1 PRO - SE CUSTODY PACKET
Instructions For Completing The Custody FormsAll Forms Should Be Typed If Possible, Or Neatly Printed In Black Ink .
This packet contains two sets of documents needed to file a Pro - Se Custody Complaint.
The first set of documents has numbered blanks, which need to be filled in with the information
pertaining to your particular case. This is not the set that you will file. It is only to be used as a
guide to fill in the blanks on the second set. The second set has corresponding blanks, but the
blanks are not numbered. This is the set that you want to complete after your participation today
in the Pro - Se Custody Clinic. It is also the set that you want to file.
COMPLAINT FOR CUSTODY
CAPTION
The first part of the Complaint For Custody is called a Caption. The
Caption is a heading, which identifies a legal document. It contains the Court’s name,
the type of action, the names of the parties, and the docket number. This information
remains the same on each legal document filed within the same custody action. The docket
number is assigned by the Court when the Complaint is filed and is used on future documents
filed in the same case.
(1) Plaintiff’s Name. The Plaintiff is the person initiating the custody action.
Fill in your full, legal name.
(2) Defendant’s Name. The Defendant is the person whom the custody action is
being brought against. Fill in that person’s full, legal name.
COMPLAINT
(3) Fill in your full, legal name.
Paragraph 1, (4) Fill in your full, legal name.
Paragraph 1, (5) Fill in your full mailing address (Name or Number of the Street or
Avenue, P. O. Box Number, City, County (e.g., Mercer County),
State, and Zip Code.
Paragraph 2, (6) Fill in the Defendant’s full, legal name.
Paragraph 2, (7) Fill in the Defendant’s full mailing address (Name or Number of
the Street or Avenue, P. O. Box Number, City, County
(e.g., Mercer County), State, and Zip Code.
Paragraph 3 (8) Circle the type of custody you want the court to award you. If you
are unsure what the different types of custody are, please see the
“DEFINITIONS” page attached to these instructions.
Also, list the full, legal name(s), present residence(s), and date(s)
of birth of the child(ren) involved in this case.
Paragraph 4 Circle the words, which correctly state whether the child or
children were born out of wedlock.
Paragraph 5 (9) and (10) Fill in the full, legal name(s) and address of the person(s) with
whom the child or children now live with.
Paragraph 6 List all the persons with whom the child(ren)
(has/have) resided with during the past five years.
List all the addresses where the child(ren) (has/have) resided at
during the past five years. Also, list the dates.
Paragraph 7 (11) and (12)
Fill in the full, legal name and address of the natural
mother of the child(ren). Also, circle the marital status that
applies to the mother.
Paragraph 8 (13) and (14)
Fill in the full, legal name and address of the natural father of the
child(ren). Also, circle the marital status that applies to the father.
Paragraph 9 (15) State your relationship to the child(ren)
(e.g., Mother, Father, Grandmother, etc.).
Paragraph 10 List everyone who now lives with you and your relationship to
each of these people.
Paragraph 11 (16) State the Defendant’s relationship to the child(ren)
(e.g., Mother, Father, Grandmother, etc.)
Paragraph 12 List everyone who now lives with the Defendant and his or her
relationship with each of these people.
Paragraph 13 Circle whichever phrase applies.
Paragraph 14 Circle whichever phrase applies.
Paragraph 15 Circle whichever phrase applies.
Paragraph 16 (17) Fill in the full, legal name(s) of the child(ren).
Paragraph 16 (18) State the reasons you believe Shared Legal Custody, Sole Legal
Custody, Partial Physical Custody, Primary Physical Custody,
Shared Physical Custody, Sole Physical Custody, Supervised
Physical Custody should be awarded to you.
Paragraph 17 List any other person that you believe has a right to be a part of the
hearing concerning custody because they have standing. These
individuals must also be served with a copy of the Complaint.
Paragraph 18, (19) If you are a grandparent who is not in loco parentis to the child,
you must state facts that establish that your relationship with the
child began with the consent of a parent of the child or under court
order, that you are willing to assume responsibility for the child,
AND one of the following conditions exists: the child has been
determined to be dependent child, the child is substantially at risk
due to parental abuse, neglect, drug or alcohol abuse or incapacity,
OR the child has resided with you for 12 consecutive months (not
including brief temporary absences of the child from the home, and
is removed from the home by the parents).
