COURT OF COMMON PLEAS OF MONROE COUNTY
FORTY-THIRD JUDICIAL DISTRICT
COMMONWEALTH OF PENNSYLVANIA
________________________,
Plaintiff
vs.
________________________,
Defendant
:
:
:
:
:
:
:
NO. ______ DR 20____
NO. ______ CV 20____
ENTRY OF APPEARANCE AS A SELF-REPRESENTED PARTY
1.
I am the
Plaintiff
Defendant in the above-captioned (MARK ONE)
Protection from abuse, paternity case.
2.
Check either A, B or C below:
custody,
divorce,
support,
a.
This is or
is not a new case and I am representing myself in this case and have decided not to
hire an attorney to represent me.
b.
This is NOT a new case and ______________________________________________ (Name of
Attorney) previously represented me in this case. I 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. I have provided a copy of
this form to that attorney listed above at the following address: _______________________________________
c.
I am entering my appearance as a self-represented party (sign) ______________________________.
My attorney acknowledges his/her withdrawal as my attorney in this case.
(Attorney signature) ____________________________________________________, Esq.
(Print Attorney Name) __________________________________________________ , Esq.
3.
My address for the purpose of receiving all future pleadings and other legal notices is: ____________________
_____________________________________________________________________ (this
is
is not my
home address). I understand that this address will be the only address to which notices and pleadings in this
case will be sent, and that I am responsible to regularly check my mail at this address to ensure that I do not
miss important deadlines or proceedings.
4.
My telephone number where I can be reached during normal business hours (8:30 a.m. – 4:30 p.m. Monday –
Friday) is ______________________________________.
My email address is ______________________
My telephone number and email address are confidential pursuant to a Protection From Abuse Order.
5.
I UNDERSTAND I MUST FILE A NEW FORM EVERY TIME MY ADDRESS OR TELEPHONE NUMBER
CHANGES.
6.
I will immediately provide a copy of this form to all attorneys and other self-represented parties as
listed below: (Use reverse side if you need more space)
Name______________________________ Address__________________________________________
Name______________________________ Address__________________________________________
7.
I fully understand that by deciding to represent myself, the Court will hold me to the same standards of
knowledge regarding the statutory law, evidence law, Local and State Rules of Procedure and applicable case
law as a Pennsylvania licensed attorney, and that I must be fully prepared to meet those responsibilities.
I verify that the statements made in this Entry of Appearance as a Self-Represented Party are true and
correct. I understand that if I make false statements herein, that I am subject to the criminal penalties of
18 Pa.C.S. § 4904 relating to unsworn falsification to authorities which could result in a fine and/or
prison term.
_____________
Date
________________________________________________
Signature (Your Signature)
_____________________________________
Please Print (Your Name)
2
CUSTODY COMPLAINT
FORMS, FILING AND SERVICE PROCEDURES
And
CO-PARENT EDUCATION PROGRAM REQUIREMENTS
1. Forms
a. Attached is a packet of all forms necessary to initiate a custody
proceeding in the Monroe County Court of Common Pleas. The
attached forms are as follows (the “packet”):
i. Entry of Appearance
ii. Blank Scheduling Order
iii. Co-Parent Education Program order, information and
registration form
iv. Two blank Criminal Record/ Abuse History Verifications
v. Form Custody Complaint
vi. Verification
b. Also included as a separate document is a form Affidavit of Service.
2. Preparing the Documents for Filing
a. Complete the Entry of Appearance by filling in ALL required blanks
with accurate information.
b. Complete the Custody Complaint by filling in ALL required blanks with
accurate information.
c. Sign the Verification.
d. Complete the Criminal Record/ Abuse History Verification and sign it.
e. Once you have filled out the Complaint for Custody and signed the
verification, completed and signed the Criminal Record/ Abuse History
Verification, make 3 photocopies of the blank scheduling Order, CoParent Education Program order, information and registration form,
completed Custody Complaint, the signed Verification, and the signed
Criminal Record/ Abuse History Verification.
