Fillable Emergency Custody Petitions pursuant to the March 23, (Office of Innovation and Technology)

Fill Online, Printable, Fillable, Blank Emergency Custody Petitions pursuant to the March 23, (Office of Innovation and Technology) Form

Use Fill to complete blank online OFFICE OF INNOVATION AND TECHNOLOGY (PA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Emergency Custody Petitions pursuant to the March 23, (Office of Innovation and Technology)

On average this form takes 170 minutes to complete

The Emergency Custody Petitions pursuant to the March 23, (Office of Innovation and Technology) form is 56 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 677 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Office of Innovation and Technology

BROWSE OFFICE OF INNOVATION AND TECHNOLOGY (PA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
PETITION FOR EMERGENCY RELIEF - CUSTODY
INSTRUCTION SHEET
These instructions are meant to give you
ge
neral information and not legal advice.
Emergency Custody Petitions pursuant to the March 23, 2020 Order of the
Administrative Governing Board of the First Judicial DIstrict (No. 18 of 2020)
shall be filed as follows:
(1) An Emergency Custody Petition, setting forth all relevant information, shall be completed by
Petitioner and verified. One of the following shall also be submitted with the Emergency Petition:
a. A Complaint for Custody, if a Custody Complaint has not been filed; or
b. A Petition to Modify Custody, if a custody order has been issued and the Emergency
Petition seeks to modify the custody order; or
c. A Petition for Contempt of Custody if the Emergency Petition alleges that the current
custody has not been complied with;
2) Every Emergency Custody Petition must be accompanied by the following:
a. A fully completed Domestic Relations Information Sheet; and
b. A Criminal Record/Abuse History Verification
3) The Emergency Petition must be forwarded to Family Court by email to the following email
address: custodyemergency@courts.phila.gov.
4) The Petitioner must provide a telephone number at which they can be reached by court staff.
5) The Emergency Custody Petition will be reviewed by the designated Judge.
6) Custody emergencies warranting immediate Court intervention will be narrowly construed
during this period.
7) After review, the Petitioner will be notified by reply email and/or telephone whether the Petition
is appropriate for filing in accordance with the General Statewide Judicial Emergency Orders.
8) If acceptable for filing, the Petitioner will be provided with instructions regarding filing and
service.
IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
:
_____________________________, :
PLAINTIFF : FAMILY COURT DIVISION
:
vs. : CIVIL ACTION
:
_____________________________, :
DEFENDANT : D.R. NO.
:
PETITION FOR EMERGENCY RELIEF - CUSTODY
1. Petitioner (name) __________________________________________________________
is plaintiff or defendant (circle one) in the custody complaint,
and resides at (street, city, state, zip) _____________________________________________
__________________________________________________________________________
2. Respondent (name) _________________________________________________________
is plaintiff or defendant (circle one) in the custody complaint,
and resides at (street, city, state, zip) ______________________________________________
___________________________________________________________________________
3. Petitioner’s relationship to the following minor child(ren) is ___________________________
LIST FULL NAME(S) AND DATES OF BIRTH(S) OF CHILD(REN).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Respondent’s relationship to the child(ren) is ________________________________________
5. CIRCLE ONE:
A. No custody order exists concerning these children.
B. A custody order was entered on _________________________ (date) that states the
following:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Phone #
6. CIRCLE ONE:
A. A complaint/petition is being filed with this petition.
B. A complaint/petition was filed on (date) and a hearing has been
scheduled on (date).
7.
Petitioner believes that a situation exists that
requires an emergency hearing because:
a. ____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
b. ____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
c. ___________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
WHEREFORE, petitioner respectfully requests that this honorable court grant the following relief
Date: _________________ _________________________________
Petitioner
I verify that the statements made in this petition are true and correct. I understand that false
statements herein are made subject to the penalties of PA.C.S.A. § 4904 relating to unsworn
falsification to authorities.
Date:__________________ _________________________________
Petitioner
PROVISIONS OF LAW THAT MAY HELP YOU FILL OUT THE COMPLAINT:
§ 5322. Definitions
The following words and phrases when used
in
this subchapter shall have the meaning given to
them in this section unless the context clearly indicates otherwise.
Child
-An
unemancipated individual under
18
years
of
age.
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.
Primary physical custody- The right to assume physical custody
of
the child for the majority
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.
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.
Legal
custody-
The right to make major decisions on behalf
of
the child, including, but not
limited to, medical, religious and educational decisions.
