HomeMy WebLinkAbout02-3824
LOIE HIMES,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
Plaintiff
v.
NO.: Oc{ -3f' J.4- 2002
KEITH IDMES,
CIVIL ACTION - LAW
IN DIVORCE
Defendant
NOTICE
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this Complaint and Notice are
served, by entering a written appearance personally or by attorney and filing in writing with the
Court your defenses or objections to the claims set forth against you. You are warned that if you
fail to do so the case may proceed without you and a judgment may be entered against you by the
Court without further notice for any money claimed in the Complaint or for any other claim or
relief requested by the Plaintiff. You may lose money or property or other rights important to
you.
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 WHERE YOU CAN GET LEGAL HELP.
Cumberland County Court Administrator
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
(717) 240-6200
LOIE HIMES,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
Plaintiff
v.
NO.:
2002
KEITH HIMES,
CIVIL ACTION - LAW
IN DIVORCE
Defendant
NOTICIA
Le han demandado a usted en la corte. Si usted quiere defenderse de estas demandas
expuestas en las paginas siguientes, usted tiene viente (20) dias de plazo al partir de la fecha de
la demanda y la notificacion. Usted debe presentar una apariencia escrita 0 en persona 0 por
abogado y archivar en la corte en forma escrita sus defensas 0 sus objeciones alas demandas en
contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y puede
entrar una orden contra usted sin previo aviso 0 notificacion y por cualquier queja 0 alivio que es
pedido en la peticion de demanda. Usted puede perder dinero 0 sus propiedades 0 otros detechos
importantes para usted.
LLEVE ESTA DEMANDA A UN ABODAGO IMMEDIATAMENTE. SI NO TIENE
ABOGADO 0 SINOTIENEELDINERO SUFICIENTEDE PAGAR TALSERVICIO, VAYA
EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUY A DIRECCION SE
ENCUENTRA ESCRITA ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR
ASISTENCIA LEGAL.
Cumberland County Court Administrator
Cumberland County Courthouse
One Courthouse Square
Carlisle, PA 17013
(717) 240-6200
AVAILABILITY OF COUNSELING
THE DIVORCE CODE OF PENNSYLVANIA REQUIRES THAT YOU BE NOTIFIED
OF THE AVAILABILITY OF COUNSELING WHERE DIVOCE IS SOUGHT UNDER NY OF
THE FOLLOWING GROUNDS:
23 PAC.S. & 3301 (a}(6) ------- Indignities
23 PAC.S. & 3301 (c) ---------- Irretrievable Mutual Consent
23 PAC.S. & 3301 (d) --------- Irretrievable Breakdown; Two year separation
where the Court determines that there is a
reasonable prospect of reconciliation.
A list of marriage counselors is available in the Office of the Prothonotary,
Cumberland County Courthouse, 1 Courthouse Square, Carlisle, P 13.
Ric ard C. Rup , Esquire
Attorney for Plaintiff
355 N. 21"t St., Suite 205
Camp Hill, PA 17011
717-761-3459
LOIE HIMES,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
PlaintiH
v.
NO.:
2002
KEITH HIMES,
CIVIL ACTION - LAW
IN DIVORCE
Defendant
COMPLAINT
AND NOW, comes Plaintiff, Loie Himes, by her attorney, Richard C. Rupp, and
files this Complaint in Divorce, based upon the following:
1. Plaintiff, Loie Himes, is an adult individual residing at 34 Sunfire Avenue, Camp
Hill, Cumberland County, Pennsylvania 17011.
2. Defendant, Keith Himes, is an adult individual residing at 34 Sunfire Avenue,
Camp Hill, Cumberland County, Pennsylvania 17011.
3. Plaintiff and Defendant have been bona fide residents in the Commonwealth of
Pennsylvania for at least six (6) months previous to the filing of this Complaint.
4. Plaintiff and Defendant were married on October 21, 1988, in Harrisburg,
Dauphin County, Pennsylvania.
5. There have been no prior actions for divorce or annulment between the Parties.
6. Plaintiff and Defendant are both citizens of the United States of America.
7. Neither Plaintiff nor Defendant are a member of the Armed Services of the
United States or any of its allies.
