Instructions for Completing the Custody Forms if you DO have a current Custody Order In Mercer County

THE INFORMATION REQUESTED IN THE FOLLOWING FORMS SHOULD BE

TYPED OR NEATLY PRINTED IN THE BLANKS PROVIDED A. Body of the Petition for Modification: 1) Complete the caption of the Petition by filling in the names of the parties exactly as they are found in your previous court order. Also use the same civil number found on your previous court order. 2) At the first blank line, after the words “AND NOW comes the _____”, write in either “Plaintiff” or “Defendant” depending on how you are listed in the caption. If you are listed as the Plaintiff in the caption, then you should fill in “Plaintiff” on the first blank line. If you are listed as the Defendant in the caption, then you should fill in “Defendant” on the first blank line. 3) At number "1", fill in the date of your previous court order after the words "that on". You should also circle the type of custody that the Court entered. This can be found in your previous court order. 4) At number "2", fill in the information about the plaintiff. First fill in the Plaintiff’s name on the first blank line. Next, after the word “natural”, fill in the Plaintiff’s relationship with the child/children. Next, fill in the Plaintiff’s address. 5) At number “3”, fill in the information about the Defendant. Fill in the Defendant’s name on the first blank line. Next, after the word “natural”, fill in the Defendant’s relationship with the child/children. Next, fill in the Defendant’s address. 6) At number “4”, fill in the information about the children that the parties are parents to. 7) Number “5” asks about the current custody order in place. In the first blank, fill in the date of the Court’s Order. In the second blank, fill in names of the parties who were granted “legal custody.” In the third line, fill in the name of the parties who have “primary physical custody.” In the fourth line, fill in the name of the party who has partial custody/visitation with the child. This information will all be found in your current custody order. 8) Number “6”, asks who is requesting the modification and why. On the first blank line, fill in whether you are the Plaintiff or Defendant. On the remaining lines, explain why you believe the previous court order should be modified. For example, have you or the other parent moved, has the other parent's situation gotten worse or has yours gotten better, or does the child now express an interest that he/she wants to live with you primarily? Remember that space is limited, so here you will want to hit only the highlights. 9) Number “7” states that you have filled out and included with the Petition to Modify, a “Criminal Record / Abuse History” form.

10) Finally, sign the Petition on the line provided. 11) Attach a copy of your previous court order to the Petition before you file it with the court! B. Criminal Record / Abuse History Verification 1) You must complete and file this form with the Petition. There are two copies of this form in

this packet. You must complete one and file it with your modification petition. You must include the other blank form with the petition when you serve the opposing party. This form may be used by the Court during your custody proceedings.

2) Complete the caption of this form by filling in the names of the parties exactly as they are

found in your previous order of court. Also use the same civil number found on your previous court order.

3) Fill in the first blank line with your name.

4) You must check the box next to a crime that either you or a household member has been

convicted of, pled guilty to, or pled no contest to. You must also answer the questions that follow, if applicable. You must be truthful on this form or you could be fined at least $1,000. If you are not sure of a crime that you or a household member should list, you can visit the website listed which provides access to search, view and print the docket sheets for Pennsylvania’s courts. You should check both the Magisterial Court Docket Sheets and the Court of Common Pleas Docket Sheet: http://ujsportal.pacourts.us/DocketSheets/MDJ.aspx

5) Complete the remaining form if applicable. C. Verification

1) Complete the caption of the Verification in exactly the same way that you completed the caption of the Petition.

2) Fill in your name on the first blank.

3) Sign and date the bottom in the spaces provided.

4) By signing this form, you are stating that the information you provided in this petition are true to the best of your knowledge.

D. Order and Notice

1) Complete the caption of the Order and Notice in exactly the same way that you completed the caption of the Petition.

2) After the word “TO:” fill in the name of the party that you are sending this order to.

3) In the first line of the Order and Notice, after the word "you" insert the name of the other party. You should then circle the type of custody that was granted in your current order. Then after the word "child(ren)" insert the name(s) of the child or children who are the subject of your case.

4) On the last page of the scheduling order, there is a paragraph that tells the defendant that

he or she must file with the Court a “Criminal History/ Abuse History” form. This form will be included in the complaint.

5) Also on the last page of the scheduling order there is a paragraph that lets the opposing

party know that no party can change the child’s residence which would impair the other party’s ability to exercise custodial rights without following the required relocation procedures.