3
3. Filing
a. Take the original completed packet and 3 copies to the Prothonotary’s
office located on the 3rd floor of the Monroe County Courthouse.
b. Pay the filing fee to the Prothonotary in cash or by money order.
c. File the original packet, which shall include in the following order:
i. Completed Entry of Appearance
ii. Blank Scheduling Order
iii. Co-Parent Education Program order, information and
registration form
iv. Completed form Custody Complaint
v. Signed Verification
vi. Completed and signed Criminal Record/ Abuse History
Verification
d. Ask the Prothonotary to time-stamp the 3 copies of the packet.
e. You must file in person or by mail. Faxes and e-mails will not be
accepted.
4. Service
a. Serve the Defendant(s) with a copy of the time-stamped packet which
shall include the Blank Scheduling Order, Co-Parent Education
Program order, information and registration form, Completed form
Custody Complaint, Signed Verification, the completed and signed
Criminal Record/ Abuse History Verifications, and the blank Criminal
Record/ Abuse History Verification.
b. You may serve the complaint and accompanying documents in any of
the following manners:
i. Sheriff. You may pay the Monroe County Sheriff to serve the
Defendant(s). The Sheriff will then file an Affidavit of Service
as proof that the Sheriff served the Defendant(s).
ii. Personal Service. You may have an adult individual,
unrelated to any of the parties to the custody action,
personally serve the Defendant by handing a time-stamped
copy of the packet to the Defendant or a household member or
an adult individual who works at the Defendant’s place of
employment. The individual who serves the packet for you
4
must fill out and sign the Affidavit of Service in the presence of
a notary public. The Affidavit is included in the forms provided
to you. The Affidavit of Service must be filed with the
Prothonotary prior to your court proceeding or custody
conference. Bring a time stamped copy of you Affidavit of
Service with you to your court proceedings or custody
conference.
iii. Mail. You may serve the Defendant(s) by sending to the
Defendant one copy of the packet by regular mail and a second
copy by certified mail, return receipt requested restricted
delivery. Once you receive the signed green card back from
the post office, you must fill out and sign the Affidavit of Service
in the presence of a notary public and attach the original green
card to the Affidavit and then file them with the Prothonotary.
Service by mail is only good if you receive the signed return
receipt green card back prior to your scheduled court
proceeding or custody conference. If you do not receive the
green card back prior to your custody proceeding, you must
serve the Defendant(s) by one of the other manners listed
above. Bring a time stamped copy of you Affidavit of Service
with you to your court proceedings or custody conference.
5. Co-Parent Education Program
a. You must register to attend the Co-Parent Education Program within
15 days of receiving the court order requiring your attendance at the
program.
b. You must attend the Co-Parent Education Program within 60 days of
receiving the court order requiring your attendance at the program.
c. You will receive a certificate of attendance from the Co-Parent
Education Program once you have successfully completed the
course.
d. You must bring you certificate of attendance with you to your custody
proceeding or custody conference.
5
COURT OF COMMON PLEAS OF MONROE COUNTY
FORTY-THIRD JUDICIAL DISTRICT
COMMONWEALTH OF PENNSYLVANIA
________________________,
Plaintiff
vs.
________________________,
Defendant
:
:
:
:
:
:
:
ORDER
NO. ____ DR 20__
NO. ____ CV 20__
IN CUSTODY
You, ________________, have been sued in court to obtain/modify
custody or partial custody of the minor child(ren), ____________, born
_________, now age___ ; ____________, born _________, now age ___;
____________, born _________, now age ___; ____________, born
_________, now age ___.
AND NOW, upon consideration of the attached Complaint/Petition,
it is hereby Ordered that the parties and their respective counsel appear
before _________________________, Esquire, Custody Conciliator, on the
day of _________________, 201__ in the Conciliation Room, Second Floor,
Monroe County Courthouse at
(a.m./p.m.) for a conciliation
conference. At such conference, an effort will be made to resolve the issues
in dispute; or, if this cannot be accomplished, to define and narrow the issues
to be heard by the Court and to enter into an Interim Order. Failure to appear
at the Conference may provide grounds for the entry of a Temporary Order.
You are further ordered to bring with you the following children to the
conference:
_____________________________________________________________
______________________________________________________________
NOTE: Children under the age of eight (8) need not attend.
You are also ordered to provide to the Court and all other parties a
notarized affidavit concerning any criminal and/or abusive history, in
accordance with 23 Pa.C.S.A. §5329, Pa. Monroe Co. R.C.P. Rule 1915.3-1,
and Pa. Monroe Co. R.C.P. Rule 1915.22(5) prior to the custody conference.
