HomeMy WebLinkAbout92-0701
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State Commonwealth of Pennsylvania
Co./City/Dist. of CUMBERLAND
Date of Order/Notice 06/06/06
Case Number (See Addendum for case summary)
ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT
701000024
1138 S 93
Employer/Withholder'5 Federal EIN Number
485000022
92-701 CIVIl.
~:FOOSE, SCOTT W.
o Original Order/Notice
@ Amended Order/Notice
o Terminate Order/Notice
Employee/Obligor's Name (Last, First, MI)
168-48-3331
Employee/Obligor's Social Security Number
6530000028
Employee/Obligor's Case Identifier
(See Addendum for plaintiff names
associated with cases on attachment)
Custodial Parent's Name (Last, First, MI)
SMITH BUCKLIN & ASSOC & CO
STE 300
1200 19TH ST NW
WASHINGTON DC 20036-2428
See Addendum for dependent names and birth dates associated with cases on attachment.
ORDER INFORMA TION: 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.
$ 350.00 per month in current support
$ 0 . 00 per month in past-due support Arrears 12 weeks or greater? 0 yes (X) no
$ 0 . 00 per month in current and past-due medical support
$ 0 . 00 per month for genetic test costs
$ per month in other (specify)
for a total of $ 350.00 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:
$ 80.77 per weekly pay period.
$ 161.54 per biweekly pay period (every two weeks).
$ 175.00 per semimonthly pay period (twice a month).
$ 350.00 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 paydateldate 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 #9 on page 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: P A SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PA YMENTS 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.
Date of Order: JUN 0 7 2OQ6
BY THE COURT:
M. L. ~~, ~ ~Julge
Form EN-028
OMB No.: 0970-0154 Worker ID $IATT
000: R.J. Shadday
Service Type M
-
ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
o If (;hecked you are required to provide a copy of this form to your,employee. If YOl,.lr employe~ works in.a state hthat iSd
ditterent from the state that issued this order, a copy must be provided to your employee even If the box IS not c ecke .
1, 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.
2. 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.
3. * Repol1il1g tl,e Paydate/Date of'vVitl.l,olding. You must n~port tI,e paydate/date of ",,;tl,I,oldillg vvl,el, selldil,g tl,e paylllel't. Tl,e
paydate/date of V'Vithholdillg is tl,e date 01, ""hid, alllount vvas V'Vithheld flolI' tl,e ell,ployee's vvages. You must comply with the law of the
state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement the
withholding order and forward the support payments.
4. * 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 #9 below)
5. 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.
THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: 9848100127
EMPLOYEE'S/OBlIGOR'S NAME: FOOSE . SCOTT W.
EMPLOYEE'S CASE IDENTIFIER: 6530000028 DATE OF SEPARATION:
LAST KNOWN HOME ADDRESS:
NEW EMPLOYER'S NAME/ADDRESS:
6. 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.
7. 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.
8. 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 govems.
9. * Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Credit
Protection Act (15 U.5.c. ~ 1673 (b)l; or 2) the amounts allowed by the State of the employee's/obligor's principal place of employment.
The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory
deductions such as: State, Federal, local taxes; Social Security taxes; and Medicare taxes. For tribal orders, you may not withhold more
than the amounts allowed under the law of the issuing tribe. For tribal employers who receive a state order, you may not withhold more
than the amounts allowed under the law of the state that issued the order.
10. 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.
11.Submitted By:
DOMESTIC RELATIONS SECTION
13 N. HANOVER ST
P.O. BOX 320
CARLISLE PA 17013
If you or your employee/obligor have any questions,
contact WAGE ATTACHMENT UNIT
by telephone at (71 7) 240-6225 or
by FAX at (717) 240-6248 or
by internet www.childsupport.state.pa.us
Page 2 of 2
Form EN-028
Worker ID $IATT
Service Type M
OMB No.: 0970-0154
~
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: FOOSE, SCOTT W.
PACSES Case Number 485000022
Plaintiff Name
LAURIE J. FOOSE
Docket Attachment Amount
701 CV 92 $ 350.00
Child(ren)'s Name(s):
DaB
If you are required to enroll the child(ren)
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):
DaB
If checked, you are required to enroll the child(ren)
above in any health insurance coverage available
the employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
DaB
If checked, you are required to enroll the child(ren)
in any health insurance coverage available
employee's/obligor's employment.