8. Plaintiff avers as the grounds on which this action is based are that the marriage
is irretrievably broken.
9, Plaintiff avers that there are no children born of this marriage,
10. Plaintiff has been advised that counseling is available and the Plaintiff may have
the right to request that the Court require the Parties participate in counseling.
11. Plaintiff and Defendant separated on July 12, 2002.
12. Plaintiff asks the Court to enter a Decree in Divorce.
WHEREFORE, Plaintiff requests Your Honorable Court to enter a Decree in
Divorce dissolving the marriage between Plaintiff and Defendant and such further relief
as the Court may determine equitable and just.
Respectfully submitted,
Richard C. Rupp
Sup. Court I.D. No,: 34832
355 North 21 st Street, Suite 205
Camp Hill, PA 17011
(717) 761-3459
Attorney for Plaintiff
2
VERIFICATION
I, LOIE HIMES, verify that the statements in the foregoing Complaint in Divorce
are true and correct to the best of my knowledge, information and belief.
I understand that false statements herein are made subject to penalties of 18 Pa.
C,S. ~ 4904 relating to unsworn falsification to authorities.
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LOIE HIMES,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYL VANIA
Plaintiff
NO. 02-3824 - 2002
KEITH HIMES,
Defendant
CIVIL ACTION - LAW
IN DIVORCE
ACCEPTANCE OF SERVICE
I accept service of the Complaint on behalf of Defendant, Keith Himes, and certify that I
am authorized to do so.
METZGER, WICKERSHAM, KNAUSS & ERB
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Melissa L. VanEck, Esquire
Attorney Id. 85869
3211 North Front Street
PO Box 5300
Harrisburg, PA 17110-0300
(717) 238-8187
Attorneys for Defendant
Keith Himes
Date: August 29, 2002
Document #: 24/306,/
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LOIE HIMES,
IN THE COURT Of COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
.
.
No. 2002-3824
v.
KEITH HIMES,
Defendant
CIVIL ACTION - LAW
IN DIVORCE
AffiDAVIT Of CONSENT
1. A Complaint in Divorce under Section 3301 (c) of the Divorce Code was
filed on August 9, 2002.
2. The marriage of Plaintiff and Defendant is irretrievably broken and
ninety (90) days have elapsed from the date of filing the Complaint.
3. I consent to the entry of a final decree of divorce after service of notice
of intention to request entry of the decree.
I verify that the statements made in this affidavit are true and correct.
I understand that false statements herein are made subiect to the
penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to
authorities.
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LOIE HIMES,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
v.
No. 2002-3824
KEITH HIMES,
Defendant
CIVIL ACTION - LAW
IN DIVORCE
WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY
OF A DIVORCE DECREE UNDER SECTION 3301 (C) OF THE DIVORCE CODE
1. I consent to the entry of a final Decree of Divorce without notice.
2. I understand that I may lose rights concerning alimony, division of
property, lawyer's fees or expenses if I do not claim them before a
divorce is granted.
3. I understand that I will not be divorced under a Divorce Decree is
entered by the Court and that a copy of the Decree will be sent to me
immediately after if 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 subiect to the
penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to
authorities.
Date: II; 1JLJ 3
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LOIE HIMES,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
No. 2002-3824
v.
KEITH HIMES,
Defendant
CIVIL ACTION - LAW
IN DIVORCE
COUNSELING AFFIDAVIT
1. I have been advised of the availability of marriage counseling and
understand that I may request that the Court require that my spouse
and I participate in counseling.
2. I understand that the Court maintains a list of marriage counselors in
the Domestic Relations office, which list is available to me upon
request.
3. Being so advised, I do not request that the Court require that my
spouse and I participate in counseling prior to a divorce decree being
handed down by the Court.
I understand that false statements herein are made subiect to the
penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to
authorities.
Date:
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KEI HIMES - Defendant
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LOIE HIMES,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
No. 2002:-3824
v.