6
If you fail to appear as provided by this Order, to bring with you the minor
child(ren), or provide the notarized affidavit concerning any criminal and/or
abusive history, an Order for custody may be entered against you by the
Court or the Court may issue a warrant for your arrest.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE.
IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO
OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT
WHERE YOU CAN GET HELP:
MONROE COUNTY BAR ASSOCIATION
FIND A LAWYER PROGRAM
913 MAIN STREET
STROUDSBURG, PENNSYLVANIA 18360
(570) 424-7288
AMERICANS WITH DISABILITIES ACT OF 1990
The Court of Common Pleas of Monroe County is required by law to comply
with the Americans with Disabilities Act of 1990. For information about
accessible facilities and reasonable accommodations available to disabled
individuals having business before the Court, please contact our office. All
arrangements must be made at least 72 hours prior to any hearing or
business before the Court. You must attend the scheduled conference or
hearing.
BY THE COURT:
Date: ______________
________________________________
J.
cc:
__________________, Esq., Custody Conciliator
______________________
______________________
Custody Conciliation
7
COURT OF COMMON PLEAS OF MONROE COUNTY
FORTY-THIRD JUDICIAL DISTRICT
COMMONWEALTH OF PENNSYLVANIA
_______________________________, :
Plaintiff
:
:
vs.
:
:
_______________________________, :
Defendant :
NO. ____ DR 20___
NO. ____ CV 20___
IN CUSTODY
ORDER
AND NOW, this ____ day of _____________, 20__, ALL PARTIES ARE
HEREBY ORDERED to attend a program entitled the Co-Parent Education
Program and to bring with you the Certificate of Completion you will receive at the
program. You must register for the program using the registration form attached
within fifteen (15) days of the date that you receive this Order. Further, you must
attend and complete the program within sixty (60) days of the date that you receive
this Order.
FAILURE TO ATTEND AND COMPLETE THE PROGRAM IN
ACCORDANCE WITH THE INSTRUCTIONS ATTACHED TO THIS ORDER WILL
BE BROUGHT TO THE ATTENTION OF THE COURT AND MAY RESULT IN
THE FINDING OF CONTEMPT AND THE IMPOSITION OF SANCTIONS
BY THE COURT.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF
YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR
TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU
CAN GET HELP:
MONROE COUNTY BAR ASSOCIATION
FIND A LAWYER PROGRAM
913 MAIN STREET
STROUDSBURG, PENNSYLVANIA 18360
(570) 424-7288
8
AMERICANS WITH DISABILITIES ACT OF 1990
The Court of Common Pleas of Monroe County is required by law to comply
with the Americans with Disabilities Act of 1990. For information about accessible
facilities and reasonable accommodations available to disabled individuals having
business before the Court, please contact our office. All arrangements must be
made at least 72 hours prior to any hearing or business before the Court. You must
attend the scheduled conference or hearing.
BY THE COURT:
_______________________________
J.
cc:
__________________, Esq., Custody Conciliator
______________________
______________________
Custody Conciliation
9
2015 CO-PARENT EDUCATION PROGRAM
In cases involving minor children, attendance at a four-hour Co-Parent Education
Program is required of the parties in custody and divorce actions.
MINOR CHILDREN SHALL NOT BE BROUGHT TO THE PROGRAM
PROGRAM CONTENT
The program focuses on the impact of divorce on parents and children, with an emphasis
on fostering a child's emotional health and well-being during the periods of stress. The program
is informative, supportive, and directs people desiring additional information or help to
appropriate resources.
The Program addresses the following items:
I. Impact of Divorce on Parents and Children: tasks adults face; tasks children
face; common reactions of children of different ages; and do's and don'ts of parenting.
II. Handling the Feelings: Identifying feelings; Anger in divorce: toward your
co-parent, from your children, toward your children; Feeling and healing.
III. Video segments and Discussion: Explaining divorce, warning parents,
visitation problems, new relationships, etc.
IV. Mediation: Explanation of mediation process and its applicability to divorce
and custody matters.
When
The Program is offered every other month on one Saturday morning from 9:00 a.m. until 1:00
p.m. or every other month on one Tuesday evening from 5:30 p.m. until 9:30 p.m.