Sole legal custody - The right
of
one individual to exclusive legal custody
of
the child.
Shared legal custody - The right
of
more than one individual to legal custody
of
the child.
Note:
Pennsylvania's custody law does not use the word visitation. Partial physical custody,
shared physical custody and supervised physical custody may be what you understand visitation
to be.
§ 5324. Standing for any form
of
physical custody or legal custody.
The following individuals may file an action under this chapter for any form
of
physical custody
or legal custody:
(I)
A parent
of
the child.
(2) A person who stands in loco parentis to the child.
[in
loco parentis means acting
in
the
FOR CUSTODY
place
of
a parent]
(3) A grandparent
of
the child who is not in loco parentis
to
the child:
(i) whose relationship with the child began either with the consent
of
a parent
of
the
child or under a court order;
(ii) who assumes or is willing to assume responsibility for the child; and
(iii) when one
ofthe
following conditions is met:
(A) the child has been determined to be a dependent child under 42 Pa.C.S. Ch.
63
(relating to juvenile matters);
(B) the child is substantially at risk due to parental abuse, neglect, drug or alcohol
abuse or incapacity; or
·
(C) the child has for a period
of
at least
12
consecutive months resided with the
grandparent, excluding
brief
temporary absences
of
the child from the home,
and is removed from the home by the parents, in which case the action must
be filed within six months after the removal
of
the child from the home.
§ 5325. Standing for partial physical custody and supervised physical custody.
In addition to situations set forth in section 5324 (relating to standing for any form
of
physical
custody or legal custody), grandparents and great-grandparents may file an action under this
chapter for partial physical custody or supervised physical custody in the following situations:
(!)
where the parent
of
the child is deceased, a parent or grandparent
of
the deceased parent
may file an action under this section;
(2) where the parents
of
the child have been separated for a period
of
at least six months or
have commenced and continued a proceeding to dissolve their marriage; or
(3) when the child has, for a period
of
at least
12
consecutive months, resided with the
grandparent or great-grandparent, excluding brief temporary absences
of
the child from
the home, and is removed from the home
by
the parents, an action must be filed within
six months after the removal
of
the child from the home.
§ 5328. Factors to consider when awarding custody.
(a) Factors.--In ordering any form
of
custody, the court shall determine the best interest
of
the
child by considering all relevant factors, giving weighted consideration to those factors which
affect the safety
of
the child, including the following:
(l)
Which party is more likely to encourage and permit frequent and continuing contact
between the child and another party.
(2) The present and past abuse committed by a party or member
of
the party's household,
whether there is a continued risk
of
harm to the child or an abused party and which party
can better provide adequate physical safeguards and supervision
of
the child.
(3) The parental duties performed by each party
on
behalf
of
the child.
(4) The need for stability and continuity in the child's education, family life and community
life.
(5) The availability
of
extended family.
(6) The child's sibling relationships.
(7) The well-reasoned preference
of
the child, based
on
the child's maturity and judgment.
(8) The attempts
of
a parent to
tum
the child against the other parent, except in cases
of
domestic violence where reasonable safety measures are necessary to protect the child
from harm.
(9) Which party is more likely to maintain a loving, stable, consistent and nurturing
relationship with the child adequate for the child's emotional needs.
(1
0) Which party is more likely to attend to the daily physical, emotional, developmental,
educational and special needs
of
the child.
(11) The proximity
of
the residences
of
the parties.
(12) Each party's availability to care for the child or ability to make appropriate child-care
arrangements.
(13) The level
of
conflict between the parties and the willingness and ability
of
the parties to
cooperate with one another. A party's effort to protect a child from abuse by another party
is not evidence
of
unwillingness or inability to cooperate with that party.
(14) The history
of
drug or alcohol abuse
of
a party or member
of
a party's household.
(15) The mental and physical condition
of
a party or member
of
a party's household.
(16) Any other relevant factor.
The custody statute also lists specific criminal convictions and criminal charges for consideration
in a custody decision and procedures to be followed for such consideration.
See§
5329. Consideration
of
criminal conviction, available on the internet at
http://www.legis.state.pa.us/WU01/LIILI/CT/HTM/23/00.053.029.000
..
HTM
See §
5330. Consideration
of
criminal charge, available
on
the internet at
http://www.legis.state.pa.us/WU01/LIILIICT/HTM/23/00.053.030.000
..