Paragraph 18, (20) Complete this section if you are a grandparent seeking standing for
partial physical custody or supervised physical custody. You must
state facts that establish that EITHER (1) the parent of the child is
deceased and you are the parent of the deceased parent, (2) the
parents of the child have been separated for at least 6 months or
have started a proceeding that will dissolve their marriage, OR (3)
the child has resided with you for 12 consecutive months (not
including brief temporary absences of the child from the home, and
is removed from the home by the parents.)
Paragraph 18, (21) Complete this section if you are filing for custody because you
have acted as the child’s guardian or caretaker and have taken on
some or all of the responsibilities of a parent.
Paragraph 19 You must fill out and attached the “CRIMINAL
RECORD/ABUSE VERIFICATION” form. You must be truthful
on these forms or you could face criminal punishment.
Wherefore: Fill in which of the following that you are requesting the Court to
grant you.
(22) Sign your full, legal name
CRIMINAL RECORD / ABUSE HISTORY
You must complete and file this form with the Custody Complaint. There are two copies of this
form in this packet. You must complete one and file it with your complaint. You must include
the other blank form with the complaint when you serve the opposing party. This form may be
used by the Master and the Court during your custody proceedings.
1. Plaintiff’s name.
2. Defendant’s name
3. Your name
4. This section states that by checking any of the boxes next to a crime, you are telling the court
that either you or a household member has been convicted of, pled guilty to, or pled no contest to
that crime. 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
http://ujsportal.pacourts.us/DocketSheets/MDJ.aspx which provides access to search, view
and print the docket sheets for Pennsylvania’s courts. On this website, you should check both the
Magisterial Court Docket Sheets and the Court of Common Pleas Docket Sheet.
5. Check all that apply to either you or a household member.
6. Check all that apply to either you or a household member.
7. Again, you must be truthful! If you are not, you could face a fine of at least $1,000.
8. Sign and print your name.
VERIFICATION1. Plaintiff’s Name
2. Defendant’s Name
3. Plaintiff’s Name
4. Plaintiff’s SignatureORDER AND NOTICE
1. Plaintiff’s Name
2. Defendant’s Name
3. Defendant’s Name
4. Name(s) of the child/children
5. This paragraph informs the defendant that he/she must complete and file with the Court a “Criminal Record / Abuse History” form.
6. This paragraph 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.
ORDER APPOINTING MASTER
1. Plaintiff’s Name
2. Defendant’s Name
CERTIFICATE OF SERVICE 1. Plaintiff’s Name
2. Defendant’s Name
3. Plaintiff’s Name
4. Defendant’s Name and Address. If the current address is unknown, use the
last known address.
5. Plaintiff’s Signature
6. Plaintiff’s Address
CRIMINAL RECORD / ABUSE HISTORY
This blank copy should be sent to the defendant to fill out and file with the Court. Include
this blank copy when you serve the Complaint on the defendant.
IN FORMA PAUPERIS
Enclosed is a separate package called an IFP, which stands for In Forma Pauperis. This
is a Latin phrase, which means you do not have enough money to pay the court costs to file the
Complaint For Custody. This document must be filled out and filed at the same time the
Complaint is filed.
FILING AND SERVICE
FILING: The completed Complaint and IFP has to be filed with the Prothonotary’s
Office, located on the first floor of the Court Of Common Pleas Of Mercer County, PA.
Remember to make three copies of the Complaint and one copy of the IFP before filing these
documents. The Office will take your Complaint and give it a docket number which will
identify your case.
SERVICE: A copy of the Complaint must be served on the opposing party. You must
also include the Criminal Record / Abuse History form with the Complaint. The Complaint
should be served by certified mail, return receipt requested and regular mail. You should do this
immediately after filing the Complaint.
MASTER S CONFERENCE
After the Complaint has been filed and served, the Order Appointing Master will be
signed by one of the judges of the Court Of Common Pleas Of Mercer County, PA. A Master is
an attorney who has been appointed by the Court to hear your case. You and the opposing party
will receive a copy of this Order in the mail. Subsequently, both parties will receive a hearing
notice regarding the date and time for the Master’s Conference.DEFINITIONS
PLAINTIFF - the person who starts the lawsuit
DEFENDANT- the person who is being sued
CHILD - Any unemancipated person under 18 years of age.
SHARED LEGAL CUSTODY – The right of more than one individual to legal custody of the child.
SOLE LEGAL CUSTODY – The right of one individual to exclusive legal custody of the child.
PARTIAL PHYSICAL CUSTODY – The right to assume physical custody of the child for less than a majority of the time.
PRIMARY PHYSICAL CUSTODY – The right to assume physical custody of the child for themajority of time.