Where
The Program will be presented in Hearing Room A, lower level of the Monroe County
Courthouse, 7th & Monroe Streets, Stroudsburg, Pennsylvania, unless otherwise directed by
security. A security officer will direct you on where to go.
Attendance
Attendance at the Program is required of parties to a case where the interests of children under
the age of eighteen years are involved. Additional interested persons may attend the seminar
upon prior approval of Family/Divorce Services and certain fees may apply.
Presenters
Qualified counselors, educators and trainers selected by Family/Divorce Services will present
the Program pursuant to arrangements with the Court of Common Pleas of Monroe County.
Notification
A copy of the Order requiring the parties to attend the Program and Registration Form will be
provided to the parties at the time of the filing of the action or service of the applicable pleading.
Fees
A fee of $40.00 money order per party for the Program is required and will be used to cover all
program costs including the presenter’s fee, handouts and administration. The fee must be
submitted with the registration form.
10
Registration
The registration form must be received by Family/Divorce Services at least seven (7) days prior
to the Program date selected. Each party shall attend the Program without further notification by
the Court. Any changes in scheduling must be arranged through Family/Divorce Services.
Verification of Attendance
Upon proof of identification at the Program, Family/Divorce Services will record the party as
"present" and provide to the Prothonotary of Monroe County a Certificate of Completion, which
shall be filed of record. Each person successfully completing the program will be given a
Certificate of Attendance. Should you have a case in another County or State, you are
responsible to provide that Court with a copy of your Certificate of Completion.
Americans with Disabilities
For information about accessible facilities and reasonable accommodations available to disabled
individuals having business before the Court, please contact the Court Administrator’s office at
(570)-517-3009. All arrangements must be made at least (72) hours prior to the Co-Parent
Program and you must attend the scheduled program.
Security
The Monroe County Sheriff's Office will provide armed, uniformed deputies at each Program
immediately prior to, during and immediately after each presentation.
11
CO-PARENT EDUCATION PROGRAM – 2015 Registration Form
READ ALL INFORMATION
Register by MAIL ONLY. See form below.
The Program is held on the lower level of the Monroe County Courthouse, Stroudsburg, PA. The
Sheriff’s Department provides security.
Further questions should be directed to Family/Divorce Services at 610-366-8868.
The Program fee is $40 per person for all persons ordered to attend. Guests are welcome, but require
an additional $15 fee. Sign them up on form below.
A DVD to view and return is available ONLY to parties who reside more than 90 minutes driving
time from Stroudsburg. See order form below.
Please register at least a week before you plan to attend. Confirmations are NOT sent by mail or
by phone. Send in your form and come to the courthouse on the date you choose.
Children shall not be brought to the courthouse. Be prompt. Latecomers will not be admitted and
will have to re-schedule.
In case of a snowstorm, a message will play at 610-366-8868 if class is canceled. Also, listen to
radio 93.5FM or 840AM or WYOU TV for notices of cancellation. If you are disabled and need
special assistance to enter the courthouse, call ahead.
REGISTER BY MAIL. Choose your date, fill out the form below and send MONEY ORDER
payable to: Family/Divorce Services, P.O. Box 318, Trexlertown, PA 18087.
DOCKET NUMBERS of your divorce and custody case MUST be filled in. Include numbersletters-year of file:_______________________________________________________________
Your name_____________________________________________________________________
Address___________________________________City_______________State_______Zip____
Guest(name and relationship to child)_______________________________________________
Phone: Home____________________________Work__________________________________
Pick a Saturday morning OR a Tuesday evening:
SATURDAYS 9 am-1pm
TUESDAYS 5:30-9:30pm
__January 10, 2015
__February 10, 2015
__March 7
__April 7
__May 2
__June 9
__July 11
__August 11
__September 12
__October 6
__November 7
__December 8
____DVD: $75 fee (includes S&H and $25 deposit. Deposit is refunded when tape is returned per
instructions.)
12
COURT OF COMMON PLEAS OF MONROE COUNTY
FORTY-THIRD JUDICIAL DISTRICT
COMMONWEALTH OF PENNSYLVANIA
________________________________
Plaintiff
vs.
