFIDAVIT OF CONSENT
1. A Complaint in Divorce under Section 330 l(c) of the Divorce Code was
filed on March 1, 2002.
2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety
(90) days have elapsed from the date of the filing of the Complaint.
3. I consent to the entry of the final Decree in Divorce after service of notice
of intention to request entry of the decree.
I VERIFY THAT THE STATEMENTS MADE IN THE FOREGOING
AFFIDAVIT ARE TRUE AND CORRECT. I UNDERSTAND THAT FALSE
STATEMENTS HEREIN ARE MADE SUBJECT TO THI:] PENALTIES OF 18
PA.C.S. SECTION 4904 RELATING TO UNSWORN FALSIFICATION TO
AUTHORTIES.
DATE:
ROBERT L. NICHOLSON
ROBERT L. NICHOLSON,
Plaintiff
VS.
GEORGIA J. NICHOLSON,
Defendant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND C, OUNTY, PENNSYLVANIA
: NO. 02-985 CIVIL
: IN DIVORCE
WAIVER OF NOTICE OF INTENTION TO RE~UF-~T
ENTRY OF A DIVORCE DECREE UNDER
SECTION 3301[C[ OF THE DIVORCE CODF,
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 fried with the Prothonotary.
I VERIFY THAT THE STATEMENTS MADE 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
AUTHORTIES.
DATE:
ROBERT L. NICHOLSON
ROBERT L. NICHOLSON, : IN THE COURT OF COMMON PLEAS OF
Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA
:
vs. : NO. 02 - 985 CIVIL
:
GEORGIA J. NICHOLSON, :
Defendant : IN DIVORCE
ORDER OF COURT
AND NOW, this _~t
dav of ,...,./~/,
2004, the parties and counsel having entered~'into an agreement
and stipulation resolving the economic issues on January 27,
2004, the date set for a Master's hearing, the agreement and
stipulation having been transcribed, and subsequently signed by
the parties and counsel, the appointment: of the Master is
vacated and counsel can conclude the proceedings by the filing
of a praecipe to transmit the record with the affidavits of
consent of the parties so that a final decree in divorce can be
entered.
CC:
/Marlin L. Markley
Attorney for Plaintiff
William L. Grubb
Attorney for Defendant
BY THE COURT,
Ge~[rg~ ~. 'Ho'ffer, P~ J.
O0 ~l ~1 8~ NVr' ~00~
ROBERT L. NICHOLSON, : IN THE COURT OF COMMON PLEAS OF
Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA
:
vs. : NO. 02 - 985 CIVIL
:
GEORGIA J. NICHOLSON, :
Defendant : IN DIVORCE
Nicholson,
Defendant,
Grubb.
THE MASTER: Today is Tuesday, January 27, 2004.
This is the date set for a hearing in the above captioned
divorce proceedings.
Present in the hearing room are Robert L.
and his counsel Marlin L. Markley, and the
Georgia J. Nicholson, and her counsel William L.
This action was commenced by the filing of a
complaint in divorce on March 1, 2002,. raising grounds for
divorce of irretrievable breakdown of the marriage and the
economic claim of equitable distribution.
With respect to the grounds for divorce, the
parties have provided the Master with affidavits of consent
and waivers of notice of intention to request entry of
divorce decree dated today. The affidavits and waivers will
be filed with the Prothonotary by the Master's office;
therefore, the divorce can conclude under Section 3301(c) of
the Domestic Relations Code. Previously an affidavit under
Section 3301(d) was filed but we have determined today to go
forward under the 3301(c) section of the code.
On April 2, 2002, wife filed a petition
raising additional economic claims of alimony, alimony
pendente lite and counsel fees and expenses.
The parties were married on March 15, 1996,
and separated September 26, 2001. There are no children of
this marriage.
After negotiations this morning, the Master
has been advised that the parties have reached an agreement
with respect to the outstanding economic issues. An
agreement is going to be placed on the record in the
presence of the parties. The agreement as stated on the
record will be the substantive agreement of the parties
dealing with all economic claims. The agreement as placed
on the record will not be subject to any changes or
modifications except for correction of typographical errors
which may be made during the transcription. The agreement
as stated on the record will resolve all economic claims and
even if the parties do not subsequently sign the agreement,
they are bound by the terms of the agreement as stated on
the record at this time. The signing of the agreement by
the parties will be simply an affirmation of the terms of
settlement as stated.
