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HomeMy WebLinkAbout06-6950JOHN C. CLOUSER, JR., Plaintiff VS. ROBIN D. CLOUSER, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 64 Civil Term ACTION 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 against 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 rights important to you, including custody or visitation of your children. Where 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 at the Office of the Prothonotary, Cumberland County Courthouse. IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER'S FEES AND EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE THE RIGHT TO CLAIM 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 32 South Bedford St. Carlisle, Pa. 17013 (717) 249-3166 JOHN C. CLOUSER, JR., IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA VS. No. b G - 4JV Civil Term ROBIN D. CLOUSER, ACTION IN DIVORCE Defendant COMPLAINT IN DIVORCE 1. Plaintiff is John C. Clouser, Jr., a competent adult individual, who resides at 203 Forge Road, Boiling Springs, Cumberland County, Pa. 17007. 2. Defendant is Robin D. Clouser, a competent adult individual, who resides at 622 3rd St., New Cumberland, Cumberland County, Pennsylvania, 17070. 3. Plaintiff and Defendant have been bona fide residents of the Commonwealth for at least 6 months immediately previous to the filing of this Complaint. 4. The Plaintiff and the Defendant were married on October 4, 1975 in Cumberland County, Pennsylvania. 5. There have been no prior actions of divorce or for annulment between the parties. 6. Plaintiff has been advised that counseling is available and that plaintiff may have the right to request that the court require the parties to participate in counseling. 7. Plaintiff and Defendant have two children together; however, both are over the age of eighteen. 8. Plaintiff and Defendant are both citizens of the United States of America. 9. Neither Plaintiff or Defendant are a member of the Armed Forces of the United States of any of its allies. 10. The Plaintiff avers that the grounds on which this action is based are: That the marriage is irretrievably broken. WHEREFORE, Plaintiff requests the court to enter a decree in divorce. 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 unsworn falsification to authorities. John C. Clouser, Jr., Plaintiff Respectfully submitted, Date: lA ^ _I t !e Adams, Esquire . No. 79465 South Pitt Street Carlisle, Pa. 17013 (717) 245-8508 ATTORNEY FOR PLAINTIFF ?v v 1 n d -?C c.+a JOHN C. CLOUSER, JR., IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA vs. No. Civil Term ROBIN D. CLOUSER, : ACTION IN DIVORCE Defendant AFFIDAVIT OF SERVICE AND NOW, this December 15, 2006, I, Jane Adams, Esquire, hereby certify that on December 9, 2006, a certified true copy of the NOTICE TO DEFEND AND DIVORCE COMPLAINT was served, via certified mail, return receipt requested, addressed to: Robin D. Clouser 622 3rd St. New Cumberland, Pa. 17070 DEFENDANT ¦ Compl items 1, 2, and 3. Also complete A. Item 4 iis Restricted Delivery Is desired. ¦ Print yo r name and address on the reverse so that a can return the card to you. ¦ Attach card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: ?T6 --Z? C t.Dt?s R co?.1 3'?'` sT Agent Re*ied ? q DkW of Is delivery address ditr wd from Item 1? ? Yes tf YES, enter delivery address below: ?No -CJ?l? P?ERLI? Jll'? `3. Service Type (? q' D Mall [3 F a Mail 0 ? Registered ? Return Receipt for Merchandise ? Insured Mall ? C.O.D. 4. Restricted Delivery? (Extra Fee) Yes 2. Article Number (rmnsfer from service kd* 7004 1350 0003 7147 1656 PS Form 3811, February 2004 Domestic Return Receipt 102595-024A.1540 I Respectfully Submitted: Dhm- W. n?' J e Adams, Esquire I. . No. 79465 64 South Pitt Street Carlisle, Pa. 17013 (717) 245-8508 ATTORNEY FOR PLAINTIFF Q C?n cn 3 s xA N 0 Barbara Sumple-Sullivan, Esquire Supreme Court #32317 549 Bridge Street New Cumberland, PA 17070 (717) 774-1445 JOHN C. CLOUSER, JR., Plaintiff V. ROBIN D. CLOUSER, Defendant To: Mr. John C. Clouser, Jr. c/o Jane Adams, Esquire 64 South Pitt Street Carlisle, PA 17013 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2006 - 6950 : CIVIL ACTION -LAW : IN DIVORCE NOTICE TO PLEAD You are hereby notified to file a written response to the enclosed Defendant's Answer and Counterclaim to Plaintiff s Complaint within TWENTY (20) DAYS from service hereof or a judgment may be entered against you. Dated: January 19, 2007 Barbara Sumple-Sullivan, Esquire Attorney for Defendant/Counterclaim Plaintiff 549 Bridge Street New Cumberland, PA 17070-1931 (717) 774-1445 Supreme Court I.D. No. 32317 Barbara Sumple-Sullivan, Esquire Supreme Court #32317 549 Bridge Street New Cumberland, PA 17070 (717) 774-1445 JOHN C. CLOUSER, JR., Plaintiff V. ROBIN D. CLOUSER, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006 - 6950 CIVIL ACTION -LAW IN DIVORCE ANSWER AND COUNTERCLAIM AND NOW, this 19'h day of January, 2007, comes Defendant/Counterclaim Plaintiff, Robin D. Clouser, by and through her attorney, Barbara Sumple-Sullivan, Esquire, and files this Amended Answer and Counterclaim. 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Admitted. 6. Denied. After reasonable investigation, Defendant is without sufficient knowledge to admit or deny that Plaintiff has been advised that counseling is available and that Plaintiff may have the right to request that the court require the parties to participate in counseling. 7. Admitted. 8. Admitted. 9. Admitted. 10. Admitted. COUNTERCLAIM OF DEFENDANT/COUNTERCLAIM PLAINTIFF COUNTI FAULT DIVORCE INDIGNITIES 11. The averments in paragraphs 1 through 10 of Defendant/Counterclaim Plaintiff's Answer and Counterclaim are incorporated herein by reference thereto. 12. Defendant/Counterclaim Plaintiff is the innocent and injured party, and Plaintiff/Counterclaim Defendant has offered such indignities to the person of the Defendant/Counterclaim Plaintiff and has been mentally cruel to her so as to make her life burdensome and her condition intolerable, in violation of the marriage vows and of the laws of the Commonwealth. WHEREFORE, Defendant/Counterclaim Plaintiff requests this Court enter a divorce decree in her favor in accordance with the Pennsylvania Divorce Code. FAULT DIVORCE ADULTERY 13. The averments in paragraphs 1 through 12 of Defendant/Counterclaim Plaintiff's Answer and Counterclaim are incorporated herein by reference thereto. 2 14. Plaintiff/Counterclaim Defendant has committed adulterous acts in violation of the marriage vows and the laws of the Commonwealth of Pennsylvania. WHEREFORE, Defendant/Counterclaim Plaintiffrequests entry of a divorce decree in her favor in accordance with of the Pennsylvania Divorce Code. COUNT II EQUITABLE DISTRIBUTION 15. The averments in paragraphs 1 through 14 of Defendant/Counterclaim Plaintiff's Answer and Counterclaim are incorporated herein by reference thereto. 16. Petitioner requests your Honorable Court to equitably divide, distribute or assign the marital property between the parties in such proportions as the Court deems just pursuant to Section 3501 through Section 3508 of the Divorce Code of 1980, together with any amendments thereto. WHEREFORE, Defendant/Counterclaim Plaintiff requests entry of a divorce decree in her favor in accordance with of the Pennsylvania Divorce Code. COUNT III SUPPORT, ALIMONY PENDENTE LITE AND ALIMONY 17. The averments in paragraphs 1 through 16 of Defendant/Counterclaim Plaintiffs Answer and Counterclaim are incorporated herein by reference thereto. 18. Defendant/Counterclaim Plaintiff requires reasonable support to adequately sustain herself 3 with the standard of living established during the marriage. WHEREFORE, Defendant/Counterclaim Plaintiff requests an award of Support, Alimony and Alimony Pendente Lite. COUNT IV ATTORNEY'S FEES AND COSTS 19. The averments in paragraphs 1 through 18 of Defendant/Counterclaim Plaintiff's Answer and Counterclaim are incorporated herein by reference thereto. 20. Defendant/Counterclaim Plaintiff is unable to sustain herself during the course of this litigation and has employed Barbara Sumple-Sullivan, Esquire as counsel, but is unable to pay the necessary and reasonable attorney's fees for said counsel, and the necessary and reasonable costs and expenses. WHEREFORE, Defendant/Counterclaim Plaintiff requests an award of counsel's fees and expenses. WHEREFORE, Defendant/Counterclaim Plaintiff, Robin D. Clouser, prays this Honorable Court to enter judgment: A. Awarding Defendant/Counterclaim Plaintiff a decree in divorce; B. Equitably distributing the marital property C. Awarding Defendant/Counterclaim Plaintiff support, alimony and alimony pendente 4 lite; D. Awarding Defendant/Counterclaim Plaintiff counsel fees, costs and expenses; and E. Awarding other relief as the Court deems just and reasonable. Respectfully submitted, Dated: January 19, 2007 / --- Barbara Sumple-Sullivan, Esquire Attorney for Defendant/Counterclaim Plaintiff 549 Bridge Street New Cumberland, PA 17070-1931 (717) 774-1445 Supreme Court I.D. No. 32317 5 JOHN C. CLOUSER, JR., IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 2006 - 6950 ROBIN D. CLOUSER, : CIVIL ACTION -LAW Defendant : IN DIVORCE VERIFICATION I, Robin D. Clouser, hereby certify that the facts set forth in the foregoing ANSWER AND COUNTERCLAIM are true and correct to the best of my knowledge, information and belief. I understand that any false statements made herein are subject to penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities. DATED: 2007 R BIN D. CLOUSER 7 Barbara Sumple-Sullivan, Esquire Supreme Court #32317 549 Bridge Street New Cumberland, PA 17070 (717) 774-1445 JOHN C. CLOUSER, JR., : IN THE COURT OF COMMON PLEAS Plaintiff V. ROBIN D. CLOUSER, Defendant : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2006 - 6950 CIVIL ACTION -LAW IN DIVORCE CERTIFICATE OF SERVICE I, Barbara Sumple-Sullivan, Esquire, do hereby certify that on this date, I served a true and correct copy of the foregoing ANSWER AND COUNTERCLAIM in the above-captioned matter upon the following individual(s) by first class mail, postage prepaid, addressed as follows: Jane Adams, Esquire 64 South Pitt Street Carlisle, PA 17013 DATED: January 19, 2007 Barbara Sumple-Sullivan, Esquire Attorney for Defendant/Counter Plaintiff 549 Bridge Street New Cumberland, PA 17070-1931 (717) 774-1445 Supreme Court I.D. No. 32317 ? p 0 Chi t?? c_ r--3 C-3 C=n c._ G.7 r Q 4`ly JOHN C. CLOUSER, JR., IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA VS. No. 06 - 6950 Civil Term ROBIN D. CLOUSER, ACTION IN DIVORCE Defendant NOTICE If you wish to deny any of the statements set forth in this Affidavit, you must file a counter- affidavit within twenty days after this affidavit has been served on you or the statements will be admitted. AFFIDAVIT OF SEPARATION 1. The parties to this action separated on July 1, 2004 and have continued to live separate and apart for a period of at least two years. 2. The marriage is irretrievably broken. 3. I understand that I may lose my rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. Date: 2 - 2- Q ohn C. Clouser, Plaintiff ter. ??.? to C.. JOHN C. CLOUSER, JR., IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA vs. No. 06 - 6950 Civil Term ROBIN D. CLOUSER, ACTION IN DIVORCE Defendant AFFIDAVIT OF SERVICE AND NOW, this March 5, 2007, I, Jane Adams, Esquire, hereby certify that on or about March 1, 2007, a certified true copy of the AFFIDAVIT OF SEPARATION was served, via certified mail, return receipt requested, addressed to: Barbara Sumple-Sullivan, Esquire 549 Bridge St. New Cumberland, Pa. 17070 ATTORNEY FOR DEFENDA s *nawaxl 2,.and 3. Also complete A Signs item Delivery is desired. ? Agent ¦ Print yattaddress on the reverse O Addressee so that we can return the card to you. , Received by ( nL C. Date of Delivery ¦ Attach,this card to the back of the mailpiece, or on the frontlf space permits. L-AA) QA 1. Article Addressed to: I d item 1? 0 Yes V If YES, enter delivery address below: 9 No ?3 ? $A4A SUMPL4-?VLL! V rely a+.^. 549 'BRIDGE ST NEW CU.M.T.IE RLM A D PA, 1 7 0 7 0 3. Service lype Mail 0 EWees Mail 6 Rag' 1 1 ? Retum Receipt fbr Merchandise O insured Mau ? C.O.D. 4. Rea- ', Delivery? FA- Fee) ? Yes 2. Article Number 7006 0810 0000 7884 1248 (Hander ftm service bw Ps Form 3811, February 2004 Domestic Return Receipt 1025W -M-W1540 Respectfully Submitted: Adams, Esquire No. 79465 64 South Pitt Street Carlisle, Pa. 17013 (717) 245-8508 ATTORNEY FOR PLAINTIFF C"3 : ?' ?.., _ °tY ? ? ?t J?1 _ ?y.? - f "?? C - V _ ,? -- :..x JOHN C. CLOUSER, JR., Plaintiff V. ROBIN D. CLOUSER, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006 - 6950 CIVIL ACTION - LAW IN DIVORCE COUNTER-AFFIDAVIT UNDER SECTION 3301(d) OF THE DIVORCE CODE 1. Check either (a) or (b): _ (a) I do not oppose the entry of a divorce decree. .x (b) I oppose the entry of a divorce decree because the economic issues have not been resolved. (Check (I) (ii) or both): _ (I) The parties to this action have not lived separate and apart for a period of at least two years. (ii) The marriage is not irretrievably broken. 2. Check either (a) or (b): _ (a) I do not wish to make any claims for economic relief. 