6) After the words "BY THE COURT", leave the lines for the date and the Judge's signature blank. The Judge will sign and date the order.

E. Order Appointing Master

1) Complete the caption of the Order Appointing Master in exactly the same way that you completed the caption of the Petition.

2) You should not fill in anything else on this page. The court will fill this out and send it back to you.

3) On the next page, you should not fill in anything. The judge will sign this. F. Certificate of Service

1) Complete the caption of the Certificate of Service in exactly the same way that you completed the caption of the Petition.

2) Fill in your name on the first blank line.

3) Fill in the name(s) and address(es) for all the opposing parties in your case. These are the people you will need to send a copy of these documents to.

4) Sign your name, fill in your address, and the date. G. Criminal Record / Abuse History Verification

1) A second copy of the Criminal History / Abuse History Verification is included in this packet. It must be sent to the defendant when you send the Modification. The defendant must fill this form out and file it with the Court.

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

__________________________________, : :

Plaintiff : :

vs. : No. :

__________________________________, : :

Defendant :

PETITION FOR MODIFICATION OF CUSTODY ORDER AND NOW comes the , and respectfully represents the following:

1. That on _______________, 20___ an Order of Court was entered for (Shared

Legal Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary

Physical Custody) (Shared Physical Custody) (Sole Physical Custody)

(Supervised Physical Custody). A true and correct copy of which is attached.

2. The plaintiff is , natural , who

resides at .

3. The Defendant is , natural ,

who resides at .

4. Parties are the parents of the following child(ren):

Name Present Residence Date of Birth

____________________ _____________________ _______________

____________________ _____________________ _______________

5. The Court’s Order of , gave legal custody to

, primary physical custody of the

minor child(ren) to subject to

visitation/partial custody by .

6. The requests a modification of this Court’s prior

order because: _____________________________________________________

__________________________________________________________________

_________________________________________________________________.

7. I have attached the Criminal Record/Abuse History Verification form required

pursuant to Pa.R.C.P. No. 1915.3-2.

WHEREFORE, Petitioner requests that the Court modify the existing Order because it

will be in the best interest of the child(ren).

Respectfully submitted:

____________________________________

Petitioner, Pro Se

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

, : Plaintiff : : : vs. : No. : , : Defendant : ______________________________________________________________________________

CRIMINAL RECORD / ABUSE HISTORY VERIFICATION

I, ________________________________, hereby swear or affirm, subject to penalties of

law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:

1. Unless indicated by my checking the box next to a crime below, neither I nor any other

member of my household have been convicted or pled guilty or pled no contest or was

adjudicated delinquent where the record is publicly available pursuant to the Juvenile Act, 42

Pa.C.S. §6307 to any of the following crimes in Pennsylvania or a substantially equivalent crime

in any other jurisdiction, including pending charges:

Check Crime Self Other Date of Sentence all that Household conviction, apply Member guilty plea, no contest plea or pending charges ( ) 18 Pa.C.S. Ch.25 ( ) ( ) ______________ ______

(relating to criminal homicide) ( ) 18 Pa.C.S.§2702 ( ) ( ) ______________ ______

(relating to aggravated assault) ( ) 18 Pa.C.S.§2706 ( ) ( ) ______________ ______

(relating to terroristic threats)

( ) 18 Pa.C.S.§2709.1 ( ) ( ) ______________ ______ (relating to stalking)

( ) 18 Pa.C.S.§2901 ( ) ( ) ______________ ______

(relating to kidnapping)

( ) 18 Pa.C.S.§2902 ( ) ( ) ______________ ______

(relating to unlawful restraint) ( ) 18 Pa.C.S.§2903 ( ) ( ) ______________ ______

(relating to false imprisonment) ( ) 18 Pa.C.S.§2910 ( ) ( ) ______________ ______

(relating to luring a child into a motor

vehicle or structure) ( ) 18 Pa.C.S.§3121 ( ) ( ) ______________ ______

(relating to rape) ( ) 18 Pa.C.S.§3122.1 ( ) ( ) ______________ ______

(relating to statutory sexual assault) ( ) 18 Pa.C.S.§3123 ( ) ( ) ______________ ______

(relating to involuntary deviate sexual intercourse) ( ) 18 Pa.C.S.§3124.1 ( ) ( ) ______________ ______