The parties are going to return later today
to review the agreement for typographical errors, make any
corrections as necessary, and then affix their signatures
2
affirming the terms of settlement.
completed agreement by the Master,
an order vacating his appointment
a praecipe transmitting the record to
final decree in divorce. Mr. Grubb.
MR. GRUBB:
Upon receipt of the
the! Master will prepare
and counsel can then file
the Court requesting a
1. Regarding the equitable distribution of the marital
assets, from the joint checking account, husband agrees to
pay wife the sum of $8,389.00.
2. Each party has previously divided an IRA, one in each
name that has been divided prior to this.
3. The car that is in possesion of each will remain the
property of that person. The 2002 Saturn that is currently
being used by wife is titled in the name of husband.
Husband has agreed to cooperate fully in transferring the
title and signing any documents that may be necessary to
effectuate the transfer of title from husband to wife. The
other vehicle is in husband's name. Any amounts that are
owed on the Saturn which will become the possession of the
wife, shall become the responsibility of the wife. Husband
is currently making the payments on the car and he will
provide all payment information necessary and required for
wife to make and continue making the payments. Wife will
indemnify and hold husband harmless on account of any claim
that is made by the lienholder on the vehicle as she assumes
the obligation for payments thereof.
4. The parties have prior to this divided and split the
household furnishings in a manner which is satisfactory to
both parties.
5. The husband also agrees to pay to wife the sum of
$10,000.00 in consideration for the equitable distribution
issues regarding a house on Water Wheel Terrace. The
payments for the house and the wife's portion of the
checking account totals $18,389.00. ?he parties have agreed
that there will be a first payment of 1/2 of the total due
from husband to wife on February 15, 2004, and the second
payment of an equal amount shall be payable one year later
on February 15, 2005.
3
6. Husband agrees to have entered a QDRO dividing and
distributing his military pension in the sum of $546.00 per
month to wife. In the event that a QDRO is not allowed
under the payment plan from the plan administrator, and we
suspect that might be so because of the marriage being less
than ten (10) years, husband will execute with his bank that
the $546.00 will be taken directly out of his checking
account and sent directly to Georgia Nicholson through an
account. The $546.00 per month that is from Mr. Nicholson's
pension is a gross amount to be paid to Georgia Nicholson
and it is the intent of the parties that she is responsible
for the taxes on that portion -- that $546.00. If a QDRO
can be provided it should be accomplished within sixty (60)
days of today's date; otherwise, the payments will be
immediately set up for the transfer to wife's account from
husband's account as they mutually agree.
7. Regarding the issue of alimony, husband agrees to pay
to wife alimony in the sum of $825.00 a month to be set for
an indefinite period of time. Said alimony shall be
terminable upon the death of either party, the remarriage of
wife, or the cohabitation of wife with a person of the
opposite sex. With respect to modification or termination
otherwise in accordance with Section 370t(e) of the Domestic
Relations Code, the alimony payments may be modified or
terminate in accordance with an order of court based on a
petition filed by either party claiming changed
circumstances of a substantial and continuing nature. The
alimony is to be paid to Mrs. Nicholson through the office
of the Domestic Relations Office of Cumberland County.
The spousal support order will terminate immediately upon
the entry of the divorce decree and the first alimony
payment will be due one month from the date of the last
spousal support payment and every month thereafter until
either terminated or modified.
8. Wife withdraws her claim for counsel fees and costs.
9. Except as herein otherwise provided, each party may
dispose of his or her property in any way and each party
hereby waives and relinquishes any and all rights he or she
may now have or hereafter acquire under the present or
future laws of any jurisdiction to share in the property or
the estate of the other as a result of the marital
relationship including without limitation, statutory
allowance, widow's allowance, right of intestacy, right to
take against the will of the other, and right to act as
administrator or executor in the other's estate. Each will
at the request of the other execute, acknowledge, and
deliver any and all instruments which may be necessary or
advisable to carry into effect this mutual waiver and
relinquishment of all such interest, rights, and claims.
THE MASTER: It is the Master's understanding
that if a QDRO can be provided as a way to make the pension
payments, Mr. Markley is going to prepare
Grubb will be responsible for taking care
title of the vehicle to his client's name.
will be required to provide an account,
entered in this case, from which funds
will be paid for the pension payment due monthly.
Mr. Nicholson,
stated on the record?
MR. NICHOLSON:
THE MASTER:
it?
the QDRO; Mr.
of the transfer of
Mrs. Nicholson
if a QDRO cannot be
from Mr. Nicholson
you've heard the agreement as
Yes, sir.
Do you have any questions about
MR. NICHOLSON: No, sir.