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. x (b) I wish to claim economic relief which may include alimony, division of property, lawyer's fees or expenses or other important rights. I understand that in addition to checking (b) above, I must also file all of my economic claims with the prothonotary in writing and serve them on the other party. If I fail to do so before the date set forth on the Notice of Intention to Request Divorce Decree, the divorce decree may be entered without further notice to me, and I shall be unable thereafter to file any economic claims. I verify that the statements made in this counter-affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. Dated: 6 ;7 AZ7- ROBtN D. CLOUSER NOTICE: If you do not wish to oppose the entry of a divorce decree and you do not wish to make any claim for economic relief, you should not file this counter-affidavit. [ 4 Barbara Sumple-Sullivan, Esquire Supreme Court #32317 549 Bridge Street New Cumberland, PA 17070 (717) 774-1445 JOHN C. CLOUSER, JR., Plaintiff V. ROBIN D. CLOUSER, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006 - 6950 CIVIL ACTION -LAW IN DIVORCE CERTIFICATE OF SERVICE I, Barbara Sumple-Sullivan, Esquire, do hereby certify that on this date, I served a true and correct copy of the foregoing COUNTER-AFFIDAVIT UNDER SECTION 3301(d) OF THE DIVORCE CODE in the above-captioned matter upon the following individual(s) by first class mail, postage prepaid, addressed as follows: Jane Adams, Esquire 64 South Pitt Street Carlisle, PA 17013 DATED: March 9, 2007 arbara Sumple-Sullivan, Esquire ttorney for Defendant 549 Bridge Street New Cumberland, PA 17070-1931 (717) 774-1445 Supreme Court I.D. No. 32317 ^ 73 G 7 v:, JOHN C. CLOUSER, JR., : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA VS. No. 06 - 6950 Civil Term ROBIN D. CLOUSER, ACTION IN DIVORCE Defendant MOTION FOR APPOINTMENT OF MASTER Defendant moves this Court to appoint a master with respect to the following claims: (?O Divorce O Distribution of Property ( ) Annulment ( ) Support (X) Alimony (}?) Counsel fees (?K) Alimony Pendente Lite (?) Costs and Expenses and in support of the motion states: (1) Discovery is substantially complete as to the claim(s) for which the appointment of a master is requested. (2) The Defendant is represented by Barbara Sumple-Sullivan, Esquire. (3) The statutory ground(s) for divorce is 3301 (d). (4) Delete the inapplicable paragraph(s): (a) The action is not contested. (b) An agreement has been reached with respect to the following claims: NONE. (c) The action is contested with respect to the following claims: ALL. (5) The action does not involve complex issues of law or fact. (6) The hearing is expected to take one half day. (7) Additional information, if any, relevant to the motion: NONE. Date: ) .'vl Adams, Esquire Pitt St., Carlisle, Pa. 17013 orney for Plaintiff 17) 245-8508 ORDER APPOINTING MASTER AND NOW, this , 2007, Robert Elicker, Esquire, is appointed Master with respect to the following claims: ALL. BY THE COURT: J. ev ? C? .. ? A ? ?} ? ?,... ^yyy Fr. ? ?? ? Yi _ ^ ? y''"?? w '?..?j } y . y n?" ? ? _ Kaasi 2007?.., JOHN C. CLOUSER, JR., Plaintiff vs. ROBIN D. CLOUSER, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 06 - 6950 Civil Term : ACTION IN DIVORCE MOTION FOR APPOINTMENT OF MASTER Defendant moves this Court to appoint a master with respect to the following claims: (?() Divorce (x) Distribution of Property ( ) Annulment ( ) Support (?() Alimony (jt) Counsel fees (?K) Alimony Pendente Lite (x) Costs and Expenses and in support of the motion states: (1) Discovery is substantially complete as to the claim(s) for which the appointment of a master is requested. (2) The Defendant is represented by Barbara Sumple-Sullivan, Esquire. (3) The statutory ground(s) for divorce is 3301 (d). (4) Delete the inapplicable paragraph(s): (d)Tiie action is not contested. (b) An agreement has been reached with respect to the following claims: NONE. (c) The action is contested with respect to the following claims: ALL. (5) The action does not involve complex issues of law or fact. (6) The hearing is expected to take one half day. (7) Additional information, if any, relevant to the motion: NONE. Date: ` j -' q , ,l Adams, Esquire P Pitt St., Carlisle, Pa. 17013 omey for Plaintiff 17) 245-8508 ORDER APPOINTING MASTER AND NOW, 4bi5? as , 2007, Robert Elicker, Esquire, is appointed Master with respect to the following claims: ALL. off . ,112 BY zMCA J. 4, "3 Q 5E AM- r v p cr r f Co CL f 0. wtu -? cn 0 cr? • J J?-6q-T-oC-?-. -( MARITAL SETTLEMENT AGREEMENT THIS AGREEMENT, made this 0' day of J U n E , 2008, by and between JOHN C. CLOUSER, JR., hereinafter referred to as "HUSBAND", and ROBIN D. CLOUSER, hereinafter referred to as "WIFE". WITNESSETH, That: WHEREAS, the parties hereto are husband and wife, having been lawfully joined in marriage on October 4, 1975, in Mechanicsburg, Cumberland County, Pennsylvania; WHEREAS, the parties' two children born of this marriage are emancipated; WHEREAS, it is the intention of the parties to settle fully and finally their respective financial and property rights and obligations as between each other arising out of the marriage relationship or otherwise, including without limitation (1) the settling of all matters between them relating to the ownership of real and personal property; (2) the settling of all matters between them relating to the past, present and future support and/or maintenance of HUSBAND and WIFE; and (3) the settling of all matters between them relating to any and all rights, titles and interests, claims and possible claims in or against the estate of the other. NOW THEREFORE, with the foregoing recitals being hereinafter incorporated by reference and deemed an essential part hereof in consideration of the foregoing recitals, the mutual promises, covenants and undertakings herein set forth, and for good and valuable consideration, receipt of which is hereby acknowledged by each of the parties hereto, HUSBAND and WIFE, each intending to be legally bound hereby, covenant and agree as follows: SECTION I GENERAL PROVISIONS 1. ADVICE OF COUNSEL HUSBAND and WIFE declare that they have each had a full and fair opportunity to obtain independent legal advice of counsel of their selection. WIFE has been independently represented by Barbara Sumple-Sullivan, Esquire. HUSBAND has been independently represented by Jane Adams, Esquire. Each party further declares that they are executing this Agreement freely and voluntarily, having obtained such knowledge and disclosure of their legal rights and obligations. Each party acknowledges that this Agreement is fair and equitable and is not the result of any fraud, coercion, duress, undue influence or collusion. Both parties further acknowledge and agree that each has fully disclosed their respective financial situations to the other, including their assets, liabilities and income. Each of the parties acknowledge and agree that, after having received such information and with such knowledge, this Agreement is fair, reasonable and equitable and that it is being entered into freely, voluntarily and in good faith and that the execution of this Agreement is not the result of any duress, undue influence, coercion, collusion and/or improper or illegal Agreement. 2. PERSONAL RIGHTS HUSBAND and WIFE may and shall, at all times hereafter, live separate and apart. Each shall be free from all control, restraint, interference or authority, direct or indirect, by the other in all respects as if she or he were unmarried, except as may be necessary to carry out the provisions 2 of this Agreement. Each may reside at such place or places as she or he may select. Each may, for his or her separate use or benefit, conduct, carry on and engage in any business, occupation, profession or employment which to him or her may seem advisable. This provision shall not be taken, however, to be an admission on the part of either HUSBAND or WIFE of the lawfulness of the causes which led to, or resulted in, the continuation of their living apart. HUSBAND and WIFE shall not molest, harass, or malign the other or the respective families of each other, nor compel the other to cohabit or dwell in any manner with him or her, nor in any way interfere with the peaceful existence, separate from each other. 3. FINANCIAL DISCLOSURE The parties have fully disclosed to each other the extent of each other' s income, assets, liabilities, holdings and estate. Each party warrants that the information provided has fully and accurately described the extent of his or her holdings. Each of the parties acknowledge that he or she is aware of his or her right to seek discovery including, but not limited to, written interrogatories, motions for document production, depositions, and other means of discovery available through the Pennsylvania Rules of Civil Procedure. The parties acknowledge that they have had the right to have property fully appraised. Each party is fully satisfied that no additional information is necessary for the execution of this Agreement. 4. MUTUAL CONSENT DIVORCE The parties intend to secure a mutual consent, no fault divorce pursuant to the provisions of Section 3301(c) of the Divorce Code of 1980, as amended and will execute the documents necessary to effectuate a divorce under those provisions concurrently with the execution of this Agreement. The parties agree that the Affidavits of Consent and the Waivers of Notice shall be signed simultaneously with the execution of this Agreement. 5. SUBSEQUENT DIVORCE A decree in divorce, entered by the court of Cumberland County, shall not suspend, supersede or affect the terms of this Agreement. This Agreement, and the terms and conditions contained herein, as well as the enforcement of said terms and conditions, shall not be contingent upon the granting of a Divorce Decree to either party by the Court of Common Pleas of Cumberland County, Pennsylvania, or any other Court of competent jurisdiction. This Agreement shall remain in full force and effect even if the parties reconcile, cohabit as HUSBAND and WIFE, or attempt a reconciliation. This Agreement shall continue in full force and effect and there shall not be a modification or waiver of any of the terms hereof unless the parties, in a writing signed by both parties, execute a statement declaring this Agreement or any term of this Agreement to be null and void. Both parties hereto agree that this Agreement shall be incorporated by reference but shall not be deemed merged into any judgment or decree for divorce obtained by either party. 4 6. OTHER DOCUMENTATION HUSBAND and WIFE covenant and agree that upon request of the other party, they will forthwith execute and deliver to the other party, any and all written instruments, assignments, releases, satisfactions, deeds, notes or such other writings as may be necessary or desirable for the proper effectuation of this Agreement. 7. MUTUAL RELEASES Except as otherwise expressly provided by this Agreement, A. Each party hereby absolutely and unconditionally releases and forever discharges the other and the estate of the other for all purposes from any and all rights and obligations which either may have or at any time hereafter have for past, present or future support or maintenance, alimony pendente lite, alimony, equitable distribution, counsel fees, costs, expenses and any other right or obligation, economic or otherwise, whether arising out of the marital relationship or otherwise, including all rights and benefits under the Pennsylvania Divorce Code of 1980, its supplements and amendments, as well as under any other law of any other jurisdiction, except and only except all rights, agreements and obligations of whatsoever nature arising or which may arise under this Agreement or for the breach of any provision thereof. Neither party shall have any obligation to the other not expressly set forth herein. B. Each party hereby absolutely and unconditionally releases and forever discharges the other and his or her heirs, executors, administrators, assigns, property and estate from any and all rights, claims, demands or obligations arising out of or by virtue of the marital relationship of the parties or otherwise, whether now existing or hereafter arising. The above release shall be effective regardless of whether such claims arise out of any former or future acts, contracts, engagements or liabilities or the other or by way of dower, curtesy, widow' s rights, family exemption or similar allowance, or under the intestate laws, or the right to take against the spouse' s will, or the right to treat a lifetime conveyance by the other as testamentary, or all other rights of a surviving spouse to participate in a deceased spouse' s estate, whether arising under the laws of Pennsylvania, any state, commonwealth or territory or the United States, or any other country. It is expressly understood, however, that neither the provisions of this release nor the subsequent entry of a divorce decree are intended to defeat the right of either party to receive any insurance proceeds at the death of the other of which she or he is the named beneficiary (whether the beneficiary designation was made prior or subsequent to execution hereof), nor to defeat the right of either party to receive any legacy, bequest or residuary portion of the other' s estate under his or her will, or to act as personal representative or executor if so named by the will of the other, whether such will was executed prior or subsequent to this Agreement. C. Except for any cause of action for divorce which either party may have or claim to have, and except for the obligations of the parties contained in this Agreement and such rights as are expressly reserved herein, each party gives to the other by the execution of this Agreement an absolute and unconditional release and discharge from all causes of action, claims, rights or demands whatsoever, in law or in equity, which either party ever had or now has against the other. 8. SUCCESSOR'S RIGHTS AND LIABILITIES This Agreement shall, except as otherwise provided herein, be binding upon and inure to the benefit of the parties hereto, their respective heirs, executors, administrators, successors or assigns. 9. SEVERABILITY If any provision in this Agreement is held by a court of competent jurisdiction to be invalid, void, or unenforceable, the remaining provisions shall nevertheless continue in full force and effect without being impaired or invalidated in any way. 10. ENTIRE AGREEMENT HUSBAND and WIFE do hereby covenant and warrant that this Agreement contains all of the representations, promises and Agreements made by either of them to the other for the purposes set forth in the preamble hereinabove; that there are no claims, promises or representations not herein contained, either oral or written, which shall or may be charged or enforced or enforceable unless reduced to writing and signed by both of the parties hereto. 