(relating to sexual assault) ( ) 18 Pa.C.S.§3125 ( ) ( ) ______________ ______

(relating to aggravated indecent assault) ( ) 18 Pa.C.S.§3126 ( ) ( ) ______________ ______

(relating to indecent assault) ( ) 18 Pa.C.S.§3127 ( ) ( ) ______________ ______

(relating to indecent exposure)

( ) 18 Pa.C.S.§3129 ( ) ( ) ______________ ______ (relating to sexual intercourse with animal)

( ) 18 Pa.C.S.§3130 ( ) ( ) ______________ ______

(relating to conduct relating to sex offenders) ( ) 18 Pa.C.S.§3301 ( ) ( ) ______________ ______

(relating to arson and related offenses)

( ) 18 Pa.C.S.§4302 ( ) ( ) ______________ ______

(relating to incest) ( ) 18 Pa.C.S.§4303 ( ) ( ) ______________ ______

(relating to concealing death of child)

( ) 18 Pa.C.S.§4304 ( ) ( ) ______________ ______

(relating to endangering welfare of children)

( ) 18 Pa.C.S.§4305 ( ) ( ) ______________ ______

(relating to dealing in infant children)

( ) 18 Pa.C.S.§5902(b) ( ) ( ) ______________ ______

(relating to prostitution and related offenses)

( ) 18 Pa.C.S.§5903(c) ( ) ( ) ______________ ______

or (d) (relating to obscene and other sexual materials and performances)

( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______

(relating to corruption of minors)

( ) 18 Pa.C.S.§6312 ( ) ( ) ______________ ______

(relating to sexual abuse of children)

( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______ (relating to unlawful contact with minor)

( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______

(relating to sexual exploitation of children)

( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______

(relating to contempt for violation of protection order or agreement)

( ) Driving under the ( ) ( ) ______________ ______

influence of drugs or alcohol ( ) Manufacturing, sale, ( ) ( ) ______________ ______

Delivery, holding Offering for sale or possession of any controlled substance or other drug or device

2. Unless indicated by my checking the box next to an item below, neither I nor any other member of my household have a history of violent or abusive conduct including the following: Check Self Other Date all that Household apply Member ( ) A finding of abuse by a Children & ( ) ( ) ________ Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction ( ) Abusive conduct as defined under the ( ) ( ) ________ Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction ( ) Other: __________________________ ( ) ( ) ________

3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse: _______________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________.

4. If any conviction above applies to household member, not a party, state that person’s name, date of birth and relationship to the child. ______________________________________ ___________________________________________________________________________________________________________________________________________________________.

5. If you are aware that the other party or members of the other party’s household has or have a criminal/abuse history, please explain: _________________________________________ ___________________________________________________________________________________________________________________________________________________________. I verify that the information above is true and correct to the best of my knowledge, information or belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. ___________________________ Signature ____________________________ Printed Name

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW ___________________________________, :

: Plaintiff :

: vs. : No. :

, : :

Defendant :

VERIFICATION

I, _________________________, do hereby state, subject to the penalties of 18 Pa. C. S.

§ 4904 relating to unsworn falsification to authorities, that the facts set forth in the foregoing

Petition for Modification of Custody Order are true and correct to the best of my knowledge,

information, and belief.

__________________________________ DATE Petitioner, Pro Se

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION – LAW

__________________________________, :

: Plaintiff :

: vs. : No.

: __________________________________, :

: Defendant :

ORDER AND NOTICE

TO:

You, _________________________, Respondent, have been sued in court to modify (Shared

Legal Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary Physical Custody)

(Shared Physical Custody) (Sole Physical Custody) (Supervised Physical Custody) of the

following child(ren): ___________________________________________________________

____________________________________________________________________________.

The Court has learned you may have a legal interest in custody of the child(ren) named.

A Conference will be scheduled by the Hearing Master.

If you wish to protect any legal interest you may have, or wish to present evidence to the

Court on those matters, you should appear at the place and time and on the date scheduled.

If you wish to claim the right of custody, or visitation, you may file a counterclaim.

If you fail to appear as provided by this Order, or to bring the child(ren), an order for

custody may be entered against you or the Court may issue a warrant for your arrest.