THE MASTER: It is your intention to have
entered as a final resolution of all
yourself and your wife?
sir.
this
this agreement
outstanding economic claims between
MR. NICHOLSON: Yes,
THE MASTER: And you understand that
agreement is entered on the record as a substantive
agreement of the parties not subject to any changes or
modifications except for correction of typographical errors?
5
present
MR. NICHOLSON: Yes, sir.
THE MASTER: Mrs. Nicholson, you've been
during the statement of the agreement on the record?
MRS. NICHOLSON: Yes.
THE MASTER: Do you have any questions about
the agreement?
MRS. NICHOLSON: No.
THE MASTER: And do you understand that when
you leave the hearing room today you are bound by the terms
of the agreement except for correction of typographical
errors?
statement
MRS. NICHOLSON:
THE MASTER:
of the agreement
MRS.
Yes, I do.
And do you. understand the
that we placed on the record?
NICHOLSON: Yes, I do.
I acknowledge that I have read the above
stipulation and agreement, that I understand the terms of
settlement as set forth herein, and that by signing below I
ratify and affirm the agreement previously made and intend
to bind myself to the settlement as a contract obligating
myself to the terms of settlement and subjecting myself to
the methods and procedures of enforcement which may be
6
imposed by law and in particular Section 3105 of the
Domestic Relations Code.
WITNESS: DATE:
~arl~W~L. Markley
AttOrney for Plaintiff
William L[ Grdbb
Attorney for Defendant
Robert L. Nicholson
ROBERT L. NICHOLSON,
Plaintiff
VS.
GEORGIA J. NICHOLSON,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 02 - 985 CIVIL
IN DIVORCE
THE MASTER:
This is the date set for a
divorce proceedings.
Today is Tuesday, January 27, 2004.
hearing in the above captioned
Present in the hearing room are Robert L.
and his counsel Marlin L. Markley, and the
Georgia J. Nicholson, and her counsel William L.
Nicholson,
Defendant,
Grubb.
This action was commenced by the filing of a
complaint in divorce on March 1, 2002, raising grounds for
divorce of irretrievable breakdown of the marriage and the
economic claim of equitable distribution.
With respect to the grounds for divorce, the
parties have provided the Master with affidavits of consent
and waivers of notice of intention to request entry of
divorce decree dated today. The affidavits and waivers will
be filed with the Prothonotary by the Master's office;
therefore, the divorce can conclude under Section 3301(c) of
the Domestic Relations Code. Previously an affidavit under
Section 3301(d) was filed but we have determined today to go
forward under the 3301(c) section of the code.
1
On April 2, 2002, wife filed a petition
raising additional economic claims of alimony, alimony
pendente lite and counsel fees and expenses.
The parties were married on March 15, 1996,
and separated September 26, 2001. There are no children of
this marriage.
After negotiations this morning, the Master
has been advised that th~ parties have reached an agreement
with respect to the outstanding economic issues. An
agreement is going to be placed on the record in the
presence of the parties. The agreement as stated on the
record will be the substantive agreement of the parties
dealing with all economic claims. The agreement as placed
on the record will not be subject to any changes or
modifications except for correction of typographical errors
which may be made during the transcription. The agreement
as stated on the record will resolve all economiC claims and
even if the parties do not subsequently sign the agreement,
they are bound by the terms of the agreement as stated on
the record at this time. The signing .of the agreement by
the parties will be simply an affirmation of the terms of
settlement as stated.
The parties are going to return later today
to review the agreement for typographical errors, make any
corrections as necessary, and then affix their signatures
2
affirming the terms of settlement. Upon receipt of the
completed agreement by the Master, the Master will prepare
an order vacating his appointment and counsel can then file
a praecipe transmitting the record to the Court requesting a
final decree in divorce. Mr. Grubb.
MR. GRUBB:
1. Regarding the equitable distribution of the marital
assets, from the joint checking account, husband agrees to
pay wife the sum of $8,389.00.
2. Each party has previousl.y divided an IRA, one in each
name that has been divided prior to this.
3. The car that is in possesion of each will remain the
property of that person. The 2002 Saturn that is currently
being used by wife is titled in the name of husband.
Husband has agreed to cooperate fully in transferring the
title and signing any documents that may be necessary to
effectuate the transfer of title from husband to wife. The
other vehicle is in husband's name. Any amounts that are
owed on the Saturn which will become 'the possession of the
wife, shall become the responsibility of the wife. Husband
is currently making the payments on the car and he will
provide all payment information necessary and required for
wife to make and continue making the payments. Wife will
indemnify and hold husband harmless on account of any claim
that is made by the lienholder on the vehicle a~ she assumes
the obligation for payments thereof.