HTM
TERMS THAT
ARE
USED IN THE COMPLAINT:
PLAINTIFF
Person who is filing complaint
DEFENDANT
Person against whom you are filing
HOW
TO FILL
IN
THE
COMPLAINT:
HEADING
(CAPTION).
Fill in the names
of
the plaintiff and defendant in the heading
of
the complaint. The Court will
give the complaint a docket number and put it on the copy that is mailed to you.
LINEl.
If
you are filing this complaint, you are the plaintiff. Fill in the name and address
of
the plaintiff.
LINE2.
Fill in the name and address
of
the defendant.
LINE3.
Indicate what type
of
custody you are seeking and fill in the names, addresses, and ages
of
the
children who are the subjects
of
the complaint. Indicate whether the children were born out
of
wedlock, who presently has custody
of
the children and where that person resides, and with
whom the children have lived for the past five years.
Provide the names, residence, and marital
status
of
the parents
of
the children.
LINE4.
Fill in your relationship to the children and identifY by name and relationship anyone who lives
with you in your home.
LINE
5.
Fill in the relationship
of
the defendant to the children and identify by name and relationship any
people who live with the defendant.
LINE6.
Circle
if
you have participated in any other litigation concerning the children in this or any other
court.
Provide details
if
you know
of
any such action(s).
If
not, skip this line.
Circle
if
you
know
if
there has been a custody action in another court. Provide details
if
you
know
of
any such action(s).
If
not, skip this line.
Circle whether you know any person(s) not a party to this complaint who has physical custody or
claims to have custody rights with respect to the children.
If
you
know
any such persons, provide
names and addresses.
If
not, skip this line.
LINE
7.
Fill in the reason you are filing this complaint.
LINE
8.
Provide the names, addresses, and relationships
of
any other people you know to have custody
rights or claim a right to custody
of
the children.
LINE 9(a).
If
you are a grandparent who does not stand in loco parentis to the children, provide facts to establish that
you have standing to obtain the custody you are requesting.
LINE 9(b).
If
you are a grandparent
or
great-grandparent, provide facts to establish that
you
have standing to obtain
partial physical custody or supervised physical custody
of
the children.
LINE 9(c).
If
you stand in loco parentis to the child, provide facts to establish in loco parentis standing.
LINE 10.
Attach the Criminal Record/Abuse History Verification Form.
SIGN AND DATE THE COMPLAINT.
DATE AND SIGN THE VERIFICATION THAT THE STATEMENTS ARE TRUE.
IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
PLAINTIFF FAMILY COURT DIVISION
vs. CIVIL ACTION
DEFENDANT Docket No.
COMPLAINT FOR CUSTODY
1.
The plaintiff
is----------~'
residing at
___________
_
2.
The defendant is
__________
~,
residing at
___________
_
3.
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 Address
Age
I
'
The child (was)(was not) born out
of
wedlock.
The child is presently
in
the custody
of
____________
, who resides
at.
__
_
During the past five years, the child has resided with the following persons and at the following
addresses:
(List All Persons) (List All Addresses)
(Dates)
A parent
of
the child is
___________
currently residing at
______
_
This parent is (married) (divorced) (single).
A parent
of
the child is
___________
currently residing at
______
_
This parent is (married) (divorced) (single).
4.
The relationship
of
plaintiff to the child is that
of
_______________
_
The
plaintiff currently resides with the following persons:
Name Relationship
5.
The relationship
of
defendant
to
the child
is
that
of
______________
_
The defendant currently resides with the following persons:
Name Relationship
6.
Plaintiff (has) (has not) participated
as
a party or witness, or in another capacity,
in
other
litigation concerning the custody
of
the child in this or another court. The court, term and number,
and its relationship to this action
is:
Plaintiff (has) (has no) information
of
a custody proceeding concerning the child pending in a court
of
this Commonwealth or any other state. The court, term and number, and its relationship to this
action
is:--------------------------------
Plaintiff (knows) (does not know)
of
a person not a party to the proceedings who has physical
custody
of
the child or claims to have custodial rights with respect to the child. The name and
address
of
such person
is:-------------------------
7.
The best interest and permanent welfare
of
the child will be served by granting the relief
requested because (set forth facts showing that the granting
of
the relief requested will be in the
best interest and permanent welfare
ofthe
child):
8.
Each parent whose parental rights to the child have not been terminated and the person who has
physical custody
of
the child 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
9.(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
§ 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.
10.
Plaintiff has attached the Criminal Record/Abuse History Verification form required pursuant
to
Pa.R.C.P. No. 1915.3-2.