KEITH HIMES,
Defendant
CIVIL ACTION - LAW
IN DIVORCE
AFFIDAVIT OF CONSEN'1[
1. A Complaint in Divorce under Section 3301 (c:) of the Divorce Code was
filed on August 9, 2002.
2. The marriage of Plaintiff and Defendant is irretrievably broken and
ninety (90) days have elapsed from the datE~ of filing the Complaint.
3. I consent to the entry of a final decree of divorce after service of notice
of intention to request entry of the decree.
I verify that the statements made in this affidavit are true and correct.
I understand that false statements herein are made subiect to the
penalties of 18 Pa.C.S. Section 4904 relating to ul1lsworn falsification to
authorities.
Date: ~A:jJ
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LOIE H~ES, Plaintiff
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LOIE HIMES,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
No. 2002-3824
v.
KEITH HIMES,
Defendant
CIVIL ACTION - LAW
IN DIVORCE
WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY
OF A DIVORCE DECREE UNDER SECTION 3301 (C) OF THE DIVORCE CODE
1. I consent to the entry of a final Decree of Divorce without notice.
2. I understand that I may lose rights concerning alimony, division of
property, lawyer1s fees or expenses if I do nOlt claim them before a
divorce is granted.
3. I understand that I will not be divorced under a Divorce Decree is
entered by the Court and that a copy of the Decree will be sent to me
immediately after if 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 subiect to the
penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to
authorities.
Date: ~/d'~J
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LOIE HI~ - PLAINTIFF
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LOIE HIMES,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
No. 2002-3824
v.
KEITH HIMES,
Defendant
CIVIL ACTION - LAW
IN DIVORCE
COUNSELING AFFIDAVn:
1. I have been advised of the availability of marriage counseling and
understand that I may request that the Cour1 require that my spouse
and I participate in counseling.
2. I understand that the Court maintains a list of marriage counselors in
the Domestic Relations office, which list is avc:lilable to me upon
request.
3. Being so advised, I do not request that the Court require that my
spouse and I participate in counseling prior t,o a divorce decree being
handed down by the Court.
I understand that false statements herein are made subiect to the
penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to
authorities.
Date: I .k ~J
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LOIE HIMES,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
No. 2002-3824
v.
KEITH HIMES,
Defendant
CIVIL ACTION - LAW
IN DIVORCE
PRAECI PE TO TRANSMIT RECORD
TO THE PROTHONOTARY:
Transmit the record, together with the following information, to the
Court for entry of a divorce decree:
1. Ground for divorce: Irretrievable breakdown under
(X) Section 3301 (c) ( ) Section 3301 (d) of the Divorce Code.
2. Date and manner of service of the complaint: 08/28/03 Acceptance of
Service
3. Complete either paragraph (a) or (b):
(a)
Date of execution of the affidavit of consent required by Section
3301 (c) of the Divorce Code: by plaintiff, 01 /08/03
by defendant, 01 /13/03
.
,
(b)(1 )
Date of execution of plaintiff's affidavit required by Section
3301 (d) of the Divorce Code:
(b)(2)
Date of service of plaintiff's affidavit upon defendant: _.
4. Related claims pending: DRO Order er
A reement which A reement is inc
reference
Date: January 22, 2003
Richard C.
Rupp & Me Ie, P.C.
Attorney I.D. #34832
355 North 21 st Street, Suite 205
Camp Hill, IPA 17011
(717) 761-3459
Counsel for PlaintiH
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IN THE COURT OF COMrMON PLEAS
OF CUMBERLAND COUNTY
STATE OF
PENNA,
LOIE HIMES,
PlaintiH
No.
21002-3824
VERSUS
I(~ITW WIMI=S,
Defendant
AND NOW,
DECREE IN
DIVORCE
cPAMlcv,
'1
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~\.M.2. , IT IS ORDERED AND
DECREED THAT
LOIE HIMES
, PLAl NTI FF,
AND
KEITH HIMES
, DEFENDANT,
ARE DIVORCED FROM THE BONDS OF MATRIMONY.