4. The parties have prior to this divided and split the
household furnishings in a manner which is satisfactory to
both parties.
5. The husband also agrees to pay to wife the sum of
$10,000.00 in consideration for the equitable distribution
issues regarding a house on Water Wheel Terrace. The
payments for the house and the wife's portion of the
checking account totals $18,389.00. The parties have agreed
that there will be a first payment of 1/2 of the total due
from husband to wife on February 15, 2004, and the second
payment of an equal amount shall be payable one year later
on February 15, 2005.
3
6. Husband agrees to have entered a QDRO dividing and
distributing his military pension in the sum of $546.00 per
month to wife. In the event that a QDRO is not allowed
under the payment plan from the plan administrator, and we
suspect that might be so because of the marriage being less
than ten (10) years, husband will execute with his bank that
the $546.00 will be taken directly out of his checking
account and sent directly to Georgia Nicholson through an
account. The $546.00 per month that is from Mr. Nicholson's
pension is a gross amount to be paid to Georgia Nicholson
and it is the intent of the parties that she is responsible
for the taxes on that portion -- that $546.00. If a QDRO
can be provided it should be accomplished within sixty (60)
days of today's date; otherwise, the ]payments will be
immediately set up for the transfer to wife's account from
husband's account as they mutually ag~ee.
7. Regarding the issue of alimony, husband agrees to pay
to wife alimony in the sum of $825.00 a month to be set for
an indefinite period of time. Said alimony shall be
terminable upon the death of either party, the remarriage of
wife, or the cohabitation of wife with a person of the
opposite sex. With respect to modification or termination
otherwise in accordance with Section 3701(e) of the Domestic
Relations Code, the alimony payments may be modified or
terminate in accordance with an order of court based on a
petition filed by either party claiming changed
circumstances of a substantial and continuing nature. The
alimony is to be paid to Mrs. Nicholson through the office
of the Domestic Relations Office of Cumberland County.
The spousal support order will terminate immediately upon
the entry of the divorce decree and tke first alimony
payment will be due one month from the date of the last
spousal support payment and every month thereafter until
either terminated or modified.
8. Wife withdraws her claim for counsel fees and costs.
9. Except as herein otherwise provided, each party may
dispose of his or her property in any way and each party
hereby waives and relinquishes any and all rights he or she
may now have or hereafter acquire under the present or
future laws of any jurisdiction to share in the property or
the estate of the other as a result of the marital
relationship including without limitation, statutory
allowance, widow's allowance, right of intestacy, right to
take against the will of the other, and right to act as
administrator or executor in the other's estate. Each will
at the request of the other execute, acknowledge, and
4
deliver any and all instruments which may be necessary or
advisable to carry into effect this mutual waiver and
relinquishment of all such interest, rights, and claims.
THE MASTER: It is the Master's understanding
that if a QDRO can be provided as a way to make the pension
payments, Mr. Markley is going to prepare the QDRO; Mr.
Grubb will be responsible for taking care of the transfer of
title of the vehicle to 5is client's name. Mrs. Nicholson
will be required to provide an account, if a QDRO cannot be
entered in this case, from which funds from Mr. Nicholson
will be paid for the pension payment due monthly.
Mr. Nicholson, you've heard the agreement as
stated on the record?
MR. NICHOLSON: Yes, sir.
THE MASTER: Do you have any questions about
it?
MR. NICHOLSON: No, sir.
THE MASTER: It is your intention to have
this agreement entered as a final resclution of all
outstanding economic claims between yourself and your wife?
MR. NICHOLSON: Yes, sir.
THE MASTER: And you understand that this
agreement is entered on the record as a substantive
agreement of the parties not subject to any changes or
modifications except for correction of typographical errors?
5
MR. NICHOLSON: Yes, sir.
THE MASTER: Mrs. Nicholson, you've been
present during the statement of the agreement on the record?
MRS. NICHOLSON: Yes.
THE MASTER: Do you have any questions about
the agreement?
MRS. NICHOLSON: No.
THE MASTER: And do you understand that when
you leave the hearing room today you are bound by the terms
for correction of typographical
of the agreement except
errors?
statement of the agreement that we placed on the
MRS. NICHOLSON: Yes, I do.
THE MASTER: And do you understand the
record?
MRS. NICHOLSON: Yes, I do.