Wherefore, plaintiff requests the court to grant (shared legal custody) (sole legal custody) (partial
physical custody) (primary physical custody) (shared physical custody) (sole physical custody)
(supervised physical custody)
of
the child.
(Attorney for Plaintiff) (Plaintiff)
I verify that the statements made in this Complaint are true and correct. I understand that false
statements herein
are
made subject
to
the pemilties
of
18
Pa.C.S. § 4904 relating to unsworn
falsification to authorities.
Plaintiff
PROVISIONS OF
LAW
THAT
MAY
HELP YOU FILL OUT THE PETITION:
§ 5322. Definitions
The following words and phrases when used in this subchapter shall have the meaning given to them in this
section unless the context clearly indicated otherwise.
Child
-An
unemancipated individual under
18
years
of
age.
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.
Primary physical
custody-
The right to assume physical custody
of
the child for the majority
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.
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.
Legal custody - The right to make major decisions on behalf
of
the child, including, but not limited to, medical,
religious and educational decisions.
Sole legal
custody-
The right
of
one individual to exclusive legal custody
of
the child.
Shared legal custody - The right
of
more than one individual to legal custody
of
the child.
Note: Pennsylvania's custody law does not use the word visitation. Partial physical custody, shared physical
custody and supervised physical custody may be what you understand visitation to be.
§ 5328. Factors to consider when awarding custody.
(a) Factors.--In ordering any form
of
custody, the court shall determine the best interest
of
the child by
considering all relevant factors, giving weighted consideration to those factors which affect the safety
of
the
child, including the following:
(I)
Which party is more likely to encourage and permit frequent and continuing contact between the child
and another party.
(2) The present and past abuse committed by a party or member
of
the party's household, whether there is a
continued risk
of
harm to the child or an abused party and which party can better provide adequate
physical safeguards and supervision
of
the child.
(3) The parental duties performed by each party
on
behalf
of
the child.
(4) The need for stability and continuity
in
the child's education, family life and community life.
(5) The availability
of
extended family.
(6) The child's sibling relationships.
(7) The well-reasoned preference
of
the child, based on the child's maturity and judgment.
(8) The attempts
of
a parent to turn the child against the other parent, except in cases
of
domestic violence
where reasonable safety measures are necessary to protect the child from harm.
(9) Which party is more likely to maintain a loving, stable, consistent and nurturing relationship with the
child adequate for the child's emotional needs.
(l
0)
Which party is more likely to attend to the daily physical, emotional, developmental, educational and ! i
special needs
ofthe
child.
(11) The proximity
of
the residences
of
the parties.
(12) Each party's availability to care for the child or ability to make appropriate child-care arrangements.
( 13) The level
of
conflict between the parties and the willingness and ability
of
the parties to cooperate with
one another. A party's effort to protect a child from abuse by another party is not evidence
of
unwillingness or inability to cooperate with that party.
(14) The history
of
drug or alcohol abuse
of
a party or member
of
a party's household.
(15) The mental and physical condition
of
a party or member
of
a party's household.
(16) Any other relevant factor.
' I
The custody statute also lists specific criminal convictions and criminal charges for consideration in a custody
decision and procedures to be followed for such consideration.
See § 5329 Consideration
of
criminal conviction, available on the internet at
http://www.legis.state.pa.us/WU0l/LI/LI/CT/HTM/23/00.053.029.000
..
HTM
See § 5330. Consideration
of
criminal charge, available on the internet at
http://www.legis.state.pa.us/WU01/LI/LI/CT/HTM/23/00.053.030.000
..
HTM
TERMS THAT ARE USED IN THE PETITION:
PLAINTIFF
Person who filed the custody complaint
DEFENDANT
Person against whom the custody complaint was filed
PETITIONER
Person who filed the petition to modify the custody order
RESPONDENT
Person against whom the petition to modify the custody order was filed
HOW TO FILL IN THE PETITION:
HEADING (CAPTION).
Fill in the names
of
the plaintiff and defendant in the heading
of
the petition exactly
as
they appear in the
custody complaint. The plaintiff is the person who filed the custody complaint. The defendant is the person
against whom the custody action was filed. The plaintiff and defendant keep those titles throughout the case.
The docket number is the number assigned your case by the Court.
You can find this number
in
the caption
of
your Complaint for Custody.
LINEl
If
you are filing the petition to modify the custody order, you are the petitioner. Fill
in
your name and address
as
the petitioner.
LINE2
The person against whom the petition is filed is the respondent. Fill in the name and address
of
the respondent.