SHARED PHYSICAL CUSTODY – The right of more than one individual to assume physical custody of the child, each having significant periods of physical custodial time with the child.
SOLE PHYSICAL CUSTODY – The right of one individual to exclusive physical custody of the child.
SUPERVISED VISITATION- Custodial time during which an agency or an adult designated by the court or agreed upon by the parties monitors the interaction between the child and the individual with those rights.
NON-CUSTODIAL PARENT- the parent who has custodial rights, but with whom the child does not live with most of the time.
THIRD PARTY- any person who is not a natural parent of the child
IN LOCO PARENTIS – a person who has acted as a parent for a child and taken on responsibilities of parenthood for a period of time.
STANDING - the legal right to be a part of a custody lawsuit
BEST INTEREST OF THE CHILD - the factors which the Court looks at in deciding with whom and where the child should reside.
SAMPLE FORMS TO FOLLOW:
1 IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL ACTION - LAW
(1) , :Plaintiff :
::
vs. : CIVIL ACTION NO.:
(2) , :Defendant :
______________________________________________________________________________
COMPLAINT FOR CUSTODY
AND NOW, comes the Plaintiff, (3) ____________________________, pro-se, and
respectfully represents as follows:
1. The Plaintiff is (4) ________________________________, residing at
(5)___________________________________________________________________________.
2. The Defendant is (6) _________________________________, residing at
(7) _________________________________________________________________________.
3. The Plaintiff seeks (8) (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):
Name Present Residence Date of Birth
______________________ _____________________ _______________
______________________ _____________________ _______________
______________________ _____________________ _______________
______________________ _____________________ _______________
4. The child(ren)(was/was not) (were/were not) born out of wedlock.
5. The child(ren)(is/are) presently in the custody of (9) _______________________
who resides at (10) _____________________________________________________________ .
6. During the past five years, the child(ren) (has/have) resided with the following
persons and at the following addresses:
Persons Addresses Dates
________________________ ______________________ ___________________
________________________ ______________________ ___________________
________________________ ______________________ ___________________
________________________ ______________________ ___________________
________________________ ______________________ ___________________
7. The mother of the child(ren) is (11) ___________________________, currently
residing at (12) ______________________________________. She is (married) (divorced)
(single).
8. The father of the child(ren) is (13) ____________________, currently residing
at (14) _________________________________________. He is (married) (divorced) (single).
9. The relationship of the Plaintiff to the child (ren) is that of (15) ______________.
10. The Plaintiff currently resides with the following persons:
Name Relationship
_______________________________ ____________________________
_______________________________ ____________________________
_______________________________ ____________________________
11. The relationship of the Defendant to the child(ren) is that of
(16) __________________________________.
12. The Defendant currently resides with the following persons:
Name Relationship
_______________________________ ___________________________
_______________________________ ___________________________
_______________________________ ___________________________
13. The Plaintiff (has) (has not) participated as a party or witness, or in another capacity, in
other litigation concerning the custody of the child(ren) in this or another court. The court, term
and number, and its relationship to this action is:
______________________________________________________________________________
_______________________________________________________________.
14. The Plaintiff (has) (has no) information of a custody proceeding concerning the
child(ren) pending in a court of this Commonwealth. The court, term and number, and its
relationship to this action is: ______________________________________________________
_______________________________________________________________.
15. The Plaintiff (knows) (does not know) of a person not a party to the proceedings
who has physical custody of the child(ren) or claims to have custodial rights with respect to the
child (ren). The name and address of such person is: ___________________________________
_____________________________________________________________ .
16. The best interest and permanent welfare of the child(ren) (17) ______________
will be served by granting the relief requested because (18) _____________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________ .
17. Each parent whose parental rights to the child(ren) have not been terminated and
the person who has physical custody of the child(ren) have been named as parties to this action.
All other persons, named below, who are known to have or claim a right to custody of the child
will be given notice of the pendency of this action and the right to intervene:
Name Address Basis of Claim
______________________________________________________________________________
______________________________________________________________________________
18. (a) If the plaintiff is a grandparent who is not in loco parentis to the child and is
seeking physical and/or legal custody pursuant to 23 Pa.C.S. §5323, you must plead facts
establishing standing pursuant to 23 Pa.C.S §5324(3).(19)_______________________________
______________________________________________________________________________
_____________________________________________________________________________.
(b) If the plaintiff is a grandparent or great-grandparent who is seeking partial
physical custody or supervised physical custody pursuant to 23 Pa.C.S. §5325, you must plead
facts establishing standing pursuant to 23 Pa.C.S. §5325. (20)____________________________
______________________________________________________________________________
_____________________________________________________________________________.
(c) If the plaintiff is a person seeking physical and/or legal custody pursuant to
23 Pa.C.S. §5324(2) as a person who stands in loco parentis to the child, you must plead facts
establishing standing. (21)______________________________________________________
____________________________________________________________________________
____________________________________________________________________________.
19. I have attached the Criminal Record/Abuse History Verification form required
pursuant to Pa.R.C.P. No. 1915.3-2.