6 11. BINDING EFFECT OF AGREEMENT/WAIVER This Agreement shall remain in full force and effect unless and until terminated under and pursuant to the terms of this Agreement. The failure of either party to insist upon strict performance of the provisions of this Agreement shall not be construed as a waiver of any subsequent default of the same or similar nature, nor shall such failure be construed as a waiver of any other term, condition, clause or provision of this Agreement. 12. BREACH If either party breaches any provision of this Agreement, the other party shall have the right, at his or her election, to sue for damages for such breach or seek such other remedies or relief as may be available to him or her, and the party breaching this contract shall be responsible for payment of reasonable legal fees and costs incurred by the other in enforcing their rights under this Agreement. 13. CONTROLLING LAW This Agreement shall be construed and governed in accordance with the laws of the Commonwealth of Pennsylvania. 14. TAX RETURNS The parties agree that in the future if any penalties or interest or any liability for failure to 7 declare income or the wrongful claiming of any deduction shall be assessed by the United States Internal Revenue Service or the Commonwealth of Pennsylvania, or any other state as a consequence of the parties' Federal and State income tax returns which were filed jointly by the parties, said tax, penalties or interest shall be the sole responsibility of the party found to have made the mistake in disclosure of income or taking an incorrect deduction. The party responsible for the mistake shall suffer the consequences solely and hold the opposite party harmless. Each party agrees to hold the other party harmless from any penalty, interest or liability for such reason arising out of the filing or failure to file any past tax return. If the liability is the result of a computation error or an error not attributable to the intentional or grossly negligent conduct of either party, the parties shall share equally in all future tax liability or tax assessment, penalties and interest. SECTION II EQUITABLE DISTRIBUTION During the marriage, the parties have accumulated various assets and liabilities, the disposition of which is intended as follows: 8 1. ASSETS A. PERSONAL and HOUSEHOLD PROPERTY HUSBAND and WIFE do hereby acknowledge that they have heretofore divided the non- marital and marital personal and household property, including but without limitation, jewelry, clothes, furniture, and other assets. HUSBAND agrees that all assets in the present possession of WIFE shall be the sole and separate property of WIFE and, WIFE agrees that all assets in the present possession of HUSBAND shall be the sole and separate property of HUSBAND. Each of the parties do hereby specifically waive, release, renounce and forever abandon whatever claims, if any, he or she may have with respect to any of the above said items which are the sole and separate property of the other. This document shall constitute a bill of sale for said sole property. B. REAL ESTATE The parties jointly owned property located at 622 Third Street, New Cumberland, Cumberland County, Pennsylvania. Said house was encumbered by two (2) PNC Bank Home Equity Loans in the collective amount of approximately EIGHTY-THREE THOUSAND FIVE HUNDRED DOLLARS ($83,500.00). The home was sold to a third parry on or about February 15, 2008. After satisfaction of all encumbrances and costs of sale, the net proceeds were received by WIFE in the amount of TWENTY-NINE THOUSAND EIGHT HUNDRED 9 THIRTY-NINE DOLLARS AND 12/100 ($29,839.12). The proceeds from the sale shall remain the sole and separate property of WIFE and HUSBAND shall waive any and all claims to same. C. MOTOR VEHICLES The parties acquired two (2) vehicles during the marriage being a 1997 GMC Sonoma driven by HUSBAND and a 2002 Chevy Impala driven by WIFE. The parties have each traded their respective vehicles after separation. The parties agree that each party shall maintain as his or her sole and separate property the proceeds from the marital vehicles as well as any vehicle which he or she drives presently which may have been received using the trade-in of his or her marital vehicle. Each party hereby waives, relinquishes and releases any claim in the vehicle which shall be the sole and separate property of the other. D. FINANCIAL ASSETS: The parties acknowledge that the marital financial accounts which existed during the marriage have been divided to the satisfaction of the parties. All jointly titled accounts have been closed. Each party hereby waives, relinquishes and releases any claims to the financial accounts in the possession of the other. 10 PENSION AND RETIREMENT ACCOUNTS: 1. Benefits of Wife. During the marriage, WIFE accumulated certain retirement benefits through her employment. These benefits consisted of an Oppenheimer 401(k), which is now held by American Funds. The marital value of same is TWENTY-THREE THOUSAND SEVEN HUNDRED NINETY-FOUR DOLLARS AND 66/100 ($23,794.66). WIFE shall retain her Oppenheimer 401(k) as her sole and separate property. HUSBAND waives any and all claims to this account. Additionally, after separation WIFE borrowed against her 401(k) in the amount of NINE THOUSAND DOLLARS ($9,000.00). This loan shall be deemed non-marital. WIFE shall be solely responsible for repayment and hereby holds HUSBAND harmless from said loan. 2. Benefits of Husband. During the marriage, HUSBAND accumulated certain retirement benefits through his employment. These consisted of. Central Pennsylvania Teamsters Retirement Income Plan: HUSBAND' S Central Pennsylvania Teamsters Retirement Income Plan had a cash value of TWO HUNDRED THIRTY-SIX THOUSAND THREE HUNDRED THIRTY-TWO DOLLARS AND 15/100 ($236,332.15) as of February 29, 2008. WIFE shall receive a rollover in the amount of ONE HUNDRED TWENTY-FIVE THOUSAND 11 DOLLARS ($125,000.00). WIFE'S sum shall be due to her effective June 1, 2008 and shall be subject to increases, net income, loss, or expense, after that date through the date of actual distribution to WIFE due to market activity. The remainder of the balance of this account shall be the sole and separate property of HUSBAND. WIFE waives any and all claims to the remainder of HUSBAND' S account after rollover to her. Counsel for HUSBAND shall be responsible to effectuate rollover into WIFE' s qualified plan within thirty (30) days of entry of the Divorce Decree or as soon as administratively possible. Central Pennsylvania Teamsters Defined Benefit Plan: HUSBAND' S Central Pennsylvania Teamsters Defined Benefit Plan has a date of separation estimated monthly pension payment of TWO HUNDRED SIXTY-FOUR DOLLARS AND 72/100 ($264.72), which is not presently in pay status. HUSBAND shall retain this benefit as his sole and separate property. WIFE shall waive any and all claims to HUSBAND' S Central Pennsylvania Teamsters Defined Benefit Plan. Wife shall sign the waiver regarding this Defined Benefit Plan contemporaneously with signing this agreement. Dupont / Berg Electronics Pension: HUSBAND has elected to receive his pension benefits from Dupont / Berg Electronics as of May, 2005. HUSBAND currently receives a monthly pension payment of TWO HUNDRED EIGHTEEN DOLLARS ($218.00) and has elected a survivor annuity on behalf of WIFE. This monthly pension benefit shall be divided between the parties with WIFE receiving 55% or 12 ONE HUNDRED NINETEEN DOLLARS 90/100 ($119.90) per month and HUSBAND receiving the remainder during his life. A Qualified Domestic Relations Order assigning WIFE' S share of the monthly payment to her shall be prepared by counsel for HUSBAND. Additionally, HUSBAND warrants that he has elected a 50% survivor annuity for WIFE which shall be irrevocable. WIFE' s continued right to receive the annuity shall be confirmed by the Qualified Domestic Relations Order. WIFE waives any and all claims to HUSBAND'S 45% share of the monthly pension and all monthly payments received by HUSBAND since separation. F. INSURANCE WIFE was the owner of a Prudential Life Insurance Policy during the marriage. Said policy was liquidated by WIFE after separation. The marital value of same was approximately TWO THOUSAND ELEVEN DOLLARS AND 34/100 ($2,011.34). HUSBAND waives any and all claims to said proceeds. HUSBAND is the owner of a Prudential Life Insurance Policy which has a marital value of SEVENTEEN THOUSAND SIX HUNDRED FIFTY DOLLARS ($17,650.00). HUSBAND shall retain this policy as his sole and separate property. WIFE waives any and all claims to said policy. However, HUSBAND shall maintain WIFE as beneficiary on this policy until such time as his alimony obligation pursuant to Section III of this Agreement is terminated. 13 DEBTS Each party represents that they have not contracted any debt or liability for the other for which the estate of the other party may be responsible or liable except as otherwise provided herein, and that except only for the rights arising out of this Agreement, neither party will hereafter incur any liability whatsoever for which the other party or the estate of the other party will be liable. Each party agrees to indemnify and hold harmless from and against all future obligations of every kind incurred by them, including those for necessities. SECTION III ALIMONY, ALIMONY PENDENTE LITE, SUPPORT, MAINTENANCE AND COUNSEL FEES There is currently in existence in the Court of Common Pleas, Cumberland County, Pennsylvania, Domestic Relations Division, Docket No. 00208 S 2007, PACSES Case No. 188109033, an Order for spousal support in the amount of FOUR HUNDRED EIGHTY-FIVE DOLLARS ($485.00) per month, payable to WIFE. Said Order shall continue in effect until the entry of a Decree in Divorce at which time the payment shall terminate. Any arrearage on the Order shall be immediately paid by HUSBAND. Upon the date of the Decree, the spousal award shall convert to alimony. HUSBAND shall pay to WIFE in the form of alimony the sum of FOUR HUNDRED EIGHTY-FIVE DOLLARS ($485.00) per month for a period of SIXTY (60) months beginning on the day following the date of entry of the Decree in Divorce. HUSBAND' s alimony payment shall be non-modifiable as to duration or amount and shall terminate only upon the first to occur of the following: 14 I . (1) The expiration of the alimony term; (2) Death of HUSBAND; (3) Death of WIFE; or (4) WIFE'S remarriage or cohabitation. Except as herein provided, both parties shall waive any other claims or demands that either may now or hereafter have against the other for support, maintenance, alimony, alimony pendente lite or counsel fees. All alimony to be paid under this agreement shall terminate upon the recipient's remarriage or cohabitation with a person of the opposite sex who is not a member of the family of the petitioner within the degrees of consanguinity or with a person of the same sex with which the recipient is living with in a same-sex relationship. For purposes of this paragraph, a cohabitation arrangement means two persons living in the same residence in the same or similar relationship as would a married couple, but without the benefit of a legal marriage. Wife agrees to notify Husband within five (5) days of when her remarriage or cohabitation begins and to refund to him any overpayments made to her by Husband as well as his reasonable legal fees if any are incurred when recovering overpayment. 15 SECTION IV 1. CONDITION PRECEDENT TO THE AGREEMENT'S EFFECTIVENESS The parties acknowledge that this Agreement shall become effective when actually signed JOHN C. CLOUSER, JR. Date: 0// " Q R IN D. CLOUSER R Date: (,1?--6/D 16 by both parties. `r t,. COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF ?.L ?, &e.42- la vj ) Before me, the undersigned officer, a Notary Public in and for said Commonwealth and County, personally appeared John C. Clouser, Jr. , who being duly affirmed according to law, deposes and says that the facts and matter set forth in the within and foregoing Marital Settlement Agreement are true and correct to the best of his knowledge, information and belief. Affirmed and subscribed to before me this 1 day of 2008. 1 a '--' ro /1 * NOTARY PUBLIC expires: COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND COMMONWEALTH Or N'NNSYL NotuiW SeW camjm rfendP 1wic CCanty MY Cmnission Expires Sept. 08 ) SS. Before me, the undersigned officer, a Notary Public in and for said Commonwealth and County, personally appeared Robin A Clouser, who being duly affirmed according to law, deposes and says that the facts and matter set forth in the within and foregoing Marital Settlement Agreement are true and correct to the best of her knowledge, information and belief. Affirmed ub rt d to before me this 2O day of 2008. rl NOTARY PUBLIC My commission expires: (SEAL) COMMONWEALTH OF PENNSYLVANIA Notarial Seal Barbara SunpleSullivan, Notary Public New Cumberland Boro, Cumberland County My Commission Expires. Nov. 15, 2011 Mfmi»r, Prnnry uaRia Aa§aeijlfl®H 8f N t flee 17 r z Q ', c ) JOHN C. CLOUSER, JR., IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 2006 - 6950 ROBIN D. CLOUSER, CIVIL ACTION - LAW Defendant : IN DIVORCE AFFIDAVIT OF CONSENT 1. A complaint in divorce under section 3301(c) of the Divorce Code was filed on December 4, 2006. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety days have elapsed from the date of the filing and service of the Complaint. 3. 1 consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I also understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904, relating to unsworn falsification to authorities. Date: b ' 2,7 L d8 ?