LINE3
Provide the date and terms
of
your last custody order and attach a copy
of
the order.
LINE4
Fill in a brief statement describing why
you
want the order changed and
how
you want the order changed.
LINES
Attach the Criminal Record/ Abuse History Verification form.
DATE AND
SIGN THE PETITION.
DATE AND SIGN THE VERIFICATION THAT THE STATEMENTS ARE TRUE.
IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
PLAINTIFF FAMILY COURT DIVISION
vs. CIVIL ACTION
DEFENDANT DOCKET NO.
PETITION FOR MODIFICATION OF A CUSTODY ORDER
1.
Petitioner
is
and resides at
------------------------
--------------------------
2.
Respondent is
_____________________
and resides at
_______________________
_
3.
Petitioner respectfully represents that on
20
_an
Order
of
Court was entered for (shared
legal custody) (sole legal custody) (partial physical custody) (primary physical custody) (shared physical
custody) (sole physical custody) (supervised physical custody). A true and correct copy
of
the Order
is
attached.
4.
This Order should be modified because:
5.
Petitioner has attached the Criminal Record/ Abuse History Verification form required pursuant to
Pa.R.C.P. No. 1915.3-2.
WHEREFORE,
Petitioner requests that the Court modify the existing Order because it will be in the best interest
of
the child(ren).
(Attorney
for
Petitioner) (Petitioner)
I verify that the statements made
in
this petition are 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
Petitioner
PROVISIONS OF LAW THAT MAY HELP YOU FILL OUT THE PETITION:
§ 5322. Definitions
The following words and phrases when used
in
this subchapter shall have the meaning given to
them
in
this section unless the context clearly indicates otherwise.
Child
- An unemancipated individual under
18
years
of
age.
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.
Primary physical custody - The right
to
assume physical custody
of
the child for the majority
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.
Partial physical custody - The right to assume physical custody
ofthe
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.
Legal custody- The right to make major decisions on behalf
of
the child, including, but not
limited to, medical, religious and educational decisions.
Sole legal custody - The right
of
one individual to exclusive legal custody
of
the child.
Shared legal custody- The right
of
more than one individual
to
legal custody
of
the child.
Note: Pennsylvania's custody law does not use the word visitation.
Partial physical custody,
shared physical custody and supervised physical custody may be what you understand visitation
to be.
HOW
TO FILL IN THE PETITION:
HEADING (CAPTION).
Fill
in
the names
of
the plaintiff and defendant in the heading
of
the petition exactly as they
appear in the custody complaint. The plaintiff is the person who filed the custody complaint.
The defendant is the person against whom the custody action was filed. The plaintiff and
defendant keep those titles throughout the case. The Domestic Relations Number (D.R. No.) is
the number assigned your case by the Court.
You can find this number
in
the caption
of
your
Complaint for Custody.
LINE I.
Indicate when the current custody order was entered, what judge entered the order, and circle
what type
of
custody you were granted. Attach a copy
of
the order.
LINE2.
Fill in a brief statement describing how respondent has violated the order.
LINE
3.
Attach the Criminal Record/ Abuse History Verification
DATE AND
SIGN THE PETITION.
DATE AND
SIGN THE VERIFICATION THAT THE STATEMENTS ARE TRUE.
IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
PLAINTIFF
FAMILY COURT DIVISION
vs.
CIVIL ACTION
DEFENDANT
D.R.NO.
PETITION FOR CIVIL CONTEMPT FOR DISOBEDIENCE OF CUSTODY ORDER
The Petition
of
___________
_,
respectfully represents:
I.
That on , Judge entered an Order awarding (Petitioner)
(Respondent) (shared legal custody) (sole legal custody) (partial physical custody) (primary
physical custody) (shared physical custody) (sole physical custody) (supervised physical custody)
of
the minor child(ren)
Names ofChild(ren)
A true and correct copy
of
the order is attached
to
this petition.
2.
Respondent has willfully failed to abide by the order in that
3. Petitioner has attached the Criminal Record/ Abuse History Verification form required pursuant
to Pa.R.C.P. No. 1915.3-2.
WHEREFORE, Petitioner requests that Respondent be held
in
contempt
of
court.
(Attorney for Petitioner) (Petitioner)
I verify that the statements made
in
this petition are 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 Petitioner
Rev 8/2020
Date
Case ID No
INFORMATION ON PARENT #1 AND/OR SPOUSE #1
Alias (if any)
Residential Address
Email Address
Date of Birth
Social Security No.