________________________________
Defendant
:
:
:
:
:
:
:
:
NO. _________ DR 20______
NO. _________ CV 20______
IN CUSTODY
PLAINTIFF 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:
Check all that apply:
Answer
Crime
Self
Other
Household
Member
Yes or No
□
□
18 Pa.C.S. Ch. 25
□
□
□
□
18 Pa.C.S. § 2702
□
□
relating to criminal homicide
relating to aggravated assault
13
Date of
Conviction,
guilty plea, no
contest plea
or pending
charges
Sentence
Answer
Crime
Yes or No
Self
Other
Household
Member
□
□
18 Pa.C.S. § 2709.1
□
□
□
□
18 Pa.C.S. § 2901
□
□
□
□
18 Pa.C.S. § 2902
□
□
□
□
18 Pa.C.S. § 2903
□
□
□
□
18 Pa.C.S. § 2910
□
□
□
□
18 Pa.C.S. § 3121
□
□
□
□
18 Pa.C.S. § 3122.1
□
□
□
□
18 Pa.C.S. § 3123
□
□
□
□
18 Pa.C.S. § 3124.1
□
□
□
□
18 Pa.C.S. § 3125
□
□
□
□
18 Pa.C.S. § 3126
□
□
relating to stalking
relating to kidnapping
relating to unlawful restraint
relating to false imprisonment
relating to luring a child into a
motor vehicle or structure
relating to rape
relating to statutory sexual
assault
relating to involuntary deviate
sexual intercourse
relating to sexual assault
relating to aggravated
indecent assault
relating to indecent assault
14
Date of
Conviction,
guilty plea, no
contest plea
or pending
charges
Sentence
Answer
Crime
Self
Other
Household
Member
Yes or No
□
□
18 Pa.C.S. § 3127
□
□
□
□
18 Pa.C.S. § 3129
□
□
□
□
18 Pa.C.S. § 3130
□
□
□
□
18 Pa.C.S. § 3301
□
□
□
□
18 Pa.C.S. § 4302
□
□
□
□
18 Pa.C.S. § 4303
□
□
□
□
18 Pa.C.S. § 4304
□
□
□
□
18 Pa.C.S. § 4305
□
□
□
□
18 Pa.C.S. § 5902(b)
□
□
□
□
18 Pa.C.S. § 5903(c) or (d)
□
□
relating to indecent exposure
relating to sexual intercourse
with animal
relating to conduct relating to
sex offenders
relating to arson and related
offenses
relating to incest
relating to concealing death of
child
relating to endangering
welfare of children
relating to dealing in infant
children
relating to prostitution and
related offenses
relating to obscene and other
15
Date of
Conviction,
guilty plea, no
contest plea
or pending
charges
Sentence
Crime
Answer
Self
Other
Household
Member
Yes or No
Date of
Conviction,
guilty plea, no
contest plea
or pending
charges
Sentence
sexual materials and
performances
□
□
18 Pa.C.S. § 6312
□
□
□
□
18 Pa.C.S. § 6318
□
□
□
□
18 Pa.C.S. § 6320
□
□
□
□
23 Pa.C.S. § 6114
□
□
□
□
□
□
□
□
□
□
relating to sexual abuse of
children
relating to unlawful contact
with minor
relating to sexual exploitation
of children
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
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 apply:
Answer
Yes or
No
□ □
□ □
Self
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
16
□
□
Other
household
member
□
□
Date
□
□
□ □
Involvement with a Children & Youth Agency or
similar agency in Pennsylvania or other another
Jurisdiction.
Where:______________________________________
Other:
□
□
□
□
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 partys
household has or have a criminal/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.
Signature
Printed Name
Date completed:
17
COURT OF COMMON PLEAS OF MONROE COUNTY
FORTY-THIRD JUDICIAL DISTRICT
COMMONWEALTH OF PENNSYLVANIA
________________________________
Plaintiff
vs.