-' , John C. Clouser, Jr., PI ntiff WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER F43301 (c) AND 43301(d) OF THE DIVORCE CODE 1. I consent to entry of a final decree of divorce without notice. 2. 1 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. 1 understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the Prothonotary. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. Date: 6, 1,7- h-l!e -'a John C. Clouser, Jr., Plainti a ; - i i rn Ca% '? JOHN C. CLOUSER, JR., IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006 - 6950 ROBIN D. CLOUSER, CIVIL ACTION - LAW Defendant : IN DIVORCE AFFIDAVIT OF CONSENT 1. A complaint in divorce under section 3301(c) of the Divorce Code was filed on December 4, 2006. 2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety days have elapsed from the date of the filing and service of the Complaint. 3. 1 consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I also understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904, relating to unsworn falsification to authorities. Date: ?. ' 2.? a DO ??, C Ro in D. Clouser, Defendant WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER 43301(c) AND §3301(d) OF THE DIVORCE CODE 1. 1 consent to entry of a final decree of divorce without notice. 2. 1 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. 1 understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the Prothonotary. i verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. Date: ?? '?? . ? ? ?/• *oi D. Clouser, Defendant N `? ?`? ?'""' _'_f tyi ;f? , :?.? ?~ ?. 4 wrr ? ? f?? ?. ?...? w ?.w ?i ?} ? gry i? LL AYR ?+ J ?-C r_°- ?3?5 •.:;. JOHN C. CLOUSER, JR., Plaintiff VS. ROBIN D. CLOUSER, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 06 - 6950 CIVIL IN DIVORCE ORDER OF COURT AND NOW, this oa day of , 2008, the economic claims raised in the proceed ngs having been resolved in accordance with a marital settlement agreement dated June 20, 2008, the appointment of the Master is vacated and counsel can file a praecipe transmitting the record to the Court requesting a final decree in divorce. cc: ? Jane Adams Attorney for Plaintiff Barbara Sumple-Sullivan Attorney for Defendant l:ppi¢.S m?,LL BY THE COURT, tj r r-- 11 CI fV 'al - C:5 5 CV IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006 - 6950 CIVIL ACTION - LAW IN DIVORCE STIPULATION REGARDING ALIMONY THIS STIPULATION REGARDING ALIMONY, is made this day of 2008, by and between John C. Clouser, Jr. (hereinafter referred to as Barbara Sumple- ullivan, Esquire Supreme Court # 2317 549 Bridge Street New Cumberland PA 17070 (717) 774-1445 JOHN C. CLO SER, JR., V. I ROBIN D. CLOUSER, Defen ant "Plaintiff'), 0 adult individual residing at 203 Forge Road, Boiling Springs, Cumberland County, Pennsylvania and Robin D. Clouser (hereinafter referred to as "Defendant"), an adult individual currently residing at 1713 Peyton Randolph Court, New Cumberland, Cumberland County, Pennsylvania and WHEREAS, Plaintiff and Defendant were marred on October 4, 1997 and separated Julys 1, 2004. the parties entered into a Marital Settlement Agreement on July 20, 2008 settling 01 claims, including Spousal Support and Alimony. NOW, THEREFORE, intending to be legally bound hereby the parties agree as follows: 1. The spousal support award in the amount of Four Hundred Eighty-Five ollars ($485.00) per month to Defendant shall continue until the entry of he Divorce Decree, at which time the payment shall terminate. 2. pon termination of the spousal support award, any arrearage shall be ediately paid by Plaintiff. 3. Beginning on the day following the date of entry of the Divorce Decree, the spousal support shall convert to alimony in the amount of Four Hundred Eighty-Five Dollars ($485.00) per month to Plaintiff. Alimony shall continue for a period of sixty (60) months. 4. The alimony payment shall be non-modifiable as to duration or amount and shall terminate upon the expiration of the alimony term, death of either party or Defendant's cohabitation or remarriage. 5. This Agreement is submitted to Domestic Relations so that an order is entered in accordance with the terms of this Agreement and continues to be processed through PACSES No. 188109033. IN WITNESS WHEREOF, the parties have set forth their hands the day and year first above SIGNED, SEALED AND DELIVERED IN THE P SENCE OF: BarBara Sumple-Sullivan, Esquire R bin D. Clouser I 9i?Adams, I Esquire John C. Clouser, Jr. ,I III 2 r l) ci f 1-0 JOHN C. CLOUSER, JR., Plaintiff vs. ROBIN D. CLOUSER, Defendant 1. Ground for divorce: irretrievable breakdown under 3301 c of the Divorce PRAECIPE TO TRANSMIT RECORD TO THE PROTHONOTARY: Please accept this request to transmit the record, together with the following information to the Court for entry of a divorce decree: Code. 2. Date and manner of the service of the Complaint: Via certified mail, restricted delivery, delivered on December 9. 2006. 3. Date of execution of the affidavit of consent required by 3301(c) of the Divorce Code: By Plaintiff: By Defendant: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 06 - 6950 Civil Term ACTION IN DIVORCE June 27. 2008. June 27. 2008. 4. Related claims pending: None. 5. Date Defendant's Waiver of Notice in §3301(c) Divorce was filed with the Prothonotary: July 14, 2008. Date Plaintiffs Waiver of Notice in §3301(c) Divorce was filed with the Prothonotary: July 14. 2008. Date: ?y Respectfully Subm J e NAdams, Esquire o. 79465 W. South St. Carlisle, Pa. 17013 (717) 245-8508 Attorney for Plaintiff v I ii ter ?. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY STATE OF PENNA. John C. Clouser, Jr., Plaintiff ;N N 0. No. 06 - 6950 Civil Term VERSUS Robin D. Clouser. Defendant DECREE IN DIVORCE AND NOW,/r.?. ZOOS , IT IS ORDERED AND DECREED THAT John C. Clouser , PLAINTIFF, AND Robin D. Clouser 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; None; The marriage settlement agreement which was signed by the parties on June 20, 2008 and filed with the Prothonotary shall be incorporated and not merged into this Decree. PROTHONOTARY O?c f G ? 3a q? . r I 1 04* Barbara Sumple-Sullivan, Esquire Supreme Court #32317 549 Bridge Street New Cumberland, PA 17070 (717) 774-1445 JOHN C. CLOUSER, JR., Plaintiff V. ROBIN D. CLOUSER, Defendant JUL 2 52008 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006 - 6950 CIVIL ACTION - LAW IN DIVORCE ORDER ADOPTING STIPULATION OF PARTIES AND NOW, to wit, this Z V day of , 2008, upon consideration of the Stipulation for Alimony dated Otule alf 2008 and on motion of Jane Adams, Esquire, counsel for Plaintiff, John C. Clouser, Jr., and Barbara Sumple-Sullivan, Esquire, counsel for Defendant, Robin D. Clouser, it is hereby ordered, adjudged and decreed that the terms, conditions and provisions of the attached Stipulation for Alimony are adopted as an Order of Court. BY THE COURT, 1444 J. 4 no L0 :11 V 6Z !PIP C13Z JOHN C. CLOUSER, JR., Plaintiff V. ROBIN D. CLOUSER, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006 - 6950 CIVIL ACTION -LAW IN DIVORCE QUALIFIED DOMESTIC RELATIONS ORDER In accordance with the agreement of the parties, this order disposes of a portion of the Participant's benefit in the Central Pennsylvania Teamsters Retirement Income Plan of 1987 (the "Plan"). 1. Participant Information: Name: John C. Clouser, Jr. Address: 203 Forge Road, Boiling Springs, Pa., 17007. Date of Birth: 3/20/47 Social Security No. To be provided separately to the plan, in writ 2. Alternative Payee Information: Name: Robin D. Clouser Address: 1713 Peyton Randolph Court, New Cumberland, Pa. 17070 Date of Birth: 9/16/55 Social Security No. To be provided separately to the plan, in writing. 3. Date of Marriage and Separation/Divorce: The Participant and Alternate Payee were married on October 4, 1975 and separated on July 1, 2004. The date of entry of the Divorce Decree is: July 29. 2008. 4. Assignment of Benefit to Alternate Payee. Alternate Payee is hereby assigned a portion of the Participant's account balance under the Plan. The Fund is to make payment of the Alternate Payee's benefits directly to the Alternate Payee. S. Method of Calculating Participant's Benefits. The Plan shall pay to the Alternate Payee a portion of the Vested accrued benefit under the Plan. The Alternate Payee shall receive the amount of $125,000.00 The Alternate Payee shall be credited with net income, loss, or expense from June 1, 2008 until the date the Alternate Payee receives the awarded benefits. 6. Form of Payment. The Alternate Payee may elect to receive payment from the Plan in any form in which benefits may be paid under the Plan to the Participant. 7. Beneficiary. The Alternate Payee may select a beneficiary to receive her benefits by filing a beneficiary designation with the Fund Office. In the event the Alternate Payee should die prior to receiving all of the assigned benefits, the Plan shall pay the benefits to the beneficiary selected by the Alternate Payee on a beneficiary form provided by the Fund Office, or if no beneficiary is selected, to the Alternate Payee's estate. 8. Date of Payment. The Alternate Payee may elect to receive payment from the Plan at the Participant's earliest retirement age, or, if earlier, at the earliest date permitted under the Plan. For purposes of this paragraph, the Participant's earliest retirement age means the earlier of: (a) the date on which the Participant is entitled to a distribution under the plan; or (b) the later of either: (i) the date the Participant attains age 50; or (ii) the earliest date on which the Participant could begin receiving benefits under the Plan if the Participant separated from service. ,4 , , 9. Construction. This order is not intended, and shall not be construed in such a manner as, to require the Plan Administrator: (a) to provide any form of benefit option not otherwise provided under the terms of the Plan; (b) to require the Plan to provide increased benefits determined on the basis of actuarial value; or (c) to require the payment of any benefits to the Alternate Payee under another order which previously was deemed to be a Qualified Domestic Relations Order. 10. Federal Tax Reporting. For federal income tax purposes, the Alternate Payee and not the Participant shall be treated as the distributee of all benefits made by the Plan to the Alternate Payee pursuant to this order. The Fund will issue a Form 1099-R to the Alterate Payee with respect to each calendar year in which the Alternate Payee receives benefits and will report such income to the IRS under the Alternate Payee's name and Social Security Number. 11. Continued Jurisdiction. The Court shall retain jurisdiction over this matter to amend the Order if necessary to establish or maintain its qualification as a Qualified Domestic Relations Order under applicable law. 12. Qualification. The Order is intended to constitute a qualified domestic relations order within the meaning of Section 414(p) of the Internal Revenue Code of 1986 as amdned, and Section 206(d) of the Employee Retirement Income Security Act of 1.974, as amended, and shall be interpreted in a manner consistent with such intention. WITNE Barbara Sumple-Sullivan, Esquire Payee 549 Bridge St. New Cumberland, Pa. 17070 Date: /aG! (717) 774-1445 Attorney for Alternate Payee Ro in D. Clouser Alternate WITNESS: J Adams, Esquire 7 . South St. C lisle, Pa. 17013 (717) 245-8508 Attorney for Participant SO ORDERED, this rg (?Fau? J, ohn C. Clouser, Jr., P rticipant Date: '-? /a O /0 8- day of , 2008. BY THE COURT: cc: arbara Sumple-Sullivan, Esquire ane Adams, Esquire _-r ? ? =r d c? ? JOHN C. CLOUSER, JR., : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2006 - 6950 ROBIN D. CLOUSER, CIVIL ACTION -LAW Defendant IN DIVORCE DOMESTIC RELATIONS ORDER AND NOW, the parties, John C. Clouser, Jr., Plaintiff, and Robin D. Clouser, Defendant, do hereby Stipulate and Agree as follows: 1. The parties hereto were husband and wife, and a divorce action is in this Court at the above number, and this Court has personal jurisdiction over the parties. The parties were married on October 4, 1975, and divorced on July 29, 2008. 2. John C. Clouser, Plaintiff, hereinafter referred to as "Participant" is a former employee of Dupont and a participant in the Dupont Pension and Retirement Plan (the Plan) which is currently in pay status. 3. Robin D. Clouser, Defendant, hereinafter referred to as "Alternate Payee" is the former spouse of Participant. 4. This stipulation and order has been executed to effectuate an equitable division of marital property. 5. The name, last known address, social security number, and date of birth of the plan "Participant" are: Name: John C. Clouser, Jr. Address: 203 Forge Road, Boiling Springs, Pa., 17007. Date of Birth: 3/20/47 Social Security No: confidential - to be provided separately. 6. The name, last known address, social security number, and date of birth of the "Alternate Payee" are: Name: Robin D. Clouser Address: 1713 Peyton Randolph Court, New Cumberland, Pa. 17070 Date of Birth: 9/16155 Social Security No. confidential - to be provided separately. It is the responsibility of the Alternate Payee to keep a current mailing address on file with Dupont at all times. 7. This Order applies to the Participant's benefit in the Dupont pension and Retirement plan and any successor plans. 8. Alternate Payee is responsible for all taxes on her benefit. Dupont shall issue individual tax forms to Participant and Alternate Participant for amounts paid to each. 9. Payee is currently receiving a monthly benefit in the amount of approximately 218.00 per month. The Alternate Payee is awarded fifty-five percent (55%) of the Participant's monthly benefit in the Plan for as long as the Participant lives. In the event that the Alternate Payee predeceases the Participant, the Alternate Payee's remaining monthly benefit will revert to the Participant. 