DPW No.
Height
Weight
Race
Hair
Eyes
Distinguishing Features
Place of Employment
Medical Insurance Carrier Name, Address
Home Phone No.
Work Phone No.
Mobile No.
Policy No.
Children Covered?
Yes No
Occupation
Attorney
’
s Name and Address
Salary
$ per
Attorney ID No.
Attorney Phone No.
INFORMATION ON PARENT #2 AND/OR SPOUSE #2
Alias (if any)
Residential Address
Email Address
Date of Birth
Social Security No.
DPW No.
Height
Weight
Race
Hair
Eyes
Distinguishing Features
Place of Employment
Medical Insurance Carrier Name, Address
Home Phone No.
Work Phone No.
Mobile No.
Policy No.
Children Covered?
Yes No
Occupation
Attorney
’
s Name and Address
Salary
$ per
Attorney ID No.
Attorney Phone No.
INFORMATION IF THERE IS A CLAIM FOR SUPPORT
Receiving Assistance?
Yes No
DPW No.
District Receiving From
Semi-monthly Grant Amount
Total No of People in
Household
Parties Ever Married?
Yes No
Marriage Date
Place
Separation Date
Divorce Date
Place
Maternal Grandmother
’
s Maiden Name
Maternal Grandfather
’
s Name
DOMESTIC RELATIONS INFORMATION SHEET
Rev 8/2020
INFORMATION ON CARETAKER OF CHILD(REN) OTHER THAN PARENTS (IF ANY)
First Name Middle Initial Last
Name
Alias (if any)
Mailing Address
Residential Address
Email Address
Home Phone No.
Work Phone No.
Mobile No.
Date of Birth
Relationship to children
INFORMATION ON CHILD(REN)
First Name Middle Initial Last Name
Gender
Date of Birth
Social Security No.
Place of Birth (City, State)
Active on Cash Assistance?
Yes No
Father Listed on Birth Certificate?
Yes No
Born Out of Wedlock?
Yes No
Was Paternity Established?
Yes No
Date of Paternity Establishment
First Name Middle Initial Last Name
Gender
Date of Birth
Social Security No.
Place of Birth (City, State)
Active on Cash Assistance?
Yes No
Father Listed on Birth Certificate?
Yes No
Born Out of Wedlock?
Yes No
Was Paternity Established?
Yes No
Date of Paternity Establishment
First Name Middle Initial Last Name
Gender
Date of Birth
Social Security No.
Place of Birth (City, State)
Active on Cash Assistance?
Yes No
Father Listed on Birth Certificate?
Yes No
Born Out of Wedlock?
Yes No
Was Paternity Established?
Yes No
Date of Paternity Establishment
First Name Middle Initial Last Name
Sex
Date of Birth
Social Security No.
Place of Birth (City, State)
Active on Cash Assistance?
Yes No
Father Listed on Birth Certificate?
Yes No
Born Out of Wedlock?
Yes No
Was Paternity Established?
Yes No
Date of Paternity Establishment
IN
THE
COURT OF COMMON PLEAS
OF
PHILADELPHIA
COUNTY, PENNSYLVANIA
Plaintiff
v.
No.
CUSTODY
Defendant
CRIMINAL RECORD I 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
all that
.wlllli
D
D
D
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)
Custody
Form
3
Criminal
Record/Abuse
History
Verification
Pa.R.C.P. 1915.3-2(c)
AOPC4.18.16
D
D
D
1
Other
household
member
D
D
D
Date of
conviction,
guilty plea or no
contest plea, or
pending
charges Sentence
Date of
conviction,
Check
guilty plea or no
Other contest plea,
all that
household or pending
l!l!.I2.!.Y.