You must file with the Court a verification regarding any criminal record or abuse history

regarding you and anyone living in your household on or before the initial in-person contact with

the court (including, but not limited to, a conference with a conference officer or judge or

conciliation) but not later than 30 days after the service of the complaint or petition.

No party may make a change in the residence of any child which significantly impairs the

ability of the other party to exercise custodial rights without first complying with all of the

applicable provisions of 23 Pa.C.S. §5337 and Pa.R.C.P. No. 1915.17 regarding relocation.

YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF

YOU DO NOT HAVE OR KNOW A LAWYER, THEN YOU SHOULD GO TO OR

TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN

GET LEGAL HELP:

MERCER COUNTY LAWYERS’ REFERRAL SERVICE c/o MERCER COUNTY BAR ASSOCIATION P.O. BOX 1302 HERMITAGE, PENNSYLVANIA 16148 (724) 342-3111 AMERICANS WITH DISABILITIES’

ACT OF 1990

The Court of Common Pleas of Mercer County is required by law to comply with the Americans and Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing.

BY THE COURT:

_________________________________J.

DATE: _____________________

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

______________________________________________________________________________ __________________________________, : Plaintiff : : vs. : CIVIL ACTION NO. : _______________________________, : Defendant : ______________________________________________________________________________ ORDER APPOINTING MASTER IN ALL DOMESTIC RELATIONS ACTIONS EXCEPT PROTECTION FROM ABUSE

AND NOW, on this day of , 20____, , is

hereby appointed Master with respect to the following claims:

( ) In all claims involving martial property

( ) Enforcement of marital agreements

( ) Alimony and modification or termination thereof

( ) Counsel fees and costs

( ) Fault Divorces

( ) Contested Divorces and Annulments

(X ) Preliminary Conferences only in custody cases

( ) Bifurcation hearings

A conference shall be held in all matters except Protection from Abuse.

A Hearing ( ) Conference (X ) shall be conducted in the Master's Hearing Room,

Domestic Relations Office, North Courthouse Annex, Mercer, PA at a time and date to be

established by the Master.

2

If a Hearing is to be held, the parties shall be prepared to produce all of their evidence at

that time.

The Master shall make a report to this Court with a proposed Order, a copy of which shall

be furnished to the parties through their attorneys, or if no attorney by regular mail to the last

known address of the party. The Master's report shall contain a notice to the parties that within

ten days of the date of the report of the Master, any party may file exceptions to the report or any

part thereof to rulings on objections to evidence, to statements or findings of fact, conclusions of

law or to other matters occurring during the hearing. Notice shall also inform the parties that

matters not covered by exceptions are deemed waived unless, prior to entry of a final Order,

leave is granted to file exceptions raising these matters. If exceptions are filed, any other party

may file exceptions within ten days of the date of service of the original exceptions.

The Notice shall also state that if no exceptions are filed within the ten-day period, the

Court shall review the report and if approved, the Court will enter a final Order.

You are advised of your right to be represented by counsel throughout these proceedings.

BY THE COURT: _________________________________, J.

DATE: _____________________

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

, : Plaintiff : : : vs. : CIVIL ACTION NO. : , : Defendant : ______________________________________________________________________________ CERTIFICATE OF SERVICE I, ___________________________, hereby certify that I am this day serving a true and

correct copy of the foregoing pleading upon the following individual(s) in the manner described

below:

Service by United States Mail, Certified, Return Receipt Requested, addressed as

follows:

____________________________________________

____________________________________________

____________________________________________

Respectfully submitted: By: ___________________________________ Plaintiff, Pro - Se ___________________________________

___________________________________

___________________________________

DATE: _______________________

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

, : Plaintiff : : : vs. : CIVIL ACTION NO. : , : Defendant : ______________________________________________________________________________

CRIMINAL RECORD / ABUSE HISTORY VERIFICATION

I, ________________________________, hereby swear or affirm, subject to penalties of

law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:

1. Unless indicated by my checking the box next to a crime below, neither I nor any other

member of my household have been convicted or pled guilty or pled no contest or was

adjudicated delinquent where the record is publicly available pursuant to the Juvenile Act, 42

Pa.C.S. §6307 to any of the following crimes in Pennsylvania or a substantially equivalent crime

in any other jurisdiction, including pending charges:

Check Crime Self Other Date of Sentence all that Household conviction, apply Member guilty plea, no contest plea or pending charges ( ) 18 Pa.C.S. Ch.25 ( ) ( ) ______________ ______

(relating to criminal homicide) ( ) 18 Pa.C.S.§2702 ( ) ( ) ______________ ______

(relating to aggravated assault)

( ) 18 Pa.C.S.§2706 ( ) ( ) ______________ ______ (relating to terroristic

threats) ( ) 18 Pa.C.S.§2709.1 ( ) ( ) ______________ ______

(relating to stalking) ( ) 18 Pa.C.S.§2901 ( ) ( ) ______________ ______

(relating to kidnapping)

( ) 18 Pa.C.S.§2902 ( ) ( ) ______________ ______

(relating to unlawful restraint) ( ) 18 Pa.C.S.§2903 ( ) ( ) ______________ ______

(relating to false imprisonment) ( ) 18 Pa.C.S.§2910 ( ) ( ) ______________ ______

(relating to luring a child into a motor

vehicle or structure) ( ) 18 Pa.C.S.§3121 ( ) ( ) ______________ ______

(relating to rape) ( ) 18 Pa.C.S.§3122.1 ( ) ( ) ______________ ______

(relating to statutory sexual assault) ( ) 18 Pa.C.S.§3123 ( ) ( ) ______________ ______

(relating to involuntary deviate sexual intercourse) ( ) 18 Pa.C.S.§3124.1 ( ) ( ) ______________ ______

(relating to sexual assault) ( ) 18 Pa.C.S.§3125 ( ) ( ) ______________ ______

(relating to aggravated indecent assault) ( ) 18 Pa.C.S.§3126 ( ) ( ) ______________ ______

(relating to indecent assault)

( ) 18 Pa.C.S.§3127 ( ) ( ) ______________ ______ (relating to indecent exposure)

( ) 18 Pa.C.S.§3129 ( ) ( ) ______________ ______

(relating to sexual intercourse with animal)

( ) 18 Pa.C.S.§3130 ( ) ( ) ______________ ______

(relating to conduct relating to sex offenders) ( ) 18 Pa.C.S.§3301 ( ) ( ) ______________ ______

(relating to arson and related offenses)

( ) 18 Pa.C.S.§4302 ( ) ( ) ______________ ______

(relating to incest) ( ) 18 Pa.C.S.§4303 ( ) ( ) ______________ ______

(relating to concealing death of child)

( ) 18 Pa.C.S.§4304 ( ) ( ) ______________ ______

(relating to endangering welfare of children)

( ) 18 Pa.C.S.§4305 ( ) ( ) ______________ ______

(relating to dealing in infant children)

( ) 18 Pa.C.S.§5902(b) ( ) ( ) ______________ ______

(relating to prostitution and related offenses)

( ) 18 Pa.C.S.§5903(c) ( ) ( ) ______________ ______

or (d) (relating to obscene and other sexual materials and performances)

( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______

(relating to corruption of minors)

( ) 18 Pa.C.S.§6312 ( ) ( ) ______________ ______ (relating to sexual abuse of children)

( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______

(relating to unlawful contact with minor)

( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______

(relating to sexual exploitation of children)

( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______

(relating to contempt for violation of protection order or agreement)

( ) Driving under the ( ) ( ) ______________ ______

influence of drugs or alcohol ( ) Manufacturing, sale, ( ) ( ) ______________ ______

Delivery, holding Offering for sale or possession of any controlled substance or other drug or device

2. Unless indicated by my checking the box next to an item below, neither I nor any other member of my household have a history of violent or abusive conduct including the following: Check Self Other Date all that Household apply Member ( ) A finding of abuse by a Children & ( ) ( ) ________ Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction ( ) Abusive conduct as defined under the ( ) ( ) ________ Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction

( ) Other: __________________________ ( ) ( ) ________

3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse: _______________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________.

4. If any conviction above applies to household member, not a party, state that person’s name, date of birth and relationship to the child. ______________________________________ ___________________________________________________________________________________________________________________________________________________________.

5. If you are aware that the other party or members of the other party’s household has or have a criminal/abuse history, please explain: _________________________________________ ___________________________________________________________________________________________________________________________________________________________. I verify that the information above is true and correct to the best of my knowledge, information or belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. ___________________________ Signature ____________________________ Printed Name