10. Payee has elected a 50% survivorship annuity for Alternate Payee. This election is irrevocable and is hereby confirmed by this Order. 11. The Plan Administrator is directed to begin distributing benefits to the Alternate Payee as soon as administratively possible. 12. Alternate Participant may not exercise any right, privilege or option offered by Dupont. 13. In no event shall Alternate Participant have greater benefits or rights other than those which are available to Participant. Alternate Participant is not entitled to any benefit not otherwise provided by Dupont. The Alternate Participant is only entitled to the specific benefits offered by Dupont as provided in this Stipulation and Agreement. All other rights, privileges and options offered by Dupont not granted to Alternate Participant are preserved for Participant. 14. It is specifically intended and agreed by the parties hereto that this Stipulation and Agreement: (a) Does not require Dupont to provide any type or form of benefit, or any option not otherwise provided under the Retirement Code; (b) Does not require Dupont to provide increased benefits (determined on the basis of actuarial value) unless increased benefits are paid to Participant based upon cost of living or increases based on other than Actuarial Values. 15. The parties intend and agree that the terms of this Stipulation and Agreement shall be approved, adopted and entered as a Domestic Relations Order, under section Title 23 Pa.C.S. §3301 et. seq. of the Domestic Relations Code of Pennsylvania. 16. The Court of Common Pleas of Cumberland County, Pennsylvania, shall retain jurisdiction to amend any Domestic Relations Order based on this Stipulation and Agreement but only for the purpose of establishing it or maintaining it as a Domestic Relations Order; provided, however, that no such amendment shall require Dupont to provide any type of form or benefit, or any option not otherwise provided by Dupont and further provided that no such amendment or right of the Court to so amend will invalidate any existing Order. 17. Upon entry as a Domestic Relations Order, a certified copy of this Stipulation and Agreement any attendant documents shall be served upon Dupont immediately. The Domestic Relations Order shall take effect immediately upon its approval and the approval of any attendant documents by Dupont shall remain in effect until further Order of Court. WITNESS: Barbaraa Sumple-Sullivan, Esquire 549 Bridge St. New Cumberland, Pa. 17070 (717) 774-1445 Attorney for Alternate Payee WITNESS: J e Adams, Esquire W. South St, adisle, Pa. 17013 17) 245-8508 Attorney for Participant ?r lo in D. Clouser, Alternate Payee Date: -D Jo (:?(o S- John C. Clouser, Jr., articipant Date: -D/a q j. SO ORDERED, this y ` day of? , 2008. cc: Barbara Sumple-Sullivan, Esqu c/ --ne Adams, Esquire BY THE COURT: C, C'7 ce) T to ?- INCOME WITHHOLDING FOR SUPPORT Q ORIGINAL INCOME WITHHOLDING ORDERMOTICE FOR SUPPORT (IWO) IJ D I Q AMENDED IWO G'?D - lo? cJL) 1 V I I O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT 1.-1 O TERMINATION OF IWO Date: R8/09/1: ? Child Support Enforcement (CSE) Agency ® Court ? Attomey ? Private Individual/Entity (Check One) NOTE: This IWO:mypt *reguW 4n'Itafa?ce. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions http://wrwvv acf hhs gov/programs/cse/newhire/employer/publication/publication htm - forms). If you receive this docu ent from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. Staterrdberrerritory Commonwealth of Pennsylvania Remittance Identifier (include w/payment): 6733101808 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket /nformalton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) SOCIAL SECURITY ADMINISTRATION STE 1 200 S SPRING GARDEN ST CARLISLE PA 17013-2578 Employer/Income Withholder's FEIN Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) RE: CLOUSER JOHN C. JR Employee/Obligor's Name (Last, irst, Middle) 175-40-5172 Employee/Obligor's Social Securi y Number (See Addendum for plaintiff na es associated with cases on attachment) Middle) NOTE: This IWO must be regular o Under certain circumstances you u this IWO and return it to the sende instructions ; http://www.acf.hhs.aov/DrQgrams/c / employer/publication/publication.ht If you receive this document from so eother than a State or Tribal CSE agency or a Court, a copy of the underlying order must a attached. 8384100092 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 M LANE Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts front theiae obligor's income until further notice. -;:x $ 0.00 per month in current child support $ 0.00 per month in past-due child support - Arrears 12 weeks or greater? O Yost Ono $ 0.00 permonth in current cash medical support ,?- $ 0.00 per month in past-due cash medical support 1> C-, $ 485.00 per month in current spousal support $ 0.00 per month in past-due spousal support = r^? $ 0.00 per month in other (must specify) for a Total Amount to Withhold of $ 485.00 per month. AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order In1 If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: $ 111.62 per weekly pay period. $ 242.50 per semimonthly pay period (twi $ 223.23 per biweekly pay period (every two weeks) $ 485.00 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 Comr of Pennsylvania (State/Tribe), you must begin withholding no later than the first pay period that occurs ten working days after the date of this Order/Notice. Send payment within seven 7 working days of the pay d you cannot withhold the full amount of support for any or all orders for this employee/obligor, withhold up to disposable income for all orders. If the employee/obligor's principal place of employment is not within the Commonwealth of Pennsylvania (State/Tribe), the employer can obtain withholding limitations, time require and any allowable employer fees at hftp•//www acf hhs gov/proarams/cse/newhire/emplover/contacts/conto htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.: 0970-0154 Form EN-028 Service Type M Worker ID $O T I a month) If > of nts, 2 ? Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU In accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): Print Name of Judge/Issuing Official 'AbWA qd Title of Judge/Issuing Official Date of Signature: If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. ? If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA TIPS CODE 42 00000 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-.8112 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: hhttg:/lw m.acf.hhs.gov(proarams/cse/newhirelemployer/contaQWcontact_r. nap htm Priority: Withholding for support has priority over any other legal process under State law against the same income (USC 42 §666(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency, you may combine, withheld amounts from more than one employee/obligor's income in a single payment. You must, however, separately identify each employee/ obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial party, court, or attorney), you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a Court, Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency, you must follow the "Remit payment to" instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment. The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the State (or Tribal law if applicable) of the employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO, contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by State or Tribal law/procedure. Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from employment, refusing to employ, or taking disciplinary action against an employee/obligor because of this IWO. OMB Expiration Date - 05/31/2014, The OMB Expiration Date has no bearing on the termination date of the IWO; it identifies the version of the form currently in use. Form EN-028 06/12 Service Type M Page 2 of 3 Worker ID $OINC Employer's Name: SOCIAL SECURITY ADMINISTRATION Employer FEIN: Employee/Obligor's Name: CLOUSER,_JOHN C. JR 6733101808 CSE Agency Case Identifier: (See Addendum for case summary Order Identifier: (See Addendum for rd I in rmado? Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Cr dit 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 s pporting 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 i dicated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal em loyers/income withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdict on in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S. . 1673 (b)). Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premium 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, tf?en 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 yo no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the sen returning this form to the address listed in the Contact Information below: 83 Q This person has never worked for this employer nor received periodic income. O This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: u or you are der by 4100092 Last known address: Final Payment Date To SDU/Tribal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT (Issuer name) by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at: www.childSUPDort.state.12a.us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, P.O. BOX 320 CARLISLE PA 17013 (Issuer address). To Employee/Obliges 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 childsupportstate a us. IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. Service Type M OMB No.: 0970-0154 Page 3 of 3 Form EN-028 06 12 Worker ID $OIN ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLOUSER, JOHN C. JR PACSES Case Number 188109033 PACSES Case Number Plaintiff Name Plaintiff Name ROBIN D. CLOUSER Docket Attachment Amount Docket Attachment Amount 06-6950 CIVIL $ 485.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACKS Case Number Plaintiff Name Plaintiff Name Docket Attachment Amount Docket Attachment mount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Docket Attachment Amount Docket Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB Addendum Form EN-02806/12 Service Type M OMB No.: 0970-0154 Worker ID $OINC INCOME WITHHOLDING FOR SUPPORT c' ` n O ORIGINAL INCOME WITHHOLDING ORDERINOTICE FOR SUPPORT (IWO) ~ ~ b r ~ `~' Q AMENDED IWO r f ~ / _ ~ ~~ ti I U i' O ONE-TIMEORDERMOTICE FOR LUMP SUM PAYMENT V 1~ l0 Q TERMINATION OF IWO Date: 8/15/12 ^ Child Support Enforcement (CSE) Agency ® Court ^ Attorney ^ Private IndividuallEntity (Chet One) NOTE: This IWO must be regular+on,~;l3!@ce. Under certain circumstances you must reject this IWO and return it to the sender ( IWO instructions h~p~I/www acf hhs gwlp~gramslcse/newhire/emRlover(~blicatioNDUblication htm -forms). If you recaeive this docu ent from someone other than a Sste or Tribal CSE agency or a Court, a copy of the underlying order must be attached. Staterrribe/Tertitory Commonwealth of Pennsylvania Remittance Identifier (include wlpayment): 873St0 8 CitylCountylDist./Tribe CUMBERLAND Order Identifier. (See Adakndum /or order/tbck~t 1 malton) Private IndividuallEntity CSE Agency Case Identifier: (See Adidendum for cabs summary) SOCIAL SECURITY ADMINISTRATION STE 1 200 S SPRING GARDEN ST CARLISLE PA 17013-2578 Employerllncome Withholder's FEIN Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) RE: CLOUSER, JOHN C. JR Employee/Obligor's Name (Last, first, Middle) »s-ao-sl~a Employee/Obligor's Social Securi Number (See Addendum fior plalntllf' na es assocfatsd with geese on attac ment) Middle) NOTE: This IWO mlust be regular o its face. Under certain clrcujrrstanc®s you m st reject this IWO and return it to the sender see IWO instructions eQ>~y lcatlon.ht - .If you receive this do ument from so eons other than a State or Tribal CSE agency r a Court, a copy of the underlying order must b attached. 8384100092 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 , Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts'fr~Tl tf~,,e,e loyee/ obligor's income until further notice. ~ Er' $ 0.00 perm n h in current child support ~. tw-~. $ 0.00 per m n in past-due child support -Arrears 12 weeks or greater? O y? Opp $ 0.00 per month in current cash medical support rnF` -- " ~ °' ca $ 0.00 per m n in past-due cash medical support " ~ v $ 0.00 per month in current spousal support ~© ~v = $ 0.00 per month in past-due spousal support ~ ~ o~, $ 0.00 perm n h in other (must specify) ~~ tv Arfi` for a Total Amount to Withhold of E 0.00 per month. .~~ AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Order Info mation. If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: $ 0.00 per weekly pay period. $ 0.00 per semimonthly pay. period (twic 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 w of Pennsylvania (StatelTribe), you must begin withholding no later than the first pay period that odcurs working days after the date of this Order/Notice. Send payment within seven (7) working days oP the pay dat If you cannot withhold the full amount of support for any or all orders for this employeefobligor, withhold up to ° of disposable income for all orders. If the employee/obligor's principal place of employment is not within the Commonwealth of Penn~rlvania (State/Tribe), the employer can obtain withholding limitations, time requirem nts, and any allowable employer fees at h f. h y r / n whir / m I r/ n t/ n m htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.: 0970-0154 Form EN-028 0 12 Service Type M Worker ID $OIN ^ Return to Sender [Compieted by EaOi!~ter 1t~hltj. Payment must be directed to an SDU in accordance with 42 USC {bx5) and (b){$) or Tribal Payee (see Payments to SDU beiaw). If payment is not directed to an SDUn'ribal Payee or this IWO is not regular on its face, you must check this box and return the IW© to the sender. Signature of Judgellss~ing C3f~ial (if required by 8~te or Tribai law): Print Name of Judge issuing C'~'taial: Title of Judgellssuln~ C3flFbiai: Daite of Signature: If the employee/obligor works in a State or for a Tribe that is differert# from the State or Tribe that issued this order, a copy of this IWfJ must be provided`to'the et'nptoyeel4~tNigor. ^ If Checked, tl1e employer/income withholder must provide a copy of this form to the employee/obligor. ADDITI~iA1. tMFQRMATION FOUR CMPLOYERS/INCO~iAE WITHHt?LDEFt:~ Penr»yiva~ia law (23 PA C.S. ~ 437Mb1) requires remittance by an if an employer is ordered to ~ l?