Crjme
Self
member
charges
Sentence
D
18 Pa.C.S. § 2709.1
D
D
(relating to stalking)
D
18 Pa.C.S. §
2901
D D
(relating to kidnapping)
D
18 Pa.C.S. § 2902
D D
(relating to unlawful
restraint)
D
18 Pa.C.S. § 2903
D D
(relating to false
imprisonment)
D
18 Pa.C.S. § 2910
D
D
(relating to luring a child
into a motor vehicle or
structure)
D
18 Pa.C.S. §
3121
D
D
(relating to rape)
D
18 Pa.C.S. § 3122.1
D D
(relating to statutory
sexual assault)
D
18 Pa.C.S. § 3123
D
D
(relating to involuntary
deviate sexual intercourse)
D
18 Pa.C.S. § 3124.1 D
D
(relating to sexual assault)
D
18 Pa.C.S. § 3125
D
D
(relating to aggravated
indecent
assault)
D
18 Pa.C.S. § 3126
(relating to indecent
D
D
assault)
2
Custody
Form
3
Criminal
Record/Abuse
History
Verification
Pa.R.C.P.1915.3-2(c)
AOPC
4.18.16
Date
of
conviction,
guilty plea or
Check
Other
no contest
plea, or
all that
household
pending
l!.!!R.!Y
Crime
Self
member
charges
Sentence
D
18 Pa.C.S. § 3127
D D
(relating to indecent
exposure)
D
18 Pa.C.S. § 3129
D
D
(relating to sexual
intercourse with animal)
D
18 Pa.C.S. § 3130
D
D
(relating to conduct
relating to sex offenders)
D
18
Pa.C.S. § 3301
D D
(relating to arson and
related offenses)
D
18 Pa.C.S. § 4302
D
D
(relating to incest)
D
18
Pa.C.S. § 4303
D
D
(relating to concealing
death
of
child)
D
18
Pa.C.S. § 4304
D D
(relating to endangering
welfare
of
children)
D
18 Pa.C.S. § 4305
D
D
(relating
to
dealing
in
infant children)
D
18 Pa.C.S. § 5902(b)
D
D
(relating to prostitution
and
related offenses)
D
18 Pa.C.S. § 5903(c) or
D D
(d) (relating to obscene
and other
sexual
materials
and
performances)
3
Custody
Form
3
Criminal
Record/Abuse
History
Verification
Pa.R.C.P. 1915.3-2(c)
AOPC4.18.16
Check
all that
~
D
D
D
D
D
D
D
Crime
Self
18 Pa.C.S. §
6301
D
(relating to corruption
of
minors)
18
Pa.C.S. § 6312
D
(relating to sexual abuse
of
children)
18 Pa.C.S. § 6318
D
(relating to unlawful
contact with minor)
18 Pa.C.S. § 6320
D
(relating to sexual
exploitation
of
children)
23 Pa.C.S. § 6114
D
(relating to contempt for
violation
of
protection
order or agreement)
Driving under the
D
influence
of
drugs or
alcohol
Manufacture, sale, delivery, D
holding, offering for sale or
possession
of
any controlled
substance or other drug or
device
Date of
conviction,
guilty plea
or no
Other
contest plea,
Household
or pending
Member
charges
Sectecce
D
D
D
D
D
D
D
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
all that
iiiD2b£
D
Custody
Form
3
A finding
of
abuse by a Children & Youth
Agency or similar agency
in
Pennsylvania
or similar statute in another jurisdiction
4
Criminal
Record/Abuse
History
Verification
Pa.R.C.P. 1915.3·2(c)
AOPC4.18.16
D
Other
Household
Member
D
Check
all
that
SW2bl
D
D
D
Abusive conduct
as
defined under the D
Protection from Abuse Act
in
Pennsylvania
or similar statute
in
another jurisdiction.
Involvement with Children & Youth or 0
similar agency
in
Pennsylvania or another
jurisdiction. Where?
______
_
Other: D
Other
Household
Member
D
D
D
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.
5.
If you are aware that the other party or members of the other party's household has or
have a
criminal record/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.
Date:
______
_
Custody
Form
3
Criminal
Record/Abuse
History
Verification
Pa.R.C.P. 1915.3-2(c)
AOPC4.18.16
Signature
Printed Name
5
Date:
CaseiD
No.
. DOMESTIC RELATIONS INFORMATION SHEET
No.
Salary$,
___
per
__
INFORMATION ON MOTHER
OF
Carrier
Name,
Address
Policy
Sruary
$,
___
per
__
Amount
$
Place Separation
Date
Divorce
Date
Last
Name
Address
Yes
No
Yes
No
IN
THE
COURT OF COMMON PLEAS
OF
PHILADELPHIA
COUNTY, PENNSYLVANIA
Plaintiff
v.
No.
CUSTODY
Defendant
CRIMINAL RECORD I 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
all that
.wlllli
D
D
D
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)
Custody
Form
3
Criminal
Record/Abuse
History
Verification
Pa.R.C.P. 1915.3-2(c)
AOPC4.18.16
D
D
D
1
Other
household
member
D
D
D
Date of
conviction,
guilty plea or no
contest plea, or
pending
charges Sentence
Date of
conviction,
Check
guilty plea or no
Other contest plea,
all that
household or pending
l!l!.I2.!.Y.
