PRO SE CUSTODY PACKET, Exams of History

Download PRO SE CUSTODY PACKET and more Exams History in PDF only on Docsity! BRADFORD COUNTY, PENNSYLVANIA PRO SE CUSTODY PACKET THIS IS NOT LEGAL ADVICE! THE COURT CAN NOT GIVE YOU LEGAL ADVICE. YOU SHOULD OBTAIN THE SERVICES OF A LAWYER FOR LEGAL ADVICE. THIS IS ONLY TO ASSIST YOU IN FILING THE INITIAL COMPLAINT. INSTRUCTIONS FOR PRO SE CUSTODY ACTIONS IN BRADFORD COUNTY, PENNSYLVANIA 1. Read and fill out all forms COMPLETELY! 1A - You are the PLAINTIFF (the person bringing the action). 1B - The DEFENDANT is the person you are bringing the action against, usually the other parent. 2. If you do not think you can pay the filing fee, you can ask the Court to waive the costs. The form you need to fill out is the Petition for In Forma Pauperis, included in this packet. The Court will review your petition and decide whether or not you will have to pay the costs of filing the action. 3. Take all completed forms, plus two (2) copies of each form, AND a large self-addressed stamped envelope to the Prothonotary’s Office, located on the second floor of the Bradford County Court House, 301 Main Street, Towanda, Pennsylvania. Be certain that your self-addressed stamped envelope is large enough and contains sufficient postage to mail two (2) copies of the forms to you. 4. Once the forms are reviewed and dates are scheduled by Court officials, they will be returned to the Prothonotary. Two (2) copies with the scheduled dates will be returned to you in the self-addressed stamped envelope that you provided. If you do not receive two (2) copies within two (2) weeks of filing, it is YOUR responsibility to contact the Prothonotary’s Office and/or the Court to determine the status of your forms. 5. The Plaintiff MUST file and serve with the Complaint the attached Criminal Record/Abuse History Verification regarding any criminal or abuse history of the Plaintiff and anyone living in the Plaintiff’s household. You MUST ALSO attach a blank Criminal Record/Abuse History Verification form to the Complaint served upon the Defendant. NOTE: There are two copies of the Criminal Record/Abuse History Verification form attached to the packet. Please fill out one copy with regard to yourself and anyone in your household. Leave the other copy blank. File your completed Criminal Record/Abuse History Verification with your Complaint in the Prothonotary’s Office. The blank form must be served upon the Defendant. 6. YOU ARE RESPONSIBLE for Service of the Complaint, Notice, Order, your filed Criminal Record/Abuse History Verification, a blank Criminal Record/Abuse History Verification, and the Education Program for Separated Parents (EPSP) brochure upon the opposing party. KEY CUSTODY DEFINITIONS PLAINTIFF – The person bringing the custody action. DEFENDANT – The person you are bringing the action against (usually the other parent). LEGAL CUSTODY – The legal right to make major decisions affecting the best interests of the minor on behalf of the child, including, but not limited to, medical, religious, and educational decisions. PHYSICAL CUSTODY – The actual physical possession and control of a child. SOLE PHYSICAL CUSTODY – The right of one individual to exclusive physical custody of the child. 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. PRIMARY PHYSICAL CUSTODY – The right to assume physical custody of the child for the majority of the time. PARTIAL PHYSICAL CUSTODY – The right to assume physical custody of the child for less than a majority of the time. SUPERVISED PHYSICAL CUSTODY - 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. BRADFORD COUNTY COURT OF COMMON PLEAS DIVORCE/CUSTODY COVER SHEET This form must be filled out if you are filing a divorce or custody action in the Prothonotary’s Office and must be given to Court Administration. PLEASE PRINT LEGIBLY. DO NOT FILE IN THE PROTHONOTARY’S OFFICE DOB. : Date Filed: DOB. DOB. : Docket No. Plaintiffs vs. DOB. DOB. DOB. ‘Defendants PLEASE CHECK ONE: DIVORCE FILING — NO CHILDREN DIVORCE FILING — CHILDREN UNDER 18/BUT NO CUSTODY COUNT DIVORCE FILING — CUSTODY COUNT CUSTODY COMPLAINT/MODIFICATION FILED BY: IMPORTANT: This form is not to be filed in the Prothonotary’s Office, but should be taken directly to Court Administration for statistical and case management purposes immediately upon the filing of a new case or new petition/complaint (custody or divorce) in a family court case (It is not needed when filing petitions for special relief). (Revised 6/20/11)  _______________________________ : IN THE COURT OF COMMON PLEAS : VS. : BRADFORD COUNTY, PENNSYLVANIA _________________________________ : NO. ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::: ORDER OF COURT You, _________________, have been sued in court to (OBTAIN)(MODIFY) (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):____________________________________________________________________________ ________________________________________________________________________. You are ordered to appear in person at the Bradford County Courthouse, Towanda Pennsylvania on _____________________________, 20____, at ____ ___.M. in ___________________, for a preliminary custody conference. 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 or anyone living in your household on or before the initial in-person contact with the court (Including, but not limited to, a conference with the conference officer or judge) but not later than 30 days after 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 are further ordered to attend the Education Program for Separated Parents: □ The parties are directed to pre-register with the Court Administrator and attend the Education Program for Separated Parents on one of the two dates listed below: 2 _____________________ __________________________________ _________________ 6. The child(ren) (was/were) (wasn’t/weren’t) born out of wedlock. 7. The child(ren) (is/are) presently in the custody of ________________________________ who resides at _________________________________________________________________. 