Service Type M
OMB No.: 0970-0154
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
DaB
If checked, you are required to enroll the child(ren)
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):
DaB
If checked, you are required to enroll the child(ren)
in any health insurance coverage available
employee's/obligor's employment.
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
DaB
If checked, you are required to enroll the child(ren)
above in any health insurance coverage available
through the employee's/obligor's employment.
Addendum
Form EN-028
Worker ID $IATT
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ORDER/NOTICE TO WITHHOLD INCOME FOR SUPPORT
State: Commonwealth of Pennsylvania
Co./City ist. Of: CUMBERLAND
Date of Order/Notice: 07/21/11
Case Number (See A en um for case summary)
Employer/Withholder's Federal EIN Number
SMITHBUCKLIN CORPORATION
401 N MICHIGAN AVE 2200
CHICAGO IL 60611-4245
RE: FOOSE. SCOTT W.
(?) Original Order/Notice
Q Amended Order/Notice
O Terminate Order/Notice
O One-Time Lump Sum/Notice
Employee/Obligor's Name (Last, First, MI)
168-48-3331
mp oyee igo s Social ecun y um er
6530000028
Employee/Obligors 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.
$ 0.00 per month in current child support
$ 0.00 per month in past-due child support
$ 0.00 per month in current medical support
$ 0.00 per month in past-due medical support
$ 350.00 per month in current spousal support
$ 0.00 per month in past-due spousal support
$ 0.00 per month for genetic test costs
$ 0.00 per month in other (specify)
$ - one-time lump sum payment
C.,
Cl -7-1
Arrears 12 weeks or greater? Fye? O-Ro
M CD
rn
c-
r- =-r;
-C
-
- i
ri
cn r tv
fV c
;<? T
? C-) ? 7
3
-?1!
for a total of $ 350.00 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:
$ 80.77 per weekly pay period. $ 175.00 per semimonthly pay period
(twice a month)
$ 161.5.}per biweekly pay period (every two weeks) $ 350.00 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 #9 on page 2).
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 DEFENDANTS 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.
BY THE COURT:
OMB No.: 0970-0154 Form EN-028
Service Type M Worker ID $IATT
ADDITIONAL INFORMATION TO EMPLOYERS AND OTHER WITHHOLDERS
If checked you are required to provide a copy of this form to your employee. If your employee works in a state that is
different from the state that issued this order, a copy must be provided to your employee even if the box is not checked.
1. 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.
2. 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.
3.* Reporting the Paydate/Date of Withholding: You must report the paydate/date of withholding when sending the payment. The
paydate/date of withholding is the date on which amount was withheld from the employee's wages. You must comply with the law of
the state of the employee's/obligor's principal place of employment with respect to the time periods within which you must implement
the withholding order and forward the support payments.
4.* 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 #9 below)
5. 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. 4120788280
THE PERSON HAS NEVER WORKED FOR THIS EMPLOYER: Q THE EMPLOYEE/OBLIGOR NO LONGER WORKS FOR: Q
EMPLOYEE'S/OBLIGOR'S NAME: FOOSE, SCOTT W.
EMPLOYEE'S CASE IDENTIFIER: 6530000028 DATE OF SEPARATION:
LAST KNOWN HOME ADDRESS:
LAST KNOWN PHONE NUMBER:
NEW EMPLOYER'S NAME/ADDRESS:
FINAL PAYMENT AMOUNT:
6. 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.
7. 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.
8. 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.
9.* 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's/obligor's principal place
of employment. 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, that
50% limit is increased to 55% and that 60% limit is increased to 65% if the arrears are greater than 12 weeks. If permitted by the State,
you may deduct a fee for administrative costs. The support amount and the fee may not exceed the limit indicated in this section.
Arrears greater than 12 weeks: If the Order Information does not indicate whether the arrears are greater than 12 weeks, then the
employer should calculate the CCPA limit using the lower percentage. For Tribal orders, you may not withhold more than the amounts
allowed under the law of the issuing Tribe. For Tribal employers who receive a State order, you may not withhold more than the lesser
of the limit set by the law of the jurisdiction in which the employer is located or the maximum amount permitted under section 303(d) of
the CCPA (15 U.S.C. 1673 (b)). Depending upon applicable State law, you may need to take into consideration the amounts paid for
health care premiums in determining disposable income and applying appropriate withholding limits.