I acknowledge that I have read the above
stipulation and agreement, that I understand the terms of
settlement as set forth herein, and that by signing below I
ratify and affirm the agreement previously made and intend
to bind myself to the settlement as a contract obligating
myself to the terms of settlement and subjecting myself to
the methods and procedures of enforcement which may be
imposed by law and in particular Section 3105 of the
Domestic Relations Code.
WITNESS: DATE:
~'Jr li~. Markley
Attorney for Plaintiff
William L. Grubb
Attorney for Defendant
1-2-7 -2oo4
Robert L. Nicholson
7
ROBERT L. NICHOLSON, : IN THE COURT OF COMMON PLEAS OF
Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA
VS.
: No. 02-985 CIVIL
GEORGIA J. NICHOLSON,
Defendant
: IN DIVORCE
PRAt~-P~. TO TRAN~qM~IT Rtt~OR]'J
To the Prothonotary:
Transmit the record, together with the following information, to the Court for entry
of a divorce decree:
1. Ground for Divorce: In'etrievable breakdown under § 3301 (c) § 3301 ( d){ 1 ) o f the
Divorce Code. (Strike out inapplicable section)
2. Date and Manner of service of the Complaint:
Service by certified mail # 7000 1670 0005 2769 5351, delivered on March 5, 2002.
See Attached Affidavit of Service.
3. (Complete either paragraph (a) or (b).)
(a) Date of execution ofthe affidavit of consent required by § 3301 (c) of
the Divorce Code: by the Plaintiff Iammry 97. 2004
by the Defendant lammry 27. 21'104
(b)
Code:
Date of execution of the affidavit required by § 3301(d) of the Divorce
Date of filing of the Plaintiffs affidavit upon the respondent: ;
Date of service of the Plaintiffs affdavit upon the respondent:
4. Related claims pending: Nlnna All eluime rnieotl ha,aa horn qattloA hy a~t
th~ pa~i~e intn th~ ~ivnre~
5. (Complete either paragraph (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(0 Divorce was filed ~ith
the prothonotary: lam]ary 2R. 9.{'gld
Date Defendant's Waiver of Notice in § 3301(c) Divo;ce was filed with
the prothonotary: Tanlmry 2R. 9.004
Respectfiffi~ed,
Marlin L. M~l~ey, Esquire
Law Offices of Patrick F. Lauer, Jr., LLC
2108 Market Street, Aztec Building
Camp ITfll, Pennsylvania 17011-4706
ROBERT L. NICHOLSON,
Plaintiff
VS.
GEORGIA J. NICHOLSON,
Defendant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: No. 02-985 CIVIL
: IN DIVORCE
TO THE PROTHONOTARY:
I, Marlin L. Markley, Esquire, verify that the Complaint in Divorce has been
served upon the Defendant's Attomey, W'flliam H. Gmbb by first class, Certified Mail No.
7000 1670 0005 2769 5351, postage prepaid, return receipt requested, pursuant to the
requirements of Pa. 1LC.P. 1930.4.
ei SLa'NDER: I also wish to receive the fo~:~v-
13 Complel$ ~tems 1 and/or 2 for ttdditional services. Jrlg services (for an extra fee):
Complete items 3, 4a, and 4b.
[~ Print your name and address on the reverse of this form so that we can return this
D~att~ct~t~?sUiorm tothe front of the mailpiece, or onthe backif sl~acedoes not 1. [] Addressee's Address
permit ' 2 ' ·
· . . [] Restricted Dehvery
El Wnle Return Receipt Requested' on the mailpiece below tbe alticle number.
D lbs Return Receipt will show to whom he art cie was delrvered and the date
delivered.
3. Article Addressed to: 4a. Article Number
.7 Fo I q,o aao3-£7 q 3357
4b. Service Type
[] Registered
[] Express Mail [] insured
[] Retum ReceiptforMerchandise FICOD
7. Date of Deliwgry
8. Addressee's Address (On/yif requested and
fee is l~aid)
102595-99-B-0223 DoITte~tic Ret~m ReC~pl
4'Zo04
Respectfully submitted,
Law Offlce~ of Patrick F. Lauer, Jr., LLC
2108 Market Street, Aztec Building
Camp Hill, Pennsylvania 170114706
ID4t 84745 Tel. (717) 763-1800
ROBERT L. NICHOLSON,
Plaintiff
VS.
