Fillable Criminal Record Abuse History Verification (Delaware County Courthouse and Government Center)

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Criminal Record Abuse History Verification (Delaware County Courthouse and Government Center)

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Page 1 of 5
IN THE COURT OF COMMON PLEAS OF DELAWARE COUNTY, PENNSYLVANIA
TRIAL DIVISION
_____________________________________ :
Plaintiff :
: NO. _____-_________
vs. :
: In Custody
_____________________________________ :
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:
Date of conviction,
Other guilty plea, no
Check all household contest plea or
that apply Crime Self member pending charges Sentence
☐ 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)
Page 2 of 5
Date of conviction,
Other guilty plea, no
Check all household contest plea or
that apply Crime Self member pending charges Sentence
☐ 18 Pa.C.S. §2910 ☐ ☐ _______________ _______________
(Relating to luring a child into
a motor vehicle or structure)
☐ 18 Pa.C.S. §3121 ☐ ☐ _______________ _______________
(Relating to rape)
☐ 18 Pa.C.S. §3122.1 ☐ ☐ _______________ _______________
(Relating to statutory
sexual assault)
☐ 18 Pa.C.S. §3123 ☐ ☐ _______________ _______________
(Relating to involuntary
deviate sexual intercourse)
☐ 18 Pa.C.S. §3124.1 ☐ ☐ _______________ _______________
(Relating to sexual assault)
☐ 18 Pa.C.S. §3125 ☐ ☐ _______________ _______________
(Relating to aggravated
indecent assault)
☐ 18 Pa.C.S. §3126 ☐ ☐ _______________ _______________
(Relating to indecent assault)
☐ 18 Pa.C.S. §3127 ☐ ☐ _______________ _______________
(Relating to indecent exposure)
☐ 18 Pa.C.S. §3129 ☐ ☐ _______________ _______________
(Relating to sexual
intercourse with animal)
☐ 18 Pa.C.S. §3130 ☐ ☐ _______________ _______________
(Relating to conduct
relating to sex offenders)
☐ 18 Pa.C.S. §3301 ☐ ☐ _______________ _______________
(Relating to arson and
related offenses)
☐ 18 Pa.C.S. §4302 ☐ ☐ _______________ _______________
(Relating to incest)
☐ 18 Pa.C.S. §4303 ☐ ☐ _______________ _______________
(Relating to concealing
death of child)
Page 3 of 5
Date of conviction,
Other guilty plea, no
Check all household contest plea or
that apply Crime Self member pending charges Sentence
☐ 18 Pa.C.S. §4304 ☐ ☐ _______________ _______________
(Relating to endangering
welfare of children)
☐ 18 Pa.C.S. §4305 ☐ ☐ _______________ _______________
(Relating to dealing in
infant children)
☐ 18 Pa.C.S. §5902(b) ☐ ☐ _______________ _______________
(Relating to prostitution
and related offenses)
☐ 18 Pa.C.S. §5903(c) or (d) ☐ ☐ ______________ _______________
(Relating to obscene and
other sexual materials
and performances)
☐ 18 Pa.C.S. §6301 ☐ ☐ _______________ _______________
(Relating to corruption
of minors)
☐ 18 Pa.C.S. §6312 ☐ ☐ _______________ _______________
Relating to sexual abuse
of children)
☐ 18 Pa.C.S. §6318 ☐ ☐ _______________ _______________
(Relating to unlawful
contact with minor)
☐ 18 Pa.C.S. §6320 ☐ ☐ _______________ _______________
(Relating to sexual
exploitation of children)
☐ 23 Pa.C.S. §6114 ☐ ☐ _______________ _______________
(Relating to contempt for
violation of protection
order or agreement)
☐ Driving under the ☐ ☐ _______________ _______________
Influence of drugs
or alcohol
☐ Manufacture, sale, delivery ☐ ☐ _______________ _______________
holding, offering for sale
or possession of any
controlled substance or
other drug or device
Page 4 of 5
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 or involvement with a Children & Youth
Agency, including the following:
Check Other
all that household
apply Self member Date
☐ A finding of abuse by a Children & Youth Agency or ☐ ☐ _______________
similar agency in Pennsylvania or similar statute in
another jurisdiction
☐ Abusive conduct as defined under the Protection From ☐ ☐ _______________
Abuse Act in Pennsylvania or similar statute in
another jurisdiction
☐ Involvement with a Children & Youth Agency or ☐ ☐ _______________
similar agency in Pennsylvania or another jurisdiction.
Where?: ________________________________________
☐ Other: __________________________________________ ☐ ☐ _______________
State the date and circumstance of the child abuse, the named perpetrator of the abuse and the
jurisdiction or location where the abuse took place.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Please list any evaluation, counseling or other treatment received following conviction or finding of
abuse:
_________________________________________________________________________________
_________________________________________________________________________________
4. If any conviction above applies to a household member, not a party, state that person’s name, date of
birth and relationship to the child(ren).
_________________________________________________________________________________
_________________________________________________________________________________
Identify all household members by name and age that currently reside with you, and were
included in the responses to Question 1-2.
_________________________________________________________________________________
_________________________________________________________________________________
Page 5 of 5
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:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
6. State whether you or any member of your household was provided services by a child welfare agency
(e.g. Delaware County Children & Youth Services). If yes, please indicate:
a. The individuals that received services: _________________________________________________
b. The type of services provided: _______________________________________________________
c. The circumstances surrounding the provision of services: _________________________________
________________________________________________________________________________
________________________________________________________________________________
d. The time frame during which the services were or are being provided: ________________________
e. The jurisdiction or location where services were or are being provided: ________________________
_________________________________________________________________________________
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.
____________________________ __________________________________________
Date Signature
__________________________________________
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Criminal Record Abuse History Verification (Delaware County Courthouse and Government Center)

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Completed 24 July 2020

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