10. 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.
11 • Send Termination Notice and
other correspondence to:
DOMESTIC RELATIONS SECTION
13 N. HANOVER ST
P.O. BOX 320
CARLISLE PA 17013
If you or your employee/obligor have any questions
contact WAGE ATTACHMENT UNIT
by telephone at (717) 240-6225 or
by FAX at (717) 240-6248 or
by internet www childsupport state pa us
OMB No- 0970-0154
Form EN-028
r ,
ADDENDUM
Summate of Cases on Attachmen
Defendant/Obligor: FOOSE, SCOTT W.
PACSES Case Number 485000022 PACKS Case Number
Plaintiff Name Plaintiff Name
LAURIE J. FOOSE
Docket Attachment Amount Docket Attachment Amount
701 CV 92 $ 350.00 $ 0.00
Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB
PACKS Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
PACKS Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
Service Type M
PACKS Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s): DOB
Addendum
OMB No.: 0970-0154
Form EN-028
Worker ID $IATT
INCOME WITHHOLDING FOR SUPPORT
O ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT (IWO)
O AMENDED IWO
O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT
TERMINATION OF IWO
Sococ 2
-70/ C,vll
Date:
11/13/14
O Child Support Enforcement (CSE) Agency CI 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
City/County/Dist./Tribe CUMBERLAND
Private Individual/Entity
Remittance Identifier (include w/payment): 6530000028
Order Identifier: (See Addendum for order/docket information)
CSE Agency Case Identifier: (See Addendum for case summary)
SMITH BUCKLIN & ASSOC & CO
STE 2000
330 N WABASH AVE
CHICAGO IL 60611-7621
Employer/Income Withholders FEIN
Child(ren)'s Name(s) (Last, First, Middle)
Child(ren)'s Birth Date(s)
RE: FOOSE, SCOTT W.
Employee/Obligor's Name (Last, First, Middle)
168-48-3331
Employee/Obligor's Social Security Number
(See Addendum for plaintiff names
associated with cases on attachment)
Custodial Party/Obligee's Name (Last, First,
Middle)
NOTE: This IWO must be regular on its face.
Under certain circumstances you must reject
this IWO and return it to the sender (see IWO
instructions
http://www.acf.hhs.gov/programs/cse/forms/
OMB -0970-0154 instructions.pol). 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.
9848100127
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 CUMBERLAffl County,
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amountsfr8rr`"the�mplpStee/
obligor's income until further notice.co Q r—
$ 0.00 per month in current child support r '� ;
$ 0.00 per month in past -due child support - Arrears 12 weeks or greater? 0 ye:77)' ns c ,
$ 0.00 per month in current cash medical support .I- -71
$ 0.00 per month in past -due cash medical support 1c) T;
$ 0.00 per month in current spousal support c,? E
$ 0.00 per month in past -due spousal support 3' z >
$ 0.00 per month in other (must specify) co :-,e
for a Total Amount to Withhold of $ 0.00 per month.
AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Information.
If your pay cycle does not match the ordered payment cycle, withhold one of the following amount:
$ 0.00 per weekly pay period. $ 0.00 per semimonthly pay period (twice a month)
$ 0.00 per biweekly pay period (every two weeks) $ 0,00 per monthly pay period.
$ Lump Sum Payment: Do not stop any existing IWO unless you receive a termination order.
REMITTANCE INFORMATION: If the employee/obligor's principal place of employment is 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
Service Type M
OMB No.: 0970-0154
Form EN -028 11/13
Worker ID $IATT
1::] Return to Sender [Completed by Emcome Withholder]. Payment must be directed to an SDU in
accordance with 42USC §S88/b\(5) and (b)(])orTribal Payee (see Payments hoSOUbm|ow). 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 equired by S a e or Triba
Print Name of Judge/Issuing Official:
Title ofJudge/Issuing Officia|:
Date of Signature:
tY1V ?.114
If the employee/obligor works in a State or for a Tribe thais differenfrom the State or Tribe that issued this order, a copy of this IWO
must be provided to the employee/obligor.