~veatt more t empia~e and ors 15 or more garcons, or if an employer has a hlstcary of two or moro raturreed chwecka d~as to rtor~t t+xraiat. Please sell! the Penrrsyltranie~ Suite Cattsctions and Disbursernerrt UMR (PA SCDU) l$rtfer Cuar a st 1-87T~ for irr~ru~tions. PA Fi:~3 C{~Jir 42 0~0 OQ i~ ice #o: PA i3CDU d rhsClt to: Piro ~i~1, P.O. Bouc ls~y erg, Pa 171t~9112 IN At'l~AI, PAYiT~11S? a~ ThlE ~T~ A AMO TMEf PACES ~ kt3 (shaven above as the lmpifPytrw~,'tr~ d~R SQL ~6a11~'~f'y' 11R iAt 1'~"I~ 'd~lilll~f: OWD'!~fi SB11~ C~4SH SY INAtt. State-specific contact and withholding information can be found on the Federal Employer Services websitie located et; Priority: Withlwlding for support has priority aver any other le~l process under State taw against the same income (USC 42 §~66$(b)(~)}. If a Federal taxl~lrvyis in e'er ~ ~ t~ ~. C~ Patents: When remitting payn to an SDU or Tribai CSE agency, you may combine withheld amounts from more than one errlpk~yae/c~fiipor's ire in s sir+~e Pa3anant. Ycyu must, ,trrert, y kier~#y +h err+ii~~el obligor's portion of the payment. Paymenns To SOU: You must send child support payments payable by inGOms welding to ttie appropriate SDU or to a Tribal CSC agehicy. !f #i'ss IWC inserts yow ~o ,mil a ~+ an qty attar f ash Sim {ay:p., ~ the custad-al party, court, or attorney), You must check the box above and re~rrt tt-is notice to thedler. Ez~p tW0 wee sent by a Court, Attorney, 6u Private Individual/Entlty and the initial 4r w8>$ entered bef~e Jarttd~`y 1, ?'994 orth~D order was issued by a Tribal CSIr'agency, you must follow the "R+emit paymxent~to" instrdc~lcui+s on this farm. Raport(~ the Pay t~~e; You must report the pay date when s~tdir-g Ehe p~&y!#nent, The pay datGe is the dste on which the amount w8s withhaalci:. m the employee/obiigor's wages. You must ~ law of the 8t~i (or 1'ribat taw if applicable) of thb enayeeJvbligor's principal plaice ~ emp?dyr~nent r~g'titne periods wittrin which you must implement the withholding and i`orward the support payments. MuN~pla WNOs: If there is move than one i4V0 against this ert~see~abligor and you are unable to fully honor all iWOs due to Federal, State, or Tribal withhokilr~ l+rt+ts, You mgt hour a#1 i+a ttte,Qreatest e'-t pie, giirlr~ priority to current support before payment of any pest-dC+e support. Follow the ate or Tribal lavr/pro~dure of tie "em-ye~lor's principal place of employmeirtt to determine the appropriate s~Ioca~on method. Lurnp Sum Payments: You may be required to notify a S~-te or Tribal CSC agency of upccamirrg lump sure payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact tfie suer to d~irrrrrine if you are required to report and/or withhold sump sum payments. LiabWity: If you have any doubts about ~ validity of tllis IWC, corttt4ct,the r~er. tt you fait to ~aathhokf income from the employeelobligor's intxxne as the lWO directs, you are #se~ble far both t#ie accurr+w amount you sh!ouid have with4tt~ld and any pertaltles set by State or Tribatl iawlproc~dure. Ark-diecrimiaa~iprl: You are subject to a fires determined and®r State or Tribai law far discharging an empl~ryeelc~tigor from en7ployment, refusing to employ, or taking disciplinary action against en am~+aQr bye of-this lWt:1. OMB F~piration Date - 05!31!2014. The OMB F~cpiratfon Date has no bearing,. on the tsrminatiori date of the: IWO; it iOMEifles the version of the form currently in use. Form EN-028 06/12 Service Type M Page 2 of 3 Worker ID $OINC Employer's Name: SOCIAL SECURITY ADMINISTRATION Employer FEIN: Employee/Obligor's Name: CLOUSER JOHN C. JR 6733101808 CSE Agency Case Identifier: (See Addendum for case summary) Order Identifier: Withholding Limits: You may not withhold more than the lesser of: 1) the amounts allowed by the Federal Consumer Cr dit Protection Act (CCPA) (15 U.S.C. 1673(b)); or 2) the amounts allowed by the State or Tribe of the employee/obligoPs principal place of employment (see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory dedu tions such as: State, Federal, local taxes; Social Security taxes; statutory pension contributions; and Medicare taxes. The Federal li it is 50% of the disposable income if the obligor is supporting another family and 60% of the disposable income if the obligor is not su porting another family. However, those limits increase 5% - to 55% and 65% - if the arrears are greater than 12 weelks. If permitte by the State or Tribe, you may deduct a fee for administrative costs. The combined support amount and fee may not exceed the limit i dicated in this section. For Tribal orders, you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal emp oyers/incon withholders who receive a State IWO, you may not withhold more than the lesser of the limit set by the law of the jurisdicti n in which the employer/income withholder is located or the maximum amount permitted under section 303(d) of the CCPA (15 U.S. .1673 (b)). Depending upon applicable State or Tribal law, you may need to also consider the amounts paid for health care premium 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, th n 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 yo no longer withholding income for this employee/obligor, an employer must promptly notify the CSE agency and/or the se or you are er by returning this form to the address listed in the Contact Information below: 83 to0092 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 employeelobligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU/Tribal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To EmFoyer/Income Withfiolder: If you have any questions, contact WAGE ATTACHMENT UNIT (I~suer name) by phone at (717) 240-6225, by fax at ~717L240-6248, by email or website at: www.childsuccort.state. a.us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTIQ,Z, P.O. BOX 320. CARLISLE. PA. 17013 (Issuer address). To Emg'foyaslObligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT (I~suer name) by phone at (717) 240-6225, by fax at (717) 240-6248, by email or website at www.childsupport.state. 'a.us. IMPORTANT: The person completing this form is advised that the information may be shared with the employeelobligor. Service Type M OMB No.: 0970.0154 Page3of3 Form EN-028 0 /12 Worker ID $OIN ~~~ i~rf~~q~iip~ar: CL06JSER, JOHN. C. JR `,~~ 168'109©33 ~~ff Name ROBiN D. CLOU3ER 06-69`~OCiVIL $ O:gO Chid{req)'s Name(s): DOS ICI ~t~tt 0. Child{ren}'s Name(S}: DOS $ 0.00 Chiid(ren)'s Name(s): DOB D~ksS Am~'ti.Bm $ 0.00 Child(ren)'s Name(s): DOS !~S'!~t $ 3.Qf3 Child{ren)'s Name(s): 1306 PAGSE,S Cam ~r PlainEifif Name I~CkS1 ~~~~d[[t $ 0.00 Child(ren)'s Name(s); DOB Addendum Form EN-028 06/12 S~-rviCe Type M on,~-vo.i osro-o~sa Worker ID $OiNC . I INCOME WITHHOLDING FOR SUPPORT O ORIGINAL INCOME WITHHOLDING ORDERINOTICE FOR SUPPORT (IWO) I O AMENDED IWO C ?? ?[ I V 1 O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT Q TERMINATION OF IWO Date: 09/05/12 ? Child Support, Enforcement (CSE) Agency ® Court ? Attorney ? Private Individual/Entity (Check One) NOTE: This IWO must be regular Gm its .face. Under certain circumstances you must reject this IWO and return it to the sender (see IWO instructions http:Hwww.acf.hhs.gov/programs/cse/newhire/employer/Dublication/publication.htm - forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. State/Tribe/Territory 'Commonwealth of Pennsylvania Remittance Identifier (include w/payment): 6733101808 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket /nformalton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) YRC WORLDWIDE* PO BOX 471 AKRON OH 44309-0471 Employer/Income Withholder's FEIN 340492670 Child(ren)'s Name(s) (Last, First, Middle) Child(ren)'s Birth Date(s) RE: CLOUSER, JOHN C. JR Employee/Obligor's Name (Last, First, Middle) 175-40-5172 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.Qov/pro(irams/cse/newhire/ employer/publication/oublication.htm - form . If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. 3404926700 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 CUMBERLAN D-County, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts gm We erri? loyee/ obligor's income until further notice. _0:r $ 0.00 per month in current child support r r?*1 r?tr $ 0.00 per month in past-due child support - Arrears 12 weeks or greater? O Q? o $ 0.00 per month in current cash medical support Cn $ 0.00 per month in past-due cash medical support '"^ t a ? -t7 z -41 ?-a-i $ 0.00 per month in current spousal support C-) $ 0.00 per month in past-due spousal support C= w _?? $ 0.00 per month in other (must specify) ' 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 (twi ce 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. REMITTANCES 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 551/6 of disposable income for all orders. If the employee/obligor's principal place of employment is not within the Commonwealth of Pennsylvania (State/Tribe), the employer can obtain withholding limitations, time requirements, and any allowable employer fees at http://www acf hhs gov/programs/cse/newhire/employer/contacts/contact map htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.: 0970-0154 Form EN-028 06/12 Service Type M Worker ID $IATT ? Return to Sender [Completed by Employer/Income Withholder]. Payment must be directed to an SDU it accordance with 42 USC §666(b)(5) and (b)(6) or Tribal Payee (see Payments to SDU below). If payment is riot directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): .?' Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: - Date of Signature: If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. ? If checked, the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS Pennsylvania law (23 PA C.S. § 4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons, or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit (PA SCDU) Employer Customer Service at 1-877-676-9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID (shown above as the Employee/Obligor's Case Identifier) OR SOCIAL SECURITY NUMBER IN ORDER TO BE PROCESSED. DO NOT SEND CASH BY MAIL. State-specific contact and withholding information can be found on the Federal Employer Services website located at: http_//www acf hhs aov/programs/cse/newhirelem looyer/contacts/contactmap 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 SOU 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 1WO; it identifies the version of the form currently in use. Form FN-n9R nR/1 9 Employer's Name: YRC WORLDWIDE` Employer FEIN: 340492670 Employee/Obligor's Name: CLOUSER JOHN C. JR 6733101808 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 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: 3404926700 Q This person has never worked for this employer nor received periodic income. Q This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known address: Final Payment Date To SDU/Tribal Payee: New Employer's Name: Last known phone number: Final Payment Amount: 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/ bligor• 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 childsupgort state oa us. IMPORTANT: The person completing this form is advised that the information may be shared with the employee/obligor. Service Type M OMB No.: 0970-0154 Page 3 of 3 Form EN-028 06/12 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLOUSER, JOHN C. JR PACSES Case Number 188109033 PACSES Case Number Plaintiff Name Plaintiff Name ROBIN D. CLOUSER Docket Attachment Amount Docket Attachment Amount 06-6950 CIVIL $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB PACSES 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 PACSES Case Number Plaintiff Name Docket Attachment Amount $ 0.00 Child(ren)'s Name(s): DOB INCOME WITHHOLDING FOR SUPPORT IS D I D I D33 Q ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO) �� �q S� Civil Q AMENDEDIWO O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT Q TERMINATION OF IWO Date: 05/03/13 ❑ Child Support Enforcement(CSE)Agency ® Court ❑ Attorney ❑ Private Individual/Entity(Check One) NOTE: This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender(see IWO instructions http://www.acf.hhs.gov/programs/cse/newhire/employer/publication/publication htm-forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 6733101808 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket informaiton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) RE: CLOUSER,JOHN C. JR YRC WORLDWIDE" Employee/Obligor's Name(Last, First, Middle) 175-40-5172 Sent Electronically Employee/Obligor's Social Security Number (See Addendum for plaintiff names DO NOT MAIL associated with cases on attachment) Custodial Party/Obligee's Name(Last, First, Middle) - Employer/Income Withholder's FEIN 340492670 NOTE:This IWO must be regular on its face. Under certain circumstances you must reject Child(ren)'s Name(s)(Last, First,Middle) Child(ren)'s Birth Date(s) this IWO and return it to the sender(see IWO instructions http://www.acf.hhs.gov/programs/cse/newhire/ employer/publication/publication.htm-formo. 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. 