IN THE COURT OF COMMON PLEAS OF
_______________________ COUNTY, PENNSYLVANIA
_______________________________, : CIVIL ACTION – LAW
PLAINTIFF :
:
: Case No. ______________
vs. :
:
_______________________________, :
DEFENDANT : IN DIVORCE
NOTICE
If you wish to deny any of the statements set forth in this Affidavit, you must file a Counter-Affidavit
within twenty (20) days after this Affidavit has been served on you, or the statements will be admitted.
AFFIDAVIT UNDER SECTION 3301(d)
OF THE DIVORCE CODE
1. The parties to this action separated on ___________________ (month, day, and year of
separation), and have continued to live separate and apart for a period of at least two years.
2. The marriage is irretrievably broken.
3. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or
expenses if I do not claim them before a divorce is granted.
I verify that the statements in this document 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. § 4904, relating to unsworn falsification to authorities.
Date:____________________ __________________________________
(Signature)