Wherefore, the Plaintiff respectfully requests this Court to grant him/her (Shared Legal
Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary Physical Custody) (Shared
Physical Custody) (Sole Physical Custody) (Supervised Physical Custody) of the child(ren).
Respectfully submitted:
(22)______________________________________________Plaintiff, Pro – Se
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL ACTION - LAW
(1) , :Plaintiff :
::
vs. : CIVIL ACTION NO.:
(2) , :Defendant :
______________________________________________________________________________
CRIMINAL RECORD / ABUSE HISTORY VERIFICATION
I, (3) ________________________________, hereby swear or affirm, subject to
penalties of law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:
1. (4) 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: (5)
Check Crime Self Other Date of Sentenceall that Household conviction,apply Member guilty plea, no
contest plea orpending 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 motorvehicle 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 sexualintercourse 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 andother sexual materialsand performances)
( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______(relating to corruptionof minors)
( ) 18 Pa.C.S.§6312 ( ) ( ) ______________ ______
(relating to sexualabuse of children)
( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______(relating to unlawfulcontact with minor)
( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______(relating to sexualexploitation of children)
( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______(relating to contemptfor violation ofprotection order oragreement)
( ) Driving under the ( ) ( ) ______________ ______influence of drugsor alcohol
( ) Manufacturing, sale, ( ) ( ) ______________ ______Delivery, holdingOffering 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: (6)
Check Self Other Dateall that Householdapply 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 Pennsylvaniaor 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: ____________________________________________________________________________________________________________________________________________________________________________________________________.
(7) 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, PENNSYLVANIACIVIL ACTION - LAW
_____________________________________________________________________________
(1) _____________________________________, :Plaintiff :
::
VS. : CIVIL ACTION NO.::
(2) _____________________________________, :Defendant
______________________________________________________________________________
VERIFICATION
I, (3) _______________________________, do hereby state, subject to the penalties of
18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities, that the facts set forth in
the forgoing Complaint For Custody are true and correct to the best of my knowledge,
information, and belief.
______________________________ (4) __________________________________DATE PLAINTIFF, PRO - SE
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL ACTION - LAW
______________________________________________________________________________
(1) ________________________________, :Plaintiff :
:vs. : CIVIL ACTION NO.
:(2) _______________________________, :
Defendant :
ORDER AND NOTICE
TO: (3) __________________________________
A complaint has been filed in the Court of Common Pleas of Mercer County concerning
(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/children: (4)___________________________________________________
___________________________________________________________________________.
The Court has learned you may have a legal interest in custody of the child/children
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, you may file a counterclaim.
If you fail to appear as provided by this Order, 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.
(5) 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 1302HERMITAGE, PA 16148
Telephone: (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 with 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.
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL ACTION - LAW
______________________________________________________________________________
(1) _____________________________________, :Plaintiff :
:vs. : CIVIL ACTION NO.
:(2) ____________________________________, :
Defendant :______________________________________________________________________________
ORDER APPOINTING MASTERIN ALL DOMESTIC RELATIONS ACTIONS EXCEPT PROTECTION FROM ABUSE
AND NOW, on this day of , 20____, ,
Esquire, 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.
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL ACTION - LAW
(1) _____________________________________, :Plaintiff :
:vs. : CIVIL ACTION NO.