3404926700 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the employee/ obligor's income until further notice. $ 0.00 per month in current child support c $ 0.00 per month in past-due child support- Arrears 12 weeks or greater? O yes-p33D naw -} $ 0.00 per month in current cash medical support =M 1711 $ 0.00 per month in past-due cash medical support -� -, $ 485.00 per month in current spousal support `<' r> :> i c $ 0.00 per month in past-due spousal support $ 0.00 per month in other(must specify) fl ° C�nj for a Total Amount to Withhold of$ 485.00 per month. _ ca AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Or-60,r 1Aftrmation. If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: $ 111.62 per weekly pay period. $ 242.50 per semimonthly pay period (twice a month) $ 223.23 per biweekly pay period (every two weeks) $ 485.00 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.ciov/programs/cse/newhire/employer/contacts/contact map htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.:0970-0154 Form EN-428 06/12 Service Type M Worker ID $IATT ❑ Return to Sender(Completed by Employer/income Withholder). Payment must be directed to an SDU in accordance with 42 USC§666(b)(5)and (b)(6)or Tribal Payee(see Payments to SDU below). If payment is not directed to an SDU[Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/issuing Official (if required by State or Tribal law): KEVIN A HESS Print Name of Judge/Issuing Official: Title of Judge/issuing Official: _ Date of Signature: MAY 3,2013 If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order, a copy of this IWO must be provided to the employee/obligor. ❑ If checked,the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS Pennsylvania law(23 PA C.S.§4374(b)) requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons,or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit(PA SCDU)Employer Customer Service at 1-877.676-9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to PA SCDU Send check to: Pennsylvania SCDU, P.O. Box 69112, Harrisburg, Pa 17106-9112 IN ADDITION, PAYMENTS MUST INCLUDE THE DEFENDANT'S NAME AND THE PACSES MEMBER ID(shown above as the Employeel0bligior'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/newhir-e/employer/contacts/contact map,htm Priority:Withholding for support has priority over any other legal process under State law against the same income(USC 42 §666(b)(7)). If a Federal tax levy is in effect, please notify the sender. Combining Payments: When remitting payments to an SDU or Tribal CSE agency,you may combine withheld amounts from more than one employee/obligor's income in a single payment.You must, however, separately identify each employee/ obligor's portion of the payment. Payments To SDU: You must send child support payments payable by income withholding to the appropriate SDU or to a Tribal CSE agency. If this IWO instructs you to send a payment to an entity other than an SDU (e.g., payable to the custodial party, court,or attorney),you must check the box above and return this notice to the sender. Exception: If this IWO was sent by a Court,Attorney, or Private Individual/Entity and the initial order was entered before January 1, 1994 or the order was issued by a Tribal CSE agency,you must follow the"Remit payment to" instructions on this form. Reporting the Pay Date: You must report the pay date when sending the payment.The pay date is the date on which the amount was withheld from the employee/obligor's wages. You must comply with the law of the State(or Tribal law if applicable)of the employee/obligor's principal place of employment regarding time periods within which you must implement the withholding and forward the support payments. Multiple IWOs: If there is more than one IWO against this employee/obligor and you are unable to fully honor all IWOs due to Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority to current support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal place of employment to determine the appropriate allocation method. Lump Sum Payments: You may be required to notify a State or Tribal CSE agency of upcoming lump sum payments to this employee/obligor such as bonuses, commissions, or severance pay. Contact the sender to determine if you are required to report and/or withhold lump sum payments. Liability: If you have any doubts about the validity of this IWO,contact the sender. If you fail to withhold income from the employee/obligor's income as the IWO directs, you are liable for both the accumulated amount you should have withheld and any penalties set by State or Tribal law/procedure. Anti-discrimination: You are subject to a fine determined under State or Tribal law for discharging an employee/obligor from employment, refusing to employ,or taking disciplinary action against an employee/obligor because of this IWO. OMB Expiration Date—05/31/2014.The OMB Expiration Date has no bearing on the termination date of the IWO;it identifies the version of the form currently in use. Form EN-428 06/12 Service Type M Page 2 of 3 Worker ID $IATT r - Employer's Name: YRC WORLDWIDE" Employer FEIN: 340492670 Employee/Obligor's Name: CLOUSER JOHN C.JR 6733101808 CSE Agency Case Identifier:(See Addendum for case summary Order Identifier:(See Addendum for order/docket informationf 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: 3404926700 Q This person has never worked for this employer nor received periodic income. O This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU/Tribal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT(Issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at:www.childsupport.state.ga.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.chiIdsupport.state.pa.us. IMPORTANT:The person completing this form is advised that the information may be shared with the employee/obligor. OMB No.:0970-0154 Form EN-428 06/12 Service Type M Page 3 of 3 Worker ID $IATT J r X ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLOUSER, JOHN C. JR PACSES Case Number 188109033 PACSES Case Number Plaintiff Name Plaintiff Name ROBIN D.CLOUSER D c et Attachment Amount D cke Attachment Amount 06-6950 CIVIL $ 485.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name o ket Attachment Amount Docket Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Docke Attachment Amoun Docke t Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB Addendum Form EN-428 06/12 Service Type M OMB No.:09704154 Worker ID$IATT INCOME WITHHOLDING FOR SUPPORT I L)q v33 O ORIGINAL INCOME WITHHOLDING ORDERMOTICE FOR SUPPORT(IWO) D� r 69 6 D C1 v t , O AMENDEDIWO O ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT Q TERMINATION OF IWO Date: 05/06/13 ❑ Child Support Enforcement(CSE)Agency ® Court ❑ Attorney ❑ Private Individual/Entity(Check One) NOTE:This IWO must be regular on its face. Under certain circumstances you must reject this IWO and return it to the sender(see IWO instructions http://www acf hhs gov/programs/cse/newhire/employer/publication/publication htm-forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court, a copy of the underlying order must be attached. State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 6733101808 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket informaiton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) RE: CLOUSER,JOHN C.JR YRC WORLDWIDE* Employee/Obligor's Name(Last, First,Middle) 175-40-5172 Sent Electronically Employee/Obligor's Social Security Number (See Addendum for plaintiff names DO NOT MAIL associated with cases on attachment) Custodial Party/Obligee's Name(Last, First, Middle) Employer/Income Withholder's FEIN 340492670 NOTE:This IWO must be regular on its face. Under certain circumstances you must reject Child(ren)'s Name(s)(Last, First,Middle) Child(ren)'s Birth Date(s) this IWO and return it to the sender(see IWO instructions http://www.acf.hhs.gov/programs/cse/newhire/ employer/publication/publication.htm-formo. 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. 3404926700 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the employee/ obligor's income until further notice. $ 0.00 per month in current child support C* $ 0.00 per month in past-due child support- Arrears 12 weeks or greater? Q yes nf� _ $ 0.00 per month in current cash medical support r-nc -Z �e $ 0.00 per month in past-due cash medical support M x'" Cdr $ 0.00 per month in current spousal support c ,r— -�c �u � $ 0.00 per month in past-due spousal support __J r._.� $ 0.00 per month in other(must specify) �n ca for a Total Amount to Withhold of$ 0.00 per month. rvr AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Orddr In f on. 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 maw htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.:0970-0154 Form EN-428 06/12 Service Type M Worker ID $IATT Fl Return Sender SDUin / ~ accordance with w2uSC§uuu(o)(5V and ( u)or |nbal Payee(see Payments toSDUbe|ovv . K payment kunot directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): KEVIN A HESS Print Name of Judge/Issuing Official: Title of JudgelIssuing Official: Date of Signature: MAY 6,2013 |f the employee/obligor works ino State mr for o Tribe that iodifferent from the State or Tribe that issued this order, o copy of this |VVO must ba provided 0o the nmp|oyee/ob|igor. Fl |f checked,the employer/income withholder must provide a copy of this form tm the omp|oyee/ob|iQor. ADDITIONAL INFORMATION FOR EMPLOYERS/|NCOMEWUTKHOLDGRS Pennsylvania law(23 PA C.S.§4374(b))requires remittance byan electronic payment method 1fon employer|sordered to withhold income from more than one employee and employs 15 ov more persons,orif am employer has m history m6 two or more returned checks due honomwufMcimntfunds. Please call the Pennsylvania State Collections and � Disbursement Unit(PA SC0W) Employer Customer Service mt1'M77~6y6'9580for instructions. PA FIPS CODE 4288000 ! Make Remittance Payable to: PA SCDLI 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 theEmployeel0bligor's Case6dentifler)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: Priority:Withholding for support has priority over any other legal process under State law against the same income(USC42 §G66(b)(7)). |fo Federal tax levy imin effect, please notify the sender. Combining Payments: When remitting payments hoanSDUorTdba| CSEegenoy. youmoyoombinevvithho\damounhahnm 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 S0U/ You must send child support payments payable by income withholding hn the appropriate SDUortuo 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 emp|oyeo/ob|igor'a 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 AWOs: |f there io more than one |VV[)against this employee/obligor andynuanaunoh|ebofu\\yhonureU |VVOsdueho Federal, State, or Tribal withholding limits, you must honor all IWOs to the greatest extent possible, giving priority hoounant support before payment of any past-due support. Follow the State or Tribal law/procedure of the employee/obligor's principal place of employment 0o determine the appropriate allocation method. Lump Sum Payments: You may bm required hu notify a State or Tribal CGE agency of upcoming lump sum payments tothis 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/aw/pnoneduna. 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-05/3112014.The OMB Expiration Date has no bearing on the termination date of the IWO;it identifies the version of the form currently muse. Form EN-428OG/12 Service Type N1 Page of Worker|O$|/(TT Employer's Name: YRC WORLDWIDE` Employer FEIN: 340492670 Employee/Obligor's Name: CLOUSER JOHN C.JR 6733101808 CSE Agency Case Identifier:(See Addendum for case summa Order Identifier:(See Addendum for order/docket information) Withholding Limits:You may not withhold more than the lesser of: 1)the amounts allowed by the Federal Consumer Credit Protection Act(CCPA)(15 U.S.C. 1673(b));or 2)the amounts allowed by the State or Tribe of the employee/obligor's principal place of employment(see REMITTANCE INFORMATION). Disposable income is the net income left after making mandatory deductions such as: State, Federal, local taxes; Social Security taxes;statutory pension contributions;and Medicare taxes.The Federal limit is 50%of the disposable income if the obligor is supporting another family and 60%of the disposable income if the obligor is not supporting another family. However,those limits increase 5%-to 55%and 65%-if the arrears are greater than 12 weeks. If permitted by the State or Tribe,you may deduct a fee for administrative costs.The combined support amount and fee may not exceed the limit indicated in this section. For Tribal orders,you may not withhold more than the amounts allowed under the law of the issuing Tribe. For Tribal employers/income withholders who receive a State IWO,you may not withhold more than the lesser of the limit set by the law of the jurisdiction in which the employer/income withholder is located or the maximum amount permitted under section 303(d)of the CCPA(15 U.S.C. 1673(b)). Depending upon applicable State or Tribal law,you may need to also consider the amounts paid for health care premiums in determining disposable income and applying appropriate withholding limits. Arrears greater than 12 weeks?If the Order Information does not indicate that the arrears are greater than 12 weeks,then the Employer should calculate the CCPA limit using the lower percentage. Additional Information: NOTIFICATION OF EMPLOYMENT TERMINATION OR INCOME STATUS: If this employee/obligor never worked for you or you are no longer withholding income for this employee/obligor,an employer must promptly notify the CSE agency and/or the sender by returning this form to the address listed in the Contact Information below: 3404926700 Q This person has never worked for this employer nor received periodic income. O This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU/Tribal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To Employer/income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT(Issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at:www.childsupport.state.pa.us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST. P.O. BOX 320, CARLISLE. PA. 17013(Issuer address). To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT(Issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at www.childsupport.state.pa.us. IMPORTANT:The person completing this form is advised that the