GEORGIA J. NICHOLSON,
Defendant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: No. 02-985
:
: CIVIL ACTION - LAW
: IN DIVORCE
I accept service of the COMPLAINT IN DIVORCE pursuant to Pennsylvania Rule of Civil
Procedure, Rule 1930.4(d). I certify that I am authorized to accept service on behalf of the
Defendant, Georgia J. Nicholson.
Date'
W'flliam L. Grubb, Esquire
(Attorney for the Defendant)
iN THE COURT OF COMMON PLEAS
ROBERT L. NICHOLSON,
Plaintiff
VERSUS
GEORGIA J. NICHOLSON,
Defendant
OFCUMBERLANDCOUNTY
STATE OF ~,~~ ~ PENNA.
NO. 02-985 CIVIL
DECREE IN
DIVORCE
AND NOW,
DECREED THAT
Robert L. Nicholson
, PLAINTIFF,
and Georgia J. Nicholson
, 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;
The attached Agreement and Stipulation dated January 27, 2004
is incorporated, without merger~ herein.
BY THE C~,RT: /
PROTHONOTARY
ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT
State Commonwealth of Pennsylvania
Co./City/Dist of CUMBERL~ND
Date of Order/Notice 03/08/04
Tribunal/Case Number (See Addendum for case summary)
EmployerANithholder's Federal EIN Number
DFAS CLEVELAND CENTER*
C/O DFAS CODE L
GAP~NISHMENT OPS
PO BOX 998002
CLEVELAND OH 44199-8002
C) Original Order/Notice
(~) Amended Order/Notice
C) Terminate Order/Notice
RE:NICHOLSON, ROBERT L. JR
Employee/Obligor's Name (Last, First, MI)
011-38-'73'/3
Employee/Ob[igor's Social Security Number
5095100851
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.
$ 825.00 per month in current support
$ o. 00 per month in past-due support Arrears 12 weeks or greater? Oyes (~) no
$' 0. DO per month in medical support
$ 0.00 per month for genetic test costs
$ per month in other (specify)
for a total of $ 825.00 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:
$ 190.38 per weekly pay period.
$ 380. ?? per biweekly pay period (every two weeks).
$ 43.2.50 per semimonthly pay period (twice a month).
$ 825. 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),O~ SgCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED.
DO NOT SEND CASH BY MAIL. ~ 'r' '' ~ I
Date of Order: I~LJ~Rm' 0 2~' '--~/~*' ~/ BYTHE COU~,~:/Z~:...j /~~~ -~,~
~4~ "'/~Z'~'"'~ Form EN-028
Service Type M OMBNO.:097~O~S4 Worker ID $'rATT
ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER W~THHOLDERS
[] I hecke you are requ red to provide a ~:opy of this form to your~mployee, if yogr emp oyee works in a state tha~ is
Idfi~erent ~(~m the state that issued th s oraer, a copy must be proviaed to your employee even if the box s 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.
__ .~_,_,~ .... ,. ,~,_~__,~ ..... ~__ ~ ........ L,-L ............ ~-' -'~ '---- ,,,~ ~,,,~,,~,y~ ~ ,,,,~*. You must corn 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
withholdin§ 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.
WlTI-IHOLDER'S ID:
EMPLOYEE'S/OBLIGOR'SNAME: NIg]4OT,~3ON ~
EMPLOYEE'S CASE IDENTIFIER: $095'100g~'l 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)~; 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.
1 1. Additional Info:
* NOTE: If you or your agent are served with a copy of this order in the state that issued the order, you are to follow the
law of the state that issued this order with respect to these items.
Submitted By:
~DOMESTIC RELATIONS SECTION
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 (71 i~ 240-6248 or
by internet www.childsupport.state.pa, us
Page 2 of 2 Form EN-028
Service Type l~ o~, No.: 0~54 Worker ID
ADDENDUM
Summary of Cases on Attachment
DefendantfObligor: NICHOLSON, ROBERT L. JR
PACSES Case Number 688103858
Plaintiff Name
GEORGIA J. NICHOLSON
Docket Attachment Amount
02-985 CIVIL $ 825.00
Child(ren)'s Name(s): DOB
[] If checked, you are required to enroll the child(ren)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
::
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
$ 0.0o
Child(ren)'s Name(s): DOB
:::
:
:
[] If checked, you are required to enroll the child(ten)
identified above in any health insurance covera§e available
through the employee's/obli§or'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(ten)
identified above in any health insurance coverage available
through the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
[] If checked, you are required to enroll the child(ren)
identified above in any health insurance covera§e available
throu§h 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.
Addendum Form EN-02§
Service Type M OMB No.: 0970.0154 Worker ID $IATT