THE COURT RETAINS JURISDICTION OF THE FOLL.OWING CLAIMS WHICH HAVE
BEEN RAISED OF REC~~D IN THIS ACTION FOR WHICH A FINAL ORDER HAS NOT
YET BEEN ENTERED; '-J0&Ut
QDRO Order per the Marital Settlement AgrE!ement which Agreement
is incorporated (not merged) herein by referE!nce.
BYTHEfu~
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PROTHONOTARY
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LOIE HIMES,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYL VANIA
v.
NO, 02-3824 - 2002
CIVIL ACTION - LA W
KEITH HIMES,
Defendant
IN DIVORCE
PETITION FOR ENTRY OF A QUALIFIED DOMESTIC RELATIONS ORDER
AND NOW comes Petitioner, Keith Himes, who, by his attorney, Andrew C, Spears,
Esquire, respectfully represents:
1, Petitioner is Keith Himes who resides at 34 Sunfire Avenue, Camp Hill,
Cumberland County, Pennsylvania, 17011,
2, Respondent is Loie Himes who resides at 236 Constitutional Court, Mechanicsburg,
Cumberland County, Pennsylvania, 17050.
3. The marriage of the parties was dissolved by a Decree of Divorce entered by this
Honorable Court on February 4, 2003.
4. The parties have signed the within Qualified Domestic Relations Order indicating
that this represents their agreement.
Document #: 260574
WHEREFORE, Petitioner respectfully requests that this Honorable Court enter the within
Stipulation as its Qualified Domestic Relations Order.
Respectfully submitted,
METZGER, WICKERSHAM, KNAUSS & ERB, P.C,
By
~,~
Andrew C. Spears, E8qUire
Attorney I.D, No. 87737
P.O. Box 5300
3211 North Front Street
Harrisburg, PA 17110-0300
(717) 238-8187
Attorneys for Defendant/Petitioner
Dated: ':).- \ 0 - tJ ~
- 2 -
Document #: 260574
LOIE HIMES,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYL VANIA
NO. 02-3824 - 2002
KEITH HIMES,
Defendant
CIVIL ACTION -. LAW
IN DIVORCE
QUALIFIED DOMESTIC RELATIONS ORDER
1, The parties to this action have entered into a Property Settlement Agreement
dated July 30, 2002,
2, This Order creates and recognizes the existence of an Alternate Payee's right to
receive a portion of the Participant's benefits payable under an employer sponsored defined
contribution plan which is intended to be qualified under Internal Revenue Code of 1986
("Code") ~401(a), The Court intends this order to be a Qualified Domestic Relations Order
("QDRO") within the meaning of Code ~414(P). The Court enters this QDRO pursuant to its
authority under the 23 P,C.S.A. ~3502.
3. This QDRO applies to the Shaffer Cardiovascular Associates 401(k) Retirement
Savings ("Plan"). Further, this Order shall apply to any successor plan to the Plan or any other
planes) to which liability for provision of the Participant's beneults described below is incurred.
Any benefits accrued by the Participant under a predecessor plarl of the employer or any other
defined contribution plan sponsored by the Participant's employer, whereby liability for benefits
accrued under such predecessor plan or other defined contribution plan has been transferred to
the Plan, shall also be subject to the terms of this Order. Any changes in Plan Administrator,
Plan sponsor, or name of the Plan shall not affect Alternate's Payee's rights as stipulated under
this Order.
4, Keith E. Himes ("Participant") is a participant in the Plan. Loie J. Himes
("Alternate Payee") is the alternate payee for purposes of this QDRO.
are:
5. The Participant's name, mailing address, social security number, and date of birth
Name:
Keith E. Himes
Document #: 246603,]
Home Address:
34 Sunfire A venuc~
Camp Hill, PA 17011
207-44-7094
02-09-1954
88#:
DoD:
6.
birth are:
The Alternate Payee's name, mailing address, social security number, and date of
Name:
Home Address:
Loie J. Himes
236 Constitutional Court
Mechanicsburg, PA
182-40-8660
01-11-1956
88#:
DoD:
The Alternate Payee shall have the duty to notify the Plan Administrator in writing of any
changes in this mailing address subsequent to the entry of this Order.