information may be shared with the employee/obligor. OMB No.:0970-0154 Form EN-428 06/12 Service Type M Page 3 of 3 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLOUSER, JOHN C. A PACSES Case Num er 188109033 PACSES Case Number Plaintiff Name Plaintiff Name ROBIN D.CLOUSER Docket Aftachment Amount Dock Attachment Amount 06-6950 CIVIL $ 0.00 1 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Nam Docke Attachment Amoun# ocke Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Dacket Attachment Amount Docke Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB Addendum Form EN-428 06/12 Service Type M OMS No.:0970-0154 Worker ID$IATT INCOME WITHHOLDING FOR SUPPORT 09 023 @ ORIGINAL INCOME WITHHOLDING ORDER/NOTICE FOR SUPPORT(IWO) C)6 bq c) clv` I 0 AMENDED IWO 0 ONE-TIMEORDER/NOTICE FOR LUMP SUM PAYMENT 0 TERMINATION OF IWO Date: 05/20/13 ❑ Child Support Enforcement(CSE)Agency Court ❑ Attorney ❑ Private Individual/Entity(Check One) NOTE:This IWO must be regular on its face.Under certain circumstances you must reject this IWO and return it to the sender(see IWO instructions http://www.acf.hhs.gov/proarams/ese/newhire/­employer/­publication/publication,htm-forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court,a copy of the underlying order must be attached. State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 6733101808 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket Informaiton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) RE: CLOUSER,JOHN C.JR YRC WORLDWIDE* Employee/Obligor's Name(Last,First,Middle) 175-40-5172 Sent Electronically Employee/Obligors Social Security Number (See Addendum for plaintiff names DO NOT MAIL associated with cases on attachment) Custodial Party/Obligee's Name(Last, First, Middle) Employer/Income Withholder's FEIN 340492670 NOTE:This IWO must be regular on its face. Under certain circumstances you must reject Child(ren)'s Name(s)(Last,First,Middle) Child(ren)'s Birth Date(s) this IWO and return it to the sender(see IWO instructions htto://www,acf.hhs,gov/r)rograms/c.selnewhire/ emploverli)ublication/r)ublication.btm-forms).If you receive this document from someone other than a State or Tribal CSE agency or a Court,a copy of the underlying order must be attached. 3404926700 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND County, Commonwealth of Pennsylvania (State/Tribe). You are required by law to deduct these amounts from the employee/ obligor's income until further notice. $ 0.00 per month in current child support $ 0.00 per month in past-due child support-Arrears 12 weeks or greater? 0 ye�,Uj nq $ 0.00 per month in current cash medical support rn 35- 0 $ 0.00 per month in past-due cash medical support -<l _0 > r...) C� $ 485.00 per month in current spousal support [--:z —4 $ 0.00 per month in past-due spousal support CZ1 = *C-, $ 0.00 per month in other(must specify) C:1 for a Total Amount to Withhold of$ 485.00 per month. AMOUNTS TO WITHHOLD: You do not have to vary your pay cycle to be in compliance with the Ofc*r In-lbrma-Ttlion. If your pay cycle does not match the ordered payment cycle, withhold one of the following amount: $ 111.62 per weekly pay period. $ 242.50 per semimonthly pay period(twice a month) $ 223.23 per biweekly pay period(every two weeks) $ 485.00 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/r)rograms/cse/newhire/employer/contacts/contact map. htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.:0970-0154 Form EN-428 06/12 Service Type M Worker ID $IATT ❑ Return to Sender[Completed by Employer/income Withholder]. Payment must be directed to an SDU in accordance with 42 USC§666(b)(5)and (b)(6)or Tribal Payee(see Payments to SDU below). If payment is not directed to an SDU/Tribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/issuing Official (if required by State or Tribal law): KEVIN A HESS Print Name of Judge/issuing Official: Title of Judge/Issuing Official: Date of Signature: MAY 20,2013 If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order,a copy of this IWO must be provided to the employee/obligor. ❑ If checked,the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOR EMPLOYERS/INCOME WITHHOLDERS Pennsylvania law(23 PA C.S.§4374(b))requires remittance by an electronic payment method if an employer is ordered to withhold income from more than one employee and employs 15 or more persons,or if an employer has a history of two or more returned checks due to nonsufficient funds. Please call the Pennsylvania State Collections and Disbursement Unit(PA SCDU)Employer Customer Service at 1-877.676-9580 for instructions. PA FIPS CODE 42 000 00 Make Remittance Payable to: PA SCDLI Send check to: Pennsylvania SCDLI, 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.00v/proarams/­­cse/"newhire/"employer/contacts/coatact 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 SOU 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—0513112014.The OMB Expiration Date has no bearing on the termination date of the IWO;it identifies the version of the form currently in use. Form EN-428 06/12 Service Type M Page 2 of 3 Worker ID$IATT R Employer's Name: YRC WORLDWIDE' Employer FEIN: 340492670 Employee/Obligor's Name: CLOUSER JOHN C.JR 6733101808 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: 3404926700 • This person has never worked for this employer nor received periodic income. • This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU/Thbal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT(Issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at:www.childsupport.state.pa.us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST. P.O. BOX 320, CARLISLE, PA. 17013(Issuer address). To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT(Issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at www.childsupport.state.pa.us. IMPORTANT:The person completing this form is advised that the information may be shared with the employee/obligor. OMB No.:0970-0154 Form EN-428 06/12 Service Type M Page 3 of 3 Worker ID $IATT ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLOUSER, JOHN C.JR PACSES Case Number 188109033 PACSES Case Number Plaintiff Name _Plaintiff Name . ROBIN D. CLOUSER Docket Attachment Amoun Docke Attachment Amount 06-6950 CIVIL $ 485.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Do ke Attachment Amoun Docket Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Docket Attachment Amoun Docke t Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB Addendum Form EN-428 06/12 Service Type M OMB No.:0970-0154 Worker 10 $IATT INCOME WITHHOLDING FOR SUPPORT 0 ORIGINAL INCOME WITHHOLDING ORDERINOTICE FOR SUPPORT(IWO) 0 AMENDED IWO 0 ONE-TIMEORDERMOTICE FOR LUMP SUM PAYMENT TERMINATION OF IWO Date: 08/01/13 0 Child Support Enforcement(CSE)Agency (g Court 0 Attorney 0 Private Individual/Entity(Check One) NOTE:This IWO must be regular on its face.Under certain circumstances you must reject this IWO and return it to the sender(see IWO instructions http://www.acf.hhs,ciov/programs/ese/newhire/employer/publication/publication,htm-forms). If you receive this document from someone other than a State or Tribal CSE agency or a Court,a copy of the underlying order must be attached. State/Tribe/Territory Commonwealth of Pennsylvania Remittance Identifier(include w/payment): 6733101808 City/County/Dist./Tribe CUMBERLAND Order Identifier: (See Addendum for order/docket Informaiton) Private Individual/Entity CSE Agency Case Identifier: (See Addendum for case summary) RE: CLOUSER,JOHN C.JR YRC WORLDWIDE* Employee/Obligor's Name(Last,First,Middle) 175-40-5172 Sent Electronically Employee/Obligors Social Security Number (See Addendum for plaintiff names DONOT MAIL associated with cases on attachment) Custodial Party/Obligee's Name(Last, First, L Middle) Employer/Income Withholder's FEIN 340492670 NOTE:This IWO must be regular on its face. Under certain circumstances you must reject Child(ren)'s Name(s)(Last, First,Middle) Child(ren)'s Birth Date(s) this IWO and return it to the sender(see IWO instructions hfto://www.aef.hhs.-gov/programs/cae/newhire emplpyer/publir-ation/publication.htm-form$.If you receive this document from someone other than a State or Tribal CSE agency or a Court,a copy of the underlying order must be attached. 3404928700 See Addendum for dependent names and birth dates associated with cases on attachment. ORDER INFORMATION: This document is based on the support or withholding order from CUMBERLAND Cd-unty, Commonwealth of Pennsylvania (State/Tribe), You are required by law to deduct these amounts frog,-the:tnplo,ree/ obligor's income until further notice. M 00 3nr► M $ 0.00 per month in current child support r_/_ $ 0.00 per month in past-due child support-Arrears, 12 weeks or greater? Oyeg()�_& nd $ 0.00 per month in current cash medical support < $ 0.00 per month in past-due cash medical support $ 0.00 per month in current spousal support c: ra $ 0.00 per month in past-due spousal support $ 0.00 per month in other(must specify) 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/emplpyer/contacts/contact map. htm for the employee/obligor's principal place of employment. Document Tracking Identifier OMB No.:0970-0154 Form EN-428 06/12 Service Type M Worker ID $IATT r7 Return Sender 8DU \n accordance with 42 USC §666(b)(5)and (b)(6)or Tribal Payee (see Payments to SDU below), |f payment ionot directed to an SDUITribal Payee or this IWO is not regular on its face, you must check this box and return the IWO to the sender. Signature of Judge/Issuing Official (if required by State or Tribal law): KEVIN A HESS Print Name of Judge/Issuing Official: Title of Judge/Issuing Official: Date of Signature: AUGUST 1,2013 If the employee/obligor works in a State or for a Tribe that is different from the State or Tribe that issued this order,a copy of this IWO must bo provided 0o the omp(oyee/ob|igor. F71 If checked,the employer/income withholder must provide a copy of this form to the employee/obligor. ADDITIONAL INFORMATION FOREK0PLOYERS/|NC0K4E WITHHOLDERS Pennsylvania law(23 PA C.S'§4374(b))requires remittance byan electronic payment method \yanemployer is ordered to withhold income from more than one employee and employs 15 or more persons,or if an employer has history of two er more returned checks due bomommufOcientfunds. Please call the Pennsylvania State Collections and Disbursement Unit(PA SCDU) Employer Customer Service at1~877-67G'$88u for instructions. PAF!PSCODE 42 00o00 Make Remittance Payable to: PA SCDU Send check to: Pennsylvania SCDL1, Un.O. Box 69112° Harrisburg, Pa 17106-9112 AN ADDITION, PAYME]VTSDVUSTMNCLUDE THE DEFENDANT-S NAME AND THE P4CSES MEMBER AD(shown above as theEmployeelObligior's Case Identifler)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: Priority:Withholding for support has priority over any other legal process under State law against the same income(USC 42 §6G8(b)(7)). |fe Federal tax levy ia|n effect, please notify the sender. Combining Payments: When remitting payments UzanSDUnrThba\ CSEaQenoy. youmuycombinewithhe|domountahnm 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 bya Court,Attorney, 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|u the date on which the amount was withheld from the emp|oyee/ob1igor'm wages. You must comply with the law of the State(or Tribal law|f 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 IWOa: |f there ia more than one|VVO against this om |o e/bbUgorondyouaneunob|atofu|k/honqraU |VVOsduohu 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 bo required tn notify a State ur Tribal CSE agency of upcoming lump sum payments 8othis 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 |aw/pnmcedune. 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-oam,xm,'The OMB Expiration Date has""bearing o"the termmuoon date m the/wm;x identifies the version m the form currently muse. Form EN-42DD6K12 Service Type yW Page 2of3 Worker |[J$/ATT w. Employer's Name: YRC WORLDWIDE- Employer FEIN: 340492670 Employee/Obligor's Name: CLOUSER JOHN C. JR 6733101808 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: 3404926700 Q This person has never worked for this employer nor received periodic income. O This person no longer works for this employer nor receives periodic income. Please provide the following information for the employee/obligor: Termination date: Last known phone number: Last known address: Final Payment Date To SDU/Tribal Payee: Final Payment Amount: New Employer's Name: New Employer's Address: CONTACT INFORMATION: To Employer/Income Withholder: If you have any questions, contact WAGE ATTACHMENT UNIT(Issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at:www.childsupport.state.pa.us. Send termination/income status notice and other correspondence to: DOMESTIC RELATIONS SECTION, 13 N. HANOVER ST. P.O. BOX 320, CARLISLE, PA. 17013(Issuer address). To Employee/Obligor: If the employee/obligor has questions, contact WAGE ATTACHMENT UNIT(Issuer name) by phone at(717)240-6225, by fax at(717)240-6248, by email or website at www.childsupport.state_pa.us. IMPORTANT:The person completing this form is advised that the information may be shared with the employee/obligor. OMB No.:0970-0154 Form EN-428 06/12 Service Type M Page 3 of 3 Worker ID $IATT Y . ADDENDUM Summary of Cases on Attachment Defendant/Obligor: CLOUSER, JOHN C. JR PACSES Case Number 188109033 PACSES Case Number Plaintiff Name Plaintiff Name ROBIN D. CLOUSER Docke Attachment Amount Docket Attachment Amount 06-6950 CIVIL $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB 1 I PACSES C se.Number PACSES Case Number Plaintiff Name Plaintiff Name Doc Attac ment Amount Dom'.cke Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB PACSES Case Number PACSES Case Number Plaintiff Name Plaintiff Name Docke Attachment Amount Docket Attachment Amount $ 0.00 $ 0.00 Child(ren)'s Name(s): DOB Child(ren)'s Name(s): DOB Addendutrl Form EN-428 06(12 Service Type M OMB No.:0976-0154 Worker ID$IATT