0 If checked, the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL N FORMATON 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 caII 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 MUSTINCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as
bheEnployee/Obligm,'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://vmxmv.aof.hhagov/prog,omo/omo/nevvhire/emp|oyer/con1uotmtuntao1 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 e | o/ob|i r'sincomainoaing|epaymenLYnunnust.hmwever.oepora0u|yidenUfyoachemp|oyee/
obligors portion af (he 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 attorn) 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 waoYoumustonmplywith1ho|mwcftheSCote(nrThba||awif
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 fW0m:|fthere immore than one |VV0against this employee/obligor andyuuanuunab|e0ufuUyhonoroU!VVOoduoto
Federal, State, or Tribal withholding limits, you must honor all 1W0s 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 Iaw/procedure.
Anti -discrimination: You are subject to a fine determined under State or Tribal law for from
employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO.
OMB Expiration Date —05/31om4iThe OMB Expiratio"oate has no bearing on the termination date ofthe wO;xidentifies the version mthe form currently wuse.
Form EN -028 11/13
Service Type M Page 2 of 3 Worker ID $IATT
Employe/mNama: SMITH BUCKLIN & ASSOC & CO Employer FEIN:
Emp|oyank]b|igu/nNomo: FOOSE, SCOTT W. 6530000028
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 FederalCunuumerCmditP,otention
Act (CCPA)(15U.S.C.1G73(b));or2)the amounts allowed by the State orTribe oftheemp|nyee/ob|igo/nAhncipdp|oceof
employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such
as: State, Federal, Iocal taxes; SociaI 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 Tribaorders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal
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 STATUSIf thi| r you or you are
no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sendor by
returning this form to the address Iisted in the Contact Inforrnation below: *848100127
0 This person has never worked for this empoyer nor received periodic income.
{� This person no Ionger works for this employer nor receives periodic income,
Please provide the foliowing information for the employee/obligor:
Termination date: Last known phone number:
Last known address:
Final Payment Date To SDUfTribal Payee: Fina Payment Amount:
New Empoyer's Name:
New Employer's Address:
CONTACT INFORMATION:
To Emoloyer/income Withholder: If you have any questions, contact WAGE ATTAHMENT UNIT (Issuer name)
byphonaat(717)24O'G225.byfaxat(717)24D'6248.byemaUorwebaiteat:xwxmv.chUdsunpod.stmbe.oa.us.
Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECT|ON, 13 N. HANOVERST`
P.O, BOX 320. CARLISLE. PA. 17013 (Issuer address).
To igor: If the has questions, contacWAGE ATTACHMENT UNIT (Issuer name)
byphone ot(717)24O'G225.byfax at(717)34O-8248.byemail orwebsite otvwww.ohUdouopurtsteba.pe.Vo.
IMPORTANT: The person compteting this form is advised tbatthe information may be shared with the employee/obligor.
OMB No.: 0970-0154
Service Type M Page 3 of 3Worker ID $1ATT
Form EN -028 11/13
ADDENDUM
Summary of Cases on Attachment
DefendantJObligor: FOOSE, SCOTT W.
PACSES Case Number 485000022 PACSES Case Number
Plaintiff Name Plaintiff Name
LAURIE J. FOOSE
Docket Attachment Amount Docket Attachment Amount
701 CV 92 0.00 0J0
PACSES Case Number FACSES Case Number
Plaintiff Name Plaintiff Name
Docket Attachment Amount Pocket Attachmen Amount
�
0.00 � 0.00
PACSES Case Number PACSESCase Number
Plaintiff Name Plaintiff Name
Pocket Attachment Amount
�
0.00
Child(renys Name(s):
DOB
Service Type M
Docket Attachment Amount
� 0.00
Child(ren)'s Name(s):
Addendum
OMB No.: 0970-0154
Form EN -028 11/13
Worker ID $IATT
r- ~
INCOME WITHHOLDING FOR SUPPORT
@) ORIGINAL INCOME WITHHOLDING ORDERINOTICE FOR SUPPORT (IWO)
O xMswosouwo
O ONE-TIMEORDERINOTICE FOR LUMP SUM PAYMENT
[) TERMINATION OF IWO
"
000��
_ 7D/ /n/ L// /
Date: 12/02/14
O Child guppoqEnforcement (CSE)*gemcY cg Court 0 Attorney 0 PrivatIndividual/Entity (Check One)
NOTE: iWO must be regular on its face. Under certain circumstances you must reject this IWO and retum it to the sender (see IWO
instructions hUo,Xww^mecf.hha -0970-0instructioris.df). If you receive this document frorn someone
other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached.