7. The portion of the Participant's plan benefits payable to the Alternate Payee under
this QDRO is:
$40,000.00 (Forty Thousand Dollars)
The Alternate Payee's portion of the benefits described above shall be segregated and
separately maintained in account(s) established on her behalf and shall be credited with any
investment income or losses attributable thereto from the date this Order is executed, until the
date of total distribution to the Alternate Payee. Her accounts shall be established in the same
ration as the Participant's accounts as regards any elective defenal account, nondeductible
employee account, qualified nonelective contribution account, employer contribution account, or
rollover/transfer account and as regards any investment mix attributed to the Participant's
accounts, However, the investment mix shall not include any loan to the Participant which it
treated by the Plan as an investment sub-account of the Participant.
8. This QDRO does not require the Plan to provide ,my type or form of benefit the
Plan does not otherwise provide,
9. This QDRO does not require the Plan to provide increased benefits.
10. This QDRO does not require the Plan to pay any benefits which another order
previously determined to be a qualified domestic relations order requires the Plan to pay to
another Alternate Payee,
Document #: 246603.1
11. If the Alternate Payee so elects, the Plan shall distribute the amount designated in
paragraph 7 of this QDRO, together with allocable earnings, as soon as administratively feasible
following the Plan Administrator's approval of this Order. If the Plan does not permit an
immediate distribution of this amount, the Plan shall pay such amount at the Participant's earliest
retirement age as defined by Code ~414(p)(4)(B), subject to the Alternate Payee's election.
12. Benefits are to be payable to the Alternate Payee in any form or permissible
option otherwise available to the Participant and Alternate Payees under the terms of the Plan,
including, but not limited to, a lump sum cash payment. The Alternate Payee shall execute any
forms required by the Plan Administrator.
13. On and after the date that this order is deemed to be a QDRO, but before the
Alternate Payee receives her distribution under the Plan, the Alternate Payee shall be entitled to
all of the rights and election privileges that are afforded to active participants, including, but not
limited to, the rules regarding withdrawals and distributions, and the right to name a beneficiary.
14. All payments made pursuant to this order shall be conditioned on the certification
by the Alternate Payee and the Participant to the Plan Administrator of such information as the
Plan Administrator may reasonably require from such parties.
15. It is the intention of the parties that this QDRO continue to qualify as a QDRO
under Code ~414(p), as it may be amended from time to time, and that the Plan Administrator
shall reserve the right to reconfirm the qualified status of the order at the time benefits become
payable hereunder.
16. In the event that the Plan inadvertently pays to the Participant any benefits that are
assigned to the Alternate Payee pursuant to the terms of this ordl~r, the Participant shall
immediately reimburse the Alternate Payee to the extent that she;: has received such benefit
payments and shall forthwith pay such amount so received directly to the Alternate Payee within
ten (10) days of receipt.
In the event that the Plan inadvertently pays to the Alternate Payee any benefits that are
assigned to the Participant pursuant to the terms of this order, the Alternate Payee shall
immediately reimburse the Participant to the extent that he/she has received such benefit
payments and shall forthwith pay such amount so received directly to the Participant within ten
(10) days of receipt.
17. In the event that the Participant's benefits, or any portion thereof, become payable
to the Participant as a result of termination or partial termination, then the Alternate Payee shall
be entitled to commence her benefits immediately in accordance with the terms of this QDRO
and in accordance with the termination procedures of the Plan.
Document #: 246603,}
18. After payment of the amount required by this QDRO, the Alternate Payee shall
have no further claim against the Participant's interest in the Plan.
19. The Alternate Payee assumes sole responsibility for the tax consequences of the
distribution under this QDRO.