________________________________
Defendant
:
:
:
:
:
:
:
:
NO. _________ DR 20______
NO. _________ CV 20______
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:
Check all that apply:
Answer
Crime
Self
Other
Household
Member
Yes or No
□
□
18 Pa.C.S. Ch. 25
□
□
□
□
18 Pa.C.S. § 2702
□
□
relating to criminal homicide
relating to aggravated assault
18
Date of
Conviction,
guilty plea, no
contest plea
or pending
charges
Sentence
Answer
Crime
Yes or No
Self
Other
Household
Member
□
□
18 Pa.C.S. § 2709.1
□
□
□
□
18 Pa.C.S. § 2901
□
□
□
□
18 Pa.C.S. § 2902
□
□
□
□
18 Pa.C.S. § 2903
□
□
□
□
18 Pa.C.S. § 2910
□
□
□
□
18 Pa.C.S. § 3121
□
□
□
□
18 Pa.C.S. § 3122.1
□
□
□
□
18 Pa.C.S. § 3123
□
□
□
□
18 Pa.C.S. § 3124.1
□
□
□
□
18 Pa.C.S. § 3125
□
□
□
□
18 Pa.C.S. § 3126
□
□
relating to stalking
relating to kidnapping
relating to unlawful restraint
relating to false imprisonment
relating to luring a child into a
motor vehicle or structure
relating to rape
relating to statutory sexual
assault
relating to involuntary deviate
sexual intercourse
relating to sexual assault
relating to aggravated
indecent assault
relating to indecent assault
19
Date of
Conviction,
guilty plea, no
contest plea
or pending
charges
Sentence
Answer
Crime
Self
Other
Household
Member
Yes or No
□
□
18 Pa.C.S. § 3127
□
□
□
□
18 Pa.C.S. § 3129
□
□
□
□
18 Pa.C.S. § 3130
□
□
□
□
18 Pa.C.S. § 3301
□
□
□
□
18 Pa.C.S. § 4302
□
□
□
□
18 Pa.C.S. § 4303
□
□
□
□
18 Pa.C.S. § 4304
□
□
□
□
18 Pa.C.S. § 4305
□
□
□
□
18 Pa.C.S. § 5902(b)
□
□
□
□
18 Pa.C.S. § 5903(c) or (d)
□
□
relating to indecent exposure
relating to sexual intercourse
with animal
relating to conduct relating to
sex offenders
relating to arson and related
offenses
relating to incest
relating to concealing death of
child
relating to endangering
welfare of children
relating to dealing in infant
children
relating to prostitution and
related offenses
relating to obscene and other
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Date of
Conviction,
guilty plea, no
contest plea
or pending
charges
Sentence
Answer
Crime
Self
Other
Household
Member
Yes or No
Date of
Conviction,
guilty plea, no
contest plea
or pending
charges
Sentence
sexual materials and
performances
□
□
18 Pa.C.S. § 6312
□
□
□
□
18 Pa.C.S. § 6318
□
□
□
□
18 Pa.C.S. § 6320
□
□
□
□
23 Pa.C.S. § 6114
□
□
□
□
□
□
□
□
□
□
relating to sexual abuse of
children
relating to unlawful contact
with minor
relating to sexual exploitation
of children
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
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:
21
Check all that apply:
Answer
Yes or No
Self
Other
household
member
□
□
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
□
□
□
□
Other:
□
□
Date
□
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 partys
household has or have a criminal/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.
Signature
Printed Name
Date completed:
22
COURT OF COMMON PLEAS OF MONROE COUNTY
FORTY-THIRD JUDICIAL DISTRICT
COMMONWEALTH OF PENNSYLVANIA
________________________,
Plaintiff
vs.
________________________,
Defendant
:
:
:
:
:
:
:
NO. ____ DR 20__
NO. ____ CV 20__
IN CUSTODY
COMPLAINT FOR CUSTODY
TO THE HONORABLE, THE JUDGES OF SAID COURT:
Plaintiff____________________________ (your name), Pro se,
brings this Complaint for Custody based upon the following:
1. Plaintiff is _____________________________(name) an adult individual who
resides at ___________________________________________________(mailing
address), ____________________(city), County,_________________,
______(state), ______________(zip code).
Telephone Number and/or Cell Phone Number ______-________-___________.
2. Defendant is _____________________________(name) an adult individual
who resides at _____________________________________________(mailing
address),_____________________(city) County,_________________,
_______ (state), ______________(zip code).
Telephone Number and/or Cell Phone Number _____-_____ -___________.
Additional Defendant is _____________________________(name) an adult
individual who resides at ________________________________________(mailing
address),_____________________(city) County,_________________,
_______ (state), ______________(zip code).
Telephone Number and/or Cell Phone Number _____-_____ -___________.