:(2) _____________________________________, :
Defendant :
CERTIFICATE OF SERVICE
I, (3) ___________________________, 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:
(4) ____________________________________________
____________________________________________
____________________________________________
Respectfully submitted:
By: (5) ___________________________________Plaintiff, Pro - Se
(6) ___________________________________
___________________________________
___________________________________
DATE: _______________________
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL ACTION - LAW
, :
Plaintiff :::
vs. : CIVIL ACTION NO.:
, :Defendant :
______________________________________________________________________________CRIMINAL RECORD / ABUSE HISTORY VERIFICATION
(1) I, ________________________________, hereby swear or affirm, subject to
penalties of law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:
6. 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 Sentenceall that Household conviction,apply Member guilty plea, no
contest plea orpending 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 motorvehicle 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 sexualintercourse 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 andother sexual materialsand performances)
( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______(relating to corruptionof minors)
( ) 18 Pa.C.S.§6312 ( ) ( ) ______________ ______(relating to sexualabuse of children)
( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______(relating to unlawfulcontact with minor)
( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______(relating to sexualexploitation of children)
( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______(relating to contemptfor violation ofprotection order oragreement)
( ) Driving under the ( ) ( ) ______________ ______influence of drugsor alcohol
( ) Manufacturing, sale, ( ) ( ) ______________ ______Delivery, holdingOffering for sale or possession of any controlled substance or other drug or device
7. 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 Dateall that Householdapply 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 Pennsylvaniaor similar statute in another jurisdiction
( ) Other: __________________________ ( ) ( ) ________
8. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse: _____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________.
9. If any conviction above applies to household member, not a party, state that person’s name, date of birth and relationship to the child. _________________________________________________________________________________________________________________________________________________________________________________________________.
10. 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.
___________________________Defendant Signature
____________________________Printed Name
BLANK FORMS TO FOLLOW
1 IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL ACTION - LAW
, :Plaintiff :
::
vs. : CIVIL ACTION NO.:
, :Defendant :
______________________________________________________________________________
COMPLAINT FOR CUSTODY
AND NOW, comes the Plaintiff, ____________________________, pro-se, and
respectfully represents as follows:
1. The Plaintiff is ________________________________, residing at
___________________________________________________________________________.
2. The Defendant is _________________________________, residing at
_____________________________________________________________________.
3. The Plaintiff seeks (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):
Name Present Residence Date of Birth
____________________ _____________________ _______________
____________________ _____________________ _______________
____________________ _____________________ _______________
____________________ _____________________ _______________
4. The child(ren) (was/was not) (were/were not) born out of wedlock.
5. The child(ren)(is/are) presently in the custody of _________________________
who resides at ________________________________________________________________ .
6. During the past five years, the child(ren) (has/have) resided with the following
persons and at the following addresses:
Persons Addresses Dates
________________________ ______________________ ___________________
________________________ ______________________ ___________________
________________________ ______________________ ___________________
________________________ ______________________ ___________________
________________________ ______________________ ___________________
7. The mother of the child(ren) is ________________________, currently residing
at _________________________________________. She is (married) (divorced) (single).
8. The father of the child(ren) is _____________________, currently residing
at _________________________________________. He is (married) (divorced) (single).
9. The relationship of the Plaintiff to the child (ren) is that of __________________.
10. The Plaintiff currently resides with the following persons:
Name Relationship
_______________________________ ____________________________
_______________________________ ____________________________
_______________________________ ____________________________
11. The relationship of the Defendant to the child(ren) is that of
____________________.
12. The Defendant currently resides with the following persons:
Name Relationship
_________________________________ ________________________
_________________________________ ________________________
_________________________________ ________________________
13. The Plaintiff (has) (has not) participated as a party or witness, or in another capacity, in
other litigation concerning the custody of the child(ren) in this or another court. The court, term
and number, and its relationship to this action is: ______________________________________
_______________________________________________________________.
14. The Plaintiff (has) (has no) information of a custody proceeding concerning the
child(ren) pending in a court of this Commonwealth. The court, term and number, and its
relationship to this action is: ______________________________________________________
_______________________________________________________________.
15. The Plaintiff (knows) (does not know) of a person not a party to the proceedings
who has physical custody of the child(ren) or claims to have custodial rights with respect to the
child(ren). The name and address of such person is: ___________________________________
_____________________________________________________________ .
16. The best interest and permanent welfare of the child(ren) ___________________
_________________________________ will be served by granting the relief requested because
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________.
17. Each parent whose parental rights to the child(ren) have not been terminated and
the person who has physical custody of the child(ren) have been named as parties to this action.