0nte/TnuefT mmry Commonwealth of Pennsylvania
City/County/Dist/Tribe CUMBERLAND
"
Private Individual/Entity
Remittance Identifier (include w/payment): 6530000028
Order Identifier: Addendum for order/docket informaUon)
CSE Agency Case Identifier: (See Addendum for case summary)
BEACON MGMT GROUP
4045 CARIBON ST
BOWIE MD 20721-2814
Employer/Income VVithholder'sFEIN 522241766
CNU(nen)'sNamu(s) (Last, First. Middle) Cmd(mn)'s8irth Date(s)
RE:
FOOSE, SCOTT W.
Employee/Obligors Name (Last,First, Middle)
168'48'3331
Employee/Obligor's Social Security Number
(See Addendum for plainfiff names
assoc!ated w!th cases on attachment)
Custodial Party/Obligee's Name (Last, First,
Middle)
NOTE: This IWO must be regular on its face.
Under certain circumstances you must reject
this IWO and return it 10 the sender (see IWO
instructions
xtm:Vw=w.acf.*^o.00v/nronwms/con/fo,ms/
Omo'0970'015* instructions.pf. 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.
5222417660
S�A���m f�d�emd�tma��a/��������se«�t����s�ona�achmmn� 2 L.3
ORDER INFORMATION: This d
Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts fcgriphe employee/
u» 1 7.nc�
C) .
r�� +o
<o =c -r
ru
^'
`-0
obIigors ncome until further notice.
�
0.00 per month in current child support
Q
0.00 per month in past -due child support - Arrears 12 weeks or greater?
� 0.00 per rrionth in current cash medical support
�
0.00 per month in past -due cash medical support
o
350.00 per month in current spousal support
�
0.00 per month in past -due spousal support
�
0D0 per month in other (must specify)
for a Total Amount to Withhold of $ 350,00 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:
� 80J?per weekly pay period. 175.00 per semimonthly pay period (twice a moath)
� 161.q -per biweekly pay period (every two weeks) $ 35O.00per 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 |imitations. time requiremants,
and any allowable employer fees at http://ww^w.mc[hho.gov/prognamo/oue/navvhire/emo|oyar/contaots/uontaot map.
bim for the emptoyee/obligor's principal place of employment.
Document Tracking Identifier
OMB No.: 0970-0154
Service Type M
Form EN -028 11/13
Worker ID $|ATT
❑ 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 SOU/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: DEC 0 3 2014
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.
0 If checked, the employer/income withholder must provide a copy of this form to the employee/obligor.
ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS
Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered
to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of
two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and
Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00
Make Remittance Payable to: PA SCDU
Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112
IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as
the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT
SEND CASH BY MAIL.
State -specific contact and withholding information can be found on the Federal Employer Services website located at:
http://www.acf.hhs.gov/programs/cse/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: BEACON MGMT GROUP Employer FEIN: 522241766
Employee/Obligor's Name: FOOSE, SCOTT W. 6530000028
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: 5222417660
Q This person has never worked for this employer nor received periodic income.
Q This person no longer works for this employer nor receives periodic income.
Please provide the following information for the employee/obligor:
Termination date: Last known phone number:
Last known address:
Final Payment Date To SDUfT'ribal 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.oa.us.
IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor.
OMB No.: 0970-0154
Service Type M Page 3 of 3
Form EN -028 11/13
Worker ID $IATT
ADDENDUM
Summary of Cases on Attachment
Defendant/Obligor: FOOSE, SCOTT W.
PACSES Case Number 485000022
Plaintiff Name
LAURIE J. FOOSE
Docke Attachment Amount
701 CV 92 $ 350.00
Child(ren)'s Name(s):
DOB
PACSES Case Number
Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
PACSES Case Number PACSES Case Number
Plaintiff Name Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
DOB
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
PACSES Case Number PACSES Case Number
Plaintiff Name Plaintiff Name
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
DOB
Service Type M
Docket Attachment Amount
$ 0.00
Child(ren)'s Name(s):
Addendum
OMB No.: 0970-0154
Form EN -028 11/13
Worker ID $IATT