8. During the past five years, the child(ren) has/have resided with the following persons at the following addresses: (List All Persons) (List All Addresses) (Dates) ______________________ _______________________________________ ___________ ______________________ _______________________________________ ___________ ______________________ _______________________________________ ___________ ______________________ _______________________________________ ___________ ______________________ _______________________________________ ___________ 9. The mother of the child(ren) is ______________________________________________, currently residing at ____________________________________________________________. 10. She is (married)/(divorced)/(single). 11. The father of the child(ren) is _______________________________________________, currently residing at ____________________________________________________________. 12. He is (married)/(divorced)/(single). 13. The Plaintiff currently resides with the following persons: Name: Relationship: __________________________________________________ _______________________ __________________________________________________ _______________________ 3 __________________________________________________ _______________________ 14. The Defendant currently resides with the following persons: Name: Relationship: __________________________________________________ _______________________ __________________________________________________ _______________________ __________________________________________________ _______________________ 15. Plaintiff (has) (has not) participated as a party of 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: ____________________________________________________________________________. 16. 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: __________________________________________________________________. 17. 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(s) is/are: Name: Address: ______________________ __________________________________________________ ______________________ __________________________________________________ 18. □ Plaintiff has been advised of the requirement to attend the seminar titled Education Program for Separated Parents. □ The parties have previously attended the Education Program for Separated 4 Parents as evidenced by certificates of attendance (attached hereto) (contained in the official court file case number____________________________). 19. The best interest and permanent welfare of the child(ren) will be served by granting the relief requested because: (set forth facts showing that the granting of the requested relief will be in the best interest and permanent welfare of the child(ren) below): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. 20. 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 to have a right to custody of the child(ren) will be given notice of the pendency of this action and the right to intervene: Name: Address: Basis of Claim: ______________________ __________________________________ _________________ ______________________ __________________________________ _________________ ______________________ __________________________________ _________________ 21. (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). ________________________________________________________________________ : BRADFORD COUNTY, ____________________________________, : PENNSYLVANIA Plaintiff : : : vs. : NO.________________________ : ____________________________________, : Defendant. : PROOF OF SERVICE I, ______________________________________________, certify that on (your name) ______________________________, I mailed a true and correct copy of the Notice, Order, and (date mailed) Complaint for Custody by certified mail, return receipt requested, to: _______________________________________________________, at the following address: (other party’s name) ____________________________________________________________________________. (other party’s address) □ Defendant received the certified mail on ___________________________. (date received) Sender’s receipt and return receipt are attached. □ Defendant refused the certified mail. Sender’s receipt and refusal are attached. I verify that the foregoing is true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. _____________________________ ___________________________________ Date Signature : IN THE COURT OF COMMON PLEAS : BRADFORD COUNTY, ____________________________________, : PENNSYLVANIA Plaintiff : : : vs. : NO.________________________ : : ____________________________________, : Defendant. : PETITION FOR IN FORMA PAUPERIS 1. I am the (Plaintiff)(Defendant) in the above matter and because of my financial condition am unable to pay the fees and costs of prosecuting or defending the action or proceeding. 2. I am unable to obtain funds from anyone, including my family and associates, to pay the costs of litigation 3. I represent that the information below relating to my ability to pay the fees and costs is true and correct: a. NAME:_________________________________________________________ ADDRESS:______________________________________________________ ________________________________________________________________ SOCIAL SECURITY:______________________________________________ b. EMPLOYMENT: If you are presently employed, state: EMPLOYER:_____________________________________________________ ADDRESS:_______________________________________________________ SALARY OR WAGES PER MONTH:_________________________________ TYPE OF WORK:_________________________________________________ If you are presently unemployed, state: DATE OF LAST EMPLOYMENT:___________________________________ SALARY OR WAGES PER MONTH:_________________________________ TYPE OF WORK:_________________________________________________ c. OTHER INCOME WITHIN THE PAST TWELVE MONTHS: BUSINESS OR PROFESSION: $_____________________________________ OTHER SELF-EMPLOYMENT: $____________________________________ INTEREST: $_____________________________________________________ DIVIDENDS: $___________________________________________________ PENSION OR ANNUITIES: $_______________________________________ SOCIAL SECURITY BENEFITS: $___________________________________ SUPPORT PAYMENTS: $__________________________________________ DISABILITY PAYMENTS: $________________________________________ UNEMPLOYMENT COMPENSATION: $_____________________________ WORKER=S COMPENSATION: $___________________________________ PUBLIC ASSISTANCE: $__________________________________________ OTHER: $_______________________________________________________ d. OTHER CONTRIBUTIONS TO HOUSEHOLD SUPPORT: HUSBAND/WIFE - NAME:________________________________________ If your husband/wife is employed, state: EMPLOYER:____________________________________________________ SALARY OR WAGES PER MONTH: $_______________________________ Describe:___________________________________________________ g. PERSONS DEPENDANT UPON YOU FOR SUPPORT: CHILDREN, IF ANY: NAME:__________________________DATE OF BIRTH:_______________ NAME:__________________________DATE OF BIRTH:_______________ NAME:__________________________DATE OF BIRTH:_______________ NAME:__________________________DATE OF BIRTH:_______________ NAME:__________________________DATE OF BIRTH:_______________ OTHER PERSONS: NAME:_________________________________________________________ RELATIONSHIP:_________________________________________________ NAME:_________________________________________________________ RELATIONSHIP:_________________________________________________ NAME:_________________________________________________________ RELATIONSHIP:_________________________________________________ 4. I understand that I have a continuing obligation to inform the Court of improvement in my financial circumstances which would permit me to pay the costs incurred herein. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. ________________________ ___________________________________ DATE SIGNATURE : IN THE COURT OF COMMON PLEAS : BRADFORD COUNTY, ____________________________________, : PENNSYLVANIA Plaintiff : : : vs. : NO.________________________ : : ____________________________________, : Defendant. : ORDER NOW, this ___________________ day of ___________________________,_________, upon consideration of the foregoing Petition and Affidavit, IT IS ORDERED AND DIRECTED that ___________________________________________________ be permitted to proceed in this action In Forma Pauperis pursuant to Pa. R.C.P. 240(f). BY THE COURT: ________________________________________J. IN THE COURT OF COMMON PLEAS PLAINTIFF COUNTY, PENNSYLVANIA VS. NO. DEFENDANT ENTRY OF APPEARANCE AS A SELF-REPRESENTED PARTY 1am the CF] Plaintiff [] Defendant in the above-captioned case. lintend to represent myself in the [] custody, 1] divorce, (] support, C1] protection from abuse, C] paternity case. Check only one box in Question 3 oO This is a new case and! am representing myself. | have decided not to hire an attorney to represent me. ol oO This is not a new case and | am representing myself. | have decided not to hire an attorney to represent me. ol oO This is not a new case. previously (Name of Attorney) represented me in this case. | have decided not to be represented by that attorney and direct the Prothonotary to remove that attorney as my counsel of record in this case. | have provided a copy of this form to that attorney listed above at the following address: That attorney has acknowledged his/her withdrawal from this case by Signing this form. . Esq. (Attorney signature) oO lam entering my appearance as a self-represented party (Your Signature) | understand that | need to provide a street address or P.O. Box for the purpose of receiving all future pleadings and other legal notices. | further understand that this does not need to be my home address. My address for the purpose of receiving all future pleadings and other legal notices is: | understand that this address will be the only address to which notices and pleadings in this case will be sent and that | am responsible to check the mail at this address so | do not miss important deadlines or proceedings. C tam not providing my address because | reside at a confidential location protected by the Protection From Abuse Act, 23 Pa. C.S. § 6112 and/or the Address Confidentiality Program, 23 Pa. C.S. § 6701-6713, and/or the Child Custody Act, 23 Pa. C.S. § 5336(b). My telephone number where | can be reached is C | am not providing my telephone number because it is confidential pursuant to the Protection From Abuse Act, 23 Pa. C.S. § 6112 and/or the Child Custody Act, 23 Pa. C.S. § 5336(c). | UNDERSTAND | MUST FILE A NEW FORM EVERY TIME MY ADDRESS OR TELEPHONE NUMBER CHANGES. | understand that | must ensure that a copy of this form is served on all other attorneys or other self-represented Parties at the following addresses as listed below: (Use reverse side if you need more space) Name. Address. Name. Address. | verify that the statements made in this Entry of Appearance as a Self-Represented Party are true and correct. | understand that if | make false statements herein, that | am subject to the criminal penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities that could result in a fine and/or prison term. Date (Your Signature)  18 Pa.C.S. §2709.1 (relating to stalking): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §2901 (relating to kidnapping): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §2902 (relating to unlawful restraint): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §2903 (relating to false imprisonment): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §2910 (relating to luring a child into a motor vehicle or structure): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3121 (relating to rape): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3122.1 (relating to statutory sexual assault): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3123 (relating to involuntary deviate sexual assault): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3124.1 (relating to sexual assault): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3125 (relating to aggravated