20. Until the Plan completes payment of all benefits pursuant to this QDRO, the Plan
shall treat the Alternate Payee as a surviving spouse for purposes of Code ~~401(a)(II) and 417,
but the Alternate Payee shall receive, as surviving spouse, only the amount described in
paragraph 7 ofthis QDRO. The sole purpose of this paragraph 20 is to ensure payment to the
Alternate Payee in the event of Participant's death prior to payment by the Plan ofthe amount
described in paragraph 7 ofthis QDRO. In the event of the Alternate Payee's death prior to the
payment by the Plan of all benefits pursuant to this QDRO, the Plan shall pay the remaining
benefits under this QDRO to Alternate Payee's Estate or any beneficiary subsequently
designated by the Alternate Payee and recorded with the Plan .Administrator under the terms of
the Plan.
21. The Plan shall treat this QDRO in accordance with Code ~414(p )(7). While the
Plan is determining whether this order is a Qualified Domestic Relations Order, the Plan
Administrator shall separately account for the amounts which would have been payable to the
Alternate Payee while the Plan is determining the qualified status of this QDRO.
22. The Plan Administrator promptly shall notify the Participant and the Alternate
Payee of the receipt of this QDRO and shall notify the Participant and the Alternate Payee of the
Plan's procedures for determining the qualified status of this QDRO, The Plan Administrator
shall determine the qualified status of the QDRO and shall notify the Participant and the
Alternate Payee of the determination within a reasonable period of time after receipt of this
QDRO.
23, The Court shall retain jurisdiction with respect to this Order to the extent required
to maintain its qualified status and the original intent of the parties as stipulated herein.
BY THE COURT:
Judge
Document #: 246603,}
VERIFICATION
I, Keith Himes, hereby certify that the facts set forth in the within Petition for Entry of a
Qualified Domestic Relations Order are true and correct to the best of my knowledge, information
and belief, and that false statements herein are made subject to the penalties of 18 Pa. C.S,A.
~4904 relating to unsworn falsification to authorities.
~
Date:
;2/IO/D3
nnrlll'lfpnf iJ. ?lini74
CERTIFICATE OF SERVICE
I, Andrew C. Spears, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C.,
hereby certify that I served a true and exact copy of the Petition for Entry of a Qualified Domestic
Relations Order with reference to the foregoing action by first class mail, postage prepaid, this
\O~\ay of February, 2003, on the following:
Richard C. Rupp, Esquire
Rupp and Meikle
P.O, Box 395
Camp Hill, P A 17001-0395
~ _/
Andrew C. Spears, Esquire
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Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
LOIE HIMES,
v.
NO. 02-3824 - 2002
CIVIL ACTION - LAW
KEITH HIMES,
Defendant
IN DIVORCE
~
ANDNOW,iliffi '$ wyof (~
, 2003, upon review of the attached
Qualified Domestic Relations Order agreed upon and signed by the parties, the Court hereby
approves said Qualified Domestic Relations Order and enters it as an Order of this Court. The
parties are directed to comply with all of the terms and conditions of the Qualified Domestic
Relations Order.
1.
Document #: 260574
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
Lt'/e.. ,7" JjJ.-y,~5
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Plaintiff
c:2 00 ~ ~ t? ..3 <f'.,..2 /'
File No.
vs.
IN DIVORCE
kr';I~ /: #>nFJ'
Defendant
NOTICE TO RESUME PRIOR SURNAME
Notice 1S hereby given that the Plaintiff/Defendant in the
above matter, having been granted a
~ day of ~kua..-y ~cl.CJJ
prior surname of '!'~;e..J: ~/k~v
this written notice pursuant to the
DATE:
~k/c3
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Final Decree in Divorce on the
, hereby elects to resume the
, and gives
provisions of 54 P.S. S 704.
k'/k
pi" Signature
resumed
COMMONWEALTH OF PENNSYLVANIA:
SS.
COUNTY OF CUMBERLAND
On the:{(p'f--_ day of ~(~ '1.., J).~., ~, before me. a
Notary Public, personally appe~he ab e aff1ant known to me to
be the person whose name is subscribed to the within document and
acknowledged that he/She executed the foregoing for the purpose
therein contained.
seal.
In Witness Whereof, I
haC1~o,_~eQ:y_hand and official
I CL~I~~PBlfEWBW.~ ,troTARY PUBLIC
I l,ari:sle Bora, Cumberland County
I My Commission ty,pires April 4, 2005
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