Fillable IN THE COURT OF COMMON PLEAS OF (Unified Judicial System of Pennsylvania)

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IN THE COURT OF COMMON PLEAS OF (Unified Judicial System of Pennsylvania)

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  • 53 check-boxes
  • 163 other fields

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1. PLAINTIFF
First Middle Last
Plaintiff’s DOB
Plaintiff's Address:
Plaintiff's address is confidential or Plaintiff's address is:
V.
2. DEFENDANT
First Middle Last
Suffix
Defendant’s Address:
CAUTION:
Weapon Involved
3. I am filing this Petition on behalf of: Myself or Another Person
If you checked "myself", please answer all questions referring to yourself as "Plaintiff". If you ONLY checked "another person", please answer
all questions referring to that person as the "Plaintiff", and provide your name and address here, as filer, unless confidential.
Filer's Name:
Suffix
Last First Middle
Filer’s Address is Confidential or Filer’s address is:
If you checked "Another Person", indicate your relationship with Plaintiff:
parent of minor Plaintiff(s)
applicant for appointment as guardian
ad litem
of minor Plaintiff(s)
adult household member with minor Plaintiff(s)
court appointed guardian of incompetent Plaintiff(s)
4. Name(s) of all persons, including minor child/ren, who seek protection from abuse:
PETITION FOR PROTECTION
IN THE COURT OF COMMON PLEAS OF
FROM ABUSE COUNTY, PENNSYLVANIA
NO.
DEFENDANT IDENTIFIERS
DOB
HEIGHT
SEX
WEIGHT
RACE
EYES
HAIR
SSN
DRIVERS
LICENSE #
Weapon Present on the Property
EXP DATE STATE
Weapon Requested Relinquished
Defendant's Place of employment is:
Check here if you have reason to believe that Defendant is a licensed firearms dealer, employed by a licensed firearms dealer or
manufacturer; employed as a writer, researcher, or technician in the firearms or hunting industry, or is required to carry a firearm as a condition of
employment.
Suffix
5. Indicate the relationship between Plaintiff and Defendant:
CHECK ALL THAT APPLY:
spouse or former spouse of Defendant
parent of a child with Defendant
current or former sexual or intimate partner with Defendant
child of Plaintiff
child of Defendant
family member related by blood (consanguinity) to Defendant
family member related by marriage or affinity to Defendant
sibling (person who shares parenthood) of Defendant
Check here if Defendant is 17 years old or younger.
6. Have Plaintiff and Defendant been involved in any of the following court actions?
Divorce Custody Support Protection from Abuse
If you checked any of the above, briefly indicate when and where the case was
filed and the court number, if known:
7. Has Defendant been involved in any criminal court action?
If you answered Yes, is Defendant currently on probation?
Has Defendant been determined to be a perpetrator in a founded or
indicated report under the Child Protective Services Law, 23 Pa.C.S. §§ 6301 - 6386?
If you answered Yes, what county’s court or child protective services agency
issued the founded or indicated report?
8. Plaintiff and Defendant are the parents of the following minor child/ren:
Name(s) Age(s) who reside at (list address unless
confidential)
existing court order regarding their custody?
If you answered "Yes," describe the terms of the order (e.g., primary,
shared, legal or physical custody):
If you answered "yes", in what county and state was the order issued?
If you are now seeking an order of child custody as part of this petition, list the
following information:
(a) Where has each child resided during the past five years?
Child’s name Person(s) child When
lived with
Address, unless
confidential
(b) List any other persons who are known to have or claim a right to custody
of each child listed above.
Name
Address Basis of Claim
10. The following other minor child/ren presently live with Plaintiff:
Name(s) Age(s) Plaintiff’s relationship to child/ren
11. The facts of the most recent incident of abuse are as follows:
Approximate Date:
Approximate Time:
Place:
9. If Plaintiff and Defendant are parents of any minor child/ren together, is there an
Describe in detail what happened, including any physical or sexual abuse, threats,
injury, incidents of stalking, medical treatment sought, or calls to law enforcement.
(attach additional sheets of paper if necessary):
12. If Defendant has committed prior acts of abuse against Plaintiff or the minor child/
ren, describe these prior incidents, including any threats, injuries, or incidents of
stalking, and indicate approximately when such acts of abuse occurred (attach
additional sheets of paper if necessary):
13. (a) Has Defendant used or threatened to use any firearms or other weapons
against Plaintiff or the minor child/ren? If so, please describe the use or threatened use
below and list on Attachment A to Petition, which is incorporated by reference into this
petition, any firearms, other weapons, or ammun
ition Defendant used or threatened to
use against Plaintiff or the minor child/ren:
(b) Other than the firearms, other weapons,
or ammunition Defendant used
or
threatened to use against Plaintiff or the minor child/ren, does Defendant, to the best of
your knowledge or belief, own or possess any additional firearm, other weapon,
ammunition, or any firearm license? Yes No
(c) If the answer to (b) above is “yes,” list any additional firearm, other
weapon, or ammunition owned by or in the possession of Defendant on Attachment A to
Petition, which is incorporated by reference into this petition.
(d) Plaintiff (check one) DOES DOES NOT request that
the court order
Defendant to relinquish firearms, other weapons, or ammunition listed on Attachment A
to Petition. If Plaintiff does seek relinquishment, identify on Attachment A to Petition the
firearms, other weapons or ammunition Plaintiff requests the court to order Defendant to
relinquish.
14. Identify the sheriff, police department, or law enforcement agency in the area in
which Plaintiff lives that should be provided with a copy of the protection order:
15. There is an immediate and present danger of further abuse from Defendant.
CHECK THE FOLLOWING BOXES ONLY IF THEY APPLY TO YOUR CASE
AND PROVIDE THE REQUESTED INFORMATION
Plaintiff is asking the court to evict and exclude Defendant from the following
residence:
owned by (list owners, if known):
rented by (list all names, if known):
Defendant owes a duty of support to Plaintiff or the minor child/ren:
Plaintiff has suffered out-of-pocket financial losses as a result of the abuse
described above. Those losses are:
FOR THE REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT ENTER A
TEMPORARY ORDER, AND AFTER HEARING, A FINAL ORDER THAT WOULD DO
THE FOLLOWING (CHECK ALL FORMS OF RELIEF REQUESTED)
A. Restrain Defendant from abusing,harassing, stalking, threatening,
attempting or threatening to use physical force against Plaintiff or the minor child/ren in
any place where Plaintiff or the child/ren may be found.
B. Evict/exclude Defendant from Plaintiff's residence and prohibit Defendant
from attempting to enter any temporary or permanent residence of Plaintiff.
C. Require Defendant to provide Plaintiff or the minor child/ren with
other suitable housing.
D. Award Plaintiff temporary custody of the minor child/ren and place the
following restrictions on contact between Defendant and the child/ren:
E. Prohibit Defendant from having any contact with Plaintiff or the
minor child/ren, in person, by telephone, or in writing, personally or through third
persons, including but not limited to any contact at Plaintiff's school, business, or
place of employment, except as the court may find necessary with respect to partial
custody with the minor child/ren.
F. Prohibit Defendant from having any contact with Plaintiff's relatives and
Plaintiff's children listed in this petition, except as the court may find necessary with
respect to partial custody with the minor child/ren. The following persons are Plaintiff's
relatives or family and household members that Plaintiff believes require protection
from stalking and harassment by Defendant.
Name
Address (optional) Relationship to Plaintiff
G. Order Defendant to temporarily relinquish the firearms,
other weapons, or ammunition listed on Attachment A to Petition, under
Defendant’s control, or in Defendant’s possession, or any firearm license to the
sheriff or the appropriate law enforcement agency.
H. Prohibit Defendant from acquiring or possessing firearms for the duration of
the order.
I. Order Defendant to pay temporary support for Plaintiff or the minor child/ren,
including medical support and payment of the rent or mortgage on the residence.
J. Direct Defendant to pay Plaintiff for the reasonable financial losses.
K. Order Defendant to pay the costs of this action, including filing and service
L. Order Defendant to pay Plaintiff's reasonable attorney's fees.
fees.
Name
Address (optional) Relationship to Plaintiff
G. Order Defendant to temporarily relinquish the firearms,
other weapons, or ammunition listed on Attachment A to Petition, under
Defendant’s control, or in Defendant’s possession, or any firearm license to the
sheriff or the appropriate law enforcement agency.
H. Prohibit Defendant from acquiring or possessing firearms for the duration of
the order.
I. Order Defendant to pay temporary support for Plaintiff or the minor child/ren,
including medical support and payment of the rent or mortgage on the residence.
J. Direct Defendant to pay Plaintiff for the reasonable financial losses.
fees.
M. Order the following additional relief, not listed above:
N. Grant such other relief as Plaintiff requests or the court deems appropriate
O. Order the police, sheriff, or other law enforcement agency to serve
Defendant with a copy of this petition, any order issued, and the order for hearing.
Plaintiff will inform the designated authority of any addresses, other than Defendant's
residence, where Defendant can be served.
P. Direct the Pennsylvania State Police, the municipal police, or the sheriff to
accompany Plaintiff to his or her residence to retrieve personal belongings or accompany
Plaintiff while the petition or order is served on Defendant, if Plaintiff has reason to
believe his or her safety is at risk.
VERIFICATION
I verify that I am the petitioner as designated in the present action and that the facts and
statements contained in the above Petition are true and correct to the best of my
knowledge. I understand that any false statements are made subject to the penalties of
18 Pa. C.S. § 4904, relating to unsworn falsification to authorities
Signature
Date
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ATTACHMENT A TO PETITION
FIREARMS, OTHER WEAPONS, OR
AMMUNITION INVENTORY
I, , Plaintiff in this Protection from Abuse Action, hereby
(a) state that Defendant used or threatened to use the following firearms,
other weapons, or ammunition against Plaintiff or the minor child/ren
(include addresses or locations, if known, such as "front seat of blue truck", "gun
cabinet," "bedroom closet," etc.)
Firearm/Other Weapon/Ammunition Location
1.
2.
3.
4.
(b) state that Defendant, to the best of my knowledge or belief, owns or
possesses the following firearms, other weapons, or ammunition not set forth in (a)
above (include addresses or locations if, known):
Firearm/Other Weapon/Ammunition Location
1.
2.
3.
4.
5.
(c) request that the court order Defendant to relinquish the following firearms,
other weapons, or ammunition (include addresses or locations, if known):
Firearm/Other Weapon/Ammunition Location
1.
2.
3.
4.
5.
5.
□ All firearms, other weapons, or ammunition owned or possessed by
Defendant.
If more space is needed, more sheets may be attached to this document.
Name:
Date:
NOTICE: This attachment will be withheld from public inspection in
accordance with 23 Pa. C.S. § 6108 (a)(7)(v).
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IN THE COURT OF COMMON PLEAS OF (Unified Judicial System of Pennsylvania)

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Completed 27 May 2022

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