indecent assault): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3126 (relating to indecent assault): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3127 (relating to indecent exposure): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3129 (relating to sexual intercourse with animal): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3130 (relating to conduct relating to sex offenders): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3301 (relating to arson and related offenses): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §6114 (relating to contempt for violation of protection order or agreement): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Driving under the influence of drugs or alcohol: Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device: Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 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: (1) A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or under a similar statute in another jurisdiction, or (2) a history of abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction, or (3) any other history of violent or abusive conduct: Does not apply to either me or any household member Applies to me as follows: By a finding of abuse made against me by a Children & Youth Agency or similar agency in Pennsylvania or under a similar statute in another jurisdiction By a history of abusive conduct by me as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction Other: _________________________________________________________________ Date: ( / / ) Applies to another household member as follows: Name: ________________________________ A finding of abuse made against this household member by a Children & Youth Agency or similar agency in Pennsylvania or under a similar statute in another jurisdiction A history of abusive conduct by this household member as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction Other: _________________________________________________________________ Date: ( / / ) 3. If any of the preceding crimes or findings of abuse apply to you or a household member, list any evaluations, counseling or other treatment received following the conviction or finding of abuse: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 4. If any of the preceding crimes or findings of abuse apply to a household member, state that person’s name, date of birth and relationship to the child(ren): Name: ______________________________ Date of Birth: ( / / ) Relationship to the child(ren): _______________________ 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 statements made in this NOTICE AND ORDER are true and correct to the best of my knowledge, information, and belief. I understand that false statements herein are made subject to the penalties of 18 PA. C.S.A. § 4904 relating to unsworn falsification to authorities. Date: _______________ ___________________________________ Signature NOTICE: A CRIMINAL OR ABUSE HISTORY VERIFICATION FORM MUST BE FILED ALONG WITH EVERY NEW CUSTODY COMPLAINT OR CUSTODY PETITION, EVEN IF YOU HAVE ALREADY FILED ONE BEFORE. A COPY OF YOUR COMPLETED CRIMINAL OR ABUSE HISTORY VERIFICATION FORM MUST ALSO BE SERVED (PROVIDED TO) THE OTHER PARTY AT THE SAME TIME AS THE COMPLAINT OF PETITION. IN THE COURT OF COMMON PLEAS OF BRADFORD COUNTY, PENNSYLVANIA ____________________________ : Plaintiff : v. : : NO: _____ FC ______ ____________________________ : Defendant : CIVIL ACTION - CUSTODY : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : CRIMINAL RECORD/ABUSE HISTORY VERIFICATION FORM I, _____________________________, do hereby swear or affirm, subject to penalties of law, including 18 Pa.C.S.§4904 (relating to unsworn falsification to authorities) as follows: 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 to any substantially equivalent crime in any other jurisdiction (including any pending charges): FOR EACH LISTED OFFENSE, CHECK ALL BOXES THAT APPLY: 18 Pa.C.S. Ch. 25 (relating to criminal homicide): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §2702 (relating to aggravated assault): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §2706 (relating to terroristic threats): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3126 (relating to indecent assault): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3127 (relating to indecent exposure): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3129 (relating to sexual intercourse with animal): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3130 (relating to conduct relating to sex offenders): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §3301 (relating to arson and related offenses): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §4302 (relating to incest): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §4303 (relating to concealing death of child): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §4304 (relating to endangering welfare of children): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §4305 (relating to dealing in infant children): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §5902(b) (relating to prostitution and related offenses): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §5903(c) or (d) (relating to obscene and other sexual materials and performances): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §6301 (relating to corruption of minors): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §6312 (relating to sexual abuse of children): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §6318 (relating to unlawful contact with minor): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ 18 Pa.C.S. §6320 (relating to sexual exploitation of children): Does not apply to either me or any household member Applies to me as follows: By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________ Applies to another household member as follows: Name: ________________________________ By Conviction Guilty or No Contest Plea Adjudicated Delinquent Charges pending Date: ( / / ) Sentence: _______________________________________________________