______________________ : IN THE COURT OF COMMON PLEAS

Plaintiff : DAUPHIN COUNTY, PENNSYLVANIA

:

v. : No. ______________________

:

______________________ :

Defendant : CIVIL ACTION ______________________

PRAECIPE FOR ENTRY OF LIMITED APPEARANCE PURSUANT TO ADMINISTRATIVE ORDER NO.__________

TO THE PROTHONOTARY: Kindly enter my limited appearance on behalf of _________________________ , (Plaintiff/Defendant) in the above captioned matter. I hereby certify that I have accepted the representation of _________________________ as a pro bono volunteer through ________________ [name of referring agency]. My appearance is limited to the performance of the following responsibilities in the Dauphin County Court of Common Pleas: (Select all that apply)

_____ Representation in one custody conciliation conference.

_____ Representation in one custody hearing (specify nature of proceeding):

________________________________________________________

_____ Representation in one Domestic Relations Officer’s Conference

_____ Other: __________________________________________________

Upon completion of the above duties and consistent with Administrative Order No. _________ I may withdraw my appearance without further petition or order of this Court. Respectfully submitted: ______________________________ ______________________________

Type or Print Name ___________________________ Signature of Party

Counsel for: _______________________ Address: ___________________________

___________________________ Type or Print Name of Party

___________________________ Attorney ID # _______________________

Date: ______________________ Phone #: ___________________________