Crjme
Self
member
charges
Sentence
D
18 Pa.C.S. § 2709.1
D
D
(relating to stalking)
D
18 Pa.C.S. §
2901
D D
(relating to kidnapping)
D
18 Pa.C.S. § 2902
D D
(relating to unlawful
restraint)
D
18 Pa.C.S. § 2903
D D
(relating to false
imprisonment)
D
18 Pa.C.S. § 2910
D
D
(relating to luring a child
into a motor vehicle or
structure)
D
18 Pa.C.S. §
3121
D
D
(relating to rape)
D
18 Pa.C.S. § 3122.1
D D
(relating to statutory
sexual assault)
D
18 Pa.C.S. § 3123
D
D
(relating to involuntary
deviate sexual intercourse)
D
18 Pa.C.S. § 3124.1 D
D
(relating to sexual assault)
D
18 Pa.C.S. § 3125
D
D
(relating to aggravated
indecent
assault)
D
18 Pa.C.S. § 3126
(relating to indecent
D
D
assault)
2
Custody
Form
3
Criminal
Record/Abuse
History
Verification
Pa.R.C.P.1915.3-2(c)
AOPC
4.18.16
Date
of
conviction,
guilty plea or
Check
Other
no contest
plea, or
all that
household
pending
l!.!!R.!Y
Crime
Self
member
charges
Sentence
D
18 Pa.C.S. § 3127
D D
(relating to indecent
exposure)
D
18 Pa.C.S. § 3129
D
D
(relating to sexual
intercourse with animal)
D
18 Pa.C.S. § 3130
D
D
(relating to conduct
relating to sex offenders)
D
18
Pa.C.S. § 3301
D D
(relating to arson and
related offenses)
D
18 Pa.C.S. § 4302
D
D
(relating to incest)
D
18
Pa.C.S. § 4303
D
D
(relating to concealing
death
of
child)
D
18
Pa.C.S. § 4304
D D
(relating to endangering
welfare
of
children)
D
18 Pa.C.S. § 4305
D
D
(relating
to
dealing
in
infant children)
D
18 Pa.C.S. § 5902(b)
D
D
(relating to prostitution
and
related offenses)
D
18 Pa.C.S. § 5903(c) or
D D
(d) (relating to obscene
and other
sexual
materials
and
performances)
3
Custody
Form
3
Criminal
Record/Abuse
History
Verification
Pa.R.C.P. 1915.3-2(c)
AOPC4.18.16
Check
all that
~
D
D
D
D
D
D
D
Crime
Self
18 Pa.C.S. §
6301
D
(relating to corruption
of
minors)
18
Pa.C.S. § 6312
D
(relating to sexual abuse
of
children)
18 Pa.C.S. § 6318
D
(relating to unlawful
contact with minor)
18 Pa.C.S. § 6320
D
(relating to sexual
exploitation
of
children)
23 Pa.C.S. § 6114
D
(relating to contempt for
violation
of
protection
order or agreement)
Driving under the
D
influence
of
drugs or
alcohol
Manufacture, sale, delivery, D
holding, offering for sale or
possession
of
any controlled
substance or other drug or
device
Date of
conviction,
guilty plea
or no
Other
contest plea,
Household
or pending
Member
charges
Sectecce
D
D
D
D
D
D
D
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
all that
iiiD2b£
D
Custody
Form
3
A finding
of
abuse by a Children & Youth
Agency or similar agency
in
Pennsylvania
or similar statute in another jurisdiction
4
Criminal
Record/Abuse
History
Verification
Pa.R.C.P. 1915.3·2(c)
AOPC4.18.16
D
Other
Household
Member
D
Check
all
that
SW2bl
D
D
D
Abusive conduct
as
defined under the D
Protection from Abuse Act
in
Pennsylvania
or similar statute
in
another jurisdiction.
Involvement with Children & Youth or 0
similar agency
in
Pennsylvania or another
jurisdiction. Where?
______
_
Other: D
Other
Household
Member
D
D
D
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.
5.
If you are aware that the other party or members of the other party's household has or
have a
criminal record/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.
Date:
______
_
Custody
Form
3
Criminal
Record/Abuse
History
Verification
Pa.R.C.P. 1915.3-2(c)
AOPC4.18.16
Signature
Printed Name
5
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Emergency Custody Petitions pursuant to the March 23, (Office of Innovation and Technology)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document