All other persons, named below, who are known to have or claim a right to custody of the child
will be given notice of the pendency of this action and the right to intervene:
Name Address Basis of Claim
______________________________________________________________________________
______________________________________________________________________________
18. (a) If the plaintiff is a grandparent who is not in loco parentis to the child and is
seeking physical and/or legal custody pursuant to 23 Pa.C.S. §5323, you must plead facts
establishing standing pursuant to 23 Pa.C.S §5324(3). __________________________________
______________________________________________________________________________
_____________________________________________________________________________.
(b) If the plaintiff is a grandparent or great-grandparent who is seeking partial
physical custody or supervised physical custody pursuant to 23 Pa.C.S. §5325, you must plead
facts establishing standing pursuant to 23 Pa.C.S. §5325. ________________________________
______________________________________________________________________________
_____________________________________________________________________________.
(c) If the plaintiff is a person seeking physical and/or legal custody pursuant to
23 Pa.C.S. §5324(2) as a person who stands in loco parentis to the child, you must plead facts
establishing standing.___________________________________________________________
____________________________________________________________________________
____________________________________________________________________________.
19. I have attached the Criminal Record/Abuse History Verification form required
pursuant to Pa.R.C.P. No. 1915.3-2.
Wherefore, the Plaintiff respectfully requests this Court to grant him/her (Shared Legal
Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary Physical Custody) (Shared
Physical Custody) (Sole Physical Custody) (Supervised Physical Custody) of the child(ren).
Respectfully submitted:
______________________________________________Plaintiff, Pro - Se
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL 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:
11. 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 Sentenceall that Household conviction,apply Member guilty plea, no
contest plea orpending 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 motorvehicle 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 sexualintercourse 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 andother sexual materialsand performances)
( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______(relating to corruptionof minors)
( ) 18 Pa.C.S.§6312 ( ) ( ) ______________ ______
(relating to sexualabuse of children)
( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______(relating to unlawfulcontact with minor)
( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______(relating to sexualexploitation of children)
( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______(relating to contemptfor violation ofprotection order oragreement)
( ) Driving under the ( ) ( ) ______________ ______influence of drugsor alcohol
( ) Manufacturing, sale, ( ) ( ) ______________ ______delivery, holdingoffering for sale or possession of any controlled substance or other drug or device
12. 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 Dateall that Householdapply 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 Pennsylvaniaor similar statute in another jurisdiction
( ) Other: __________________________ ( ) ( ) ________
13. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse: __________________________________________________________________________________________________________________________________________________________________________________________________________________________.
14. If any conviction above applies to household member, not a party, state that person’s name, date of birth and relationship to the child. _________________________________________________________________________________________________________________________________________________________________________________________________.
15. 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, PENNSYLVANIACIVIL ACTION - LAW
_____________________________________________________________________________
_______________________________________, :Plaintiff :
::
vs. : CIVIL ACTION NO.::
_______________________________________, :Defendant
______________________________________________________________________________
VERIFICATION
I, _______________________________, do hereby state, subject to the penalties of 18
Pa. C. S. Section 4904 relating to unsworn falsification to authorities, that the facts set forth in
the forgoing Complaint For Custody are true and correct to the best of my knowledge,
information, and belief.
____________________________ ____________________________________DATE PLAINTIFF, PRO - SE
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL ACTION - LAW
__________________________________, :Plaintiff :
:vs. : CIVIL ACTION NO.
:__________________________________, :
Defendant :
ORDER AND NOTICE
TO: __________________________________
A complaint has been filed in the Court of Common Pleas of Mercer County concerning
(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/children: ___________________________________________________
___________________________________________________________________________.
The Court has learned you may have a legal interest in custody of the child/children
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 a right of custody, you may file a counterclaim.
If you fail to appear as provided by this Order, 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 1302HERMITAGE, PA 16148
Telephone: (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 with 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, PENNSYLVANIACIVIL ACTION - LAW
, :Plaintiff :
::
vs. : CIVIL ACTION NO.:
, :Defendant :
______________________________________________________________________________
ORDER APPOINTING MASTERIN 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.
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.
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIACIVIL 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, PENNSYLVANIACIVIL 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 Sentenceall that Household conviction,apply Member guilty plea, no
contest plea orpending 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 motorvehicle 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 sexualintercourse 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 andother sexual materialsand performances)
( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______(relating to corruptionof minors)
( ) 18 Pa.C.S.§6312 ( ) ( ) ______________ ______
(relating to sexualabuse of children)
( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______(relating to unlawfulcontact with minor)
( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______(relating to sexualexploitation of children)
( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______(relating to contemptfor violation ofprotection order oragreement)
( ) Driving under the ( ) ( ) ______________ ______influence of drugsor alcohol
( ) Manufacturing, sale, ( ) ( ) ______________ ______Delivery, holdingOffering 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 Dateall that Householdapply 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 Pennsylvaniaor 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.
___________________________Defendant Signature
____________________________Printed Name
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