23
3. Plaintiff seeks custody of the following child(ren):
(If more space is needed please enter on other side of page.)
Name
Present Address
Date of Birth
_________________ _________________________________ ______________
Name
Present Address
Date of Birth
___________________ _________________________________ ____________
Name
Present Address
Date of Birth
______________________ _____________________________ _____________
Name
Present Address
Date of Birth
_____________________ ______________________________ _____________
The minor child(ren) (were) or (were not) born out of wedlock.
The child(ren) are presently in the custody of___________________________
(name) Who resides at ____________________________________________
(address).
4. For the past five years the minor child(ren) ___________________________
____________________have resided with the following persons and at the
following addresses:
Persons
Address
Dates
__________________ ___________________________ ___________________
__________________ ___________________________ ___________________
__________________ ___________________________ ___________________
__________________ ___________________________ ___________________
24
5. Legal Representation:
Plaintiff New Attorney
Name:________________________________________________
Address:_____________________________________________________
Pro-Se (filing on your own): Plaintiff_____ Defendant _____ (Check one)
Defendant New Attorney
Name:____________________________________________
Address:_____________________________________________________
6. The relationship of the Plaintiff to the minor child(ren) is that of
_____________________. The Plaintiff currently resides with the following
persons.
Name
Relationship to Plaintiff
________________________________ _______________________________
________________________________ _______________________________
________________________________ _______________________________
________________________________ _______________________________
7. The relationship of the Defendant to the minor child(ren) is that of
_____________________.
25
The Defendant currently resides with the following persons.
Name
Relationship to Defendant
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
8. Plaintiff and Defendant were:
_____Never married.
_____Married on ______________________.
(Please check and answer accordingly.)
9. Plaintiff (has) (has not) participated as a party or 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:________________________________________________________________.
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10. Plaintiff does not know of a person not a party to the proceedings who has
Physical Custody of the minor child(ren) or claims to have custody rights with
respect to the child(ren).
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
11. The best interest and permanent welfare of the minor child(ren) will be served
by granting the relief requested because: [list facts showing that the granting of the
relief requested will be in the best interest and permanent welfare of the child(ren)]:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________.
12. 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 a
party 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:
Persons
Address
Basis of Claim
__________________ ___________________ ___________________________
__________________ ___________________ ___________________________
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13. Plaintiff hereby avers the following:
a) Plaintiff has been advised of the requirement to attend the CoParent Education Program and of the program description set forth following Local
Rule 1930.
b) Defendant will be provided, along with the Complaint, a copy of the
Order requiring attendance at the Co-Parent Education Program set forth herein, a
copy of an application for registration for the program, and the program description
set forth following Local Rule 1930.
WHEREFORE, Plaintiff requests the Honorable Court to grant partial
custody of the minor child(ren).
Respectfully Submitted,
_____________________________
Plaintiff, pro se
Dated: _____________________
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VERIFICATION
I verify that the statements made in the foregoing document are true
and correct. I understand that false statements made are subject to the penalties of
18 Pa. C.S. 4904, relating to unsworn falsification to authorities.
Respectfully Submitted,
_____________________________
Plaintiff, pro se
Dated: _____________________
29
COURT OF COMMON PLEAS OF MONROE COUNTY
FORTY-THIRD JUDICIAL DISTRICT
COMMONWEALTH OF PENNSYLVANIA
______________________,
Plaintiff
:
:
:
:
:
:
:
VS.
______________________,
Defendant
No. ____ DR _____
No. ____ CV _____
IN CUSTODY
AFFIDAVIT OF SERVICE
I, _________________________________________ (name of
person delivering or mailing document), being duly sworn, hereby state that I:

OR

Hand Delivered
Sent by US Certified Mail, Return Receipt Requested,
Restricted Delivery
a true and correct of the Complaint for Custody in the above-captioned action to
______________________________ (name of party to whom the document was
delivered or mailed) on ___________________ (date) at ________ o’clock __.m.
If service was made by US Certified Mail, Return Receipt Requested, Restricted
Delivery, attach returned receipt card signed by the Defendant.
______________________________
Signature of person delivering or
mailing document
Sworn to and subscribed before me this ____ day of ______________, 201___.
___________________________
Notary Public
30