INSTRUCTIONS FOR FILING A CUSTODY COMPLAINT The following documents should be completed and filed with the filing fees, unless or neatly printed: INTAKE FORM Complete this form in its entirety. COVER SHEET and address. You are the plaintiff. The person you are filing against is the defendant. the word ORDER OF COURT FOR CONFERENCE/HEARING Insert your name on the first line on the left side of the top of the form (This is called the caption). Inof the form. The Court will complete the rest of the form. ORDER OF COURT Insert your name on the first line on the left side of the top of the form (This is called the caption). of the form. Please complete numbers 1, 5, 6 and 8 with your proposed recommendations for custody. COMPLAINT FOR CUSTODY Insert your name on the first line on the left side of the top of the form (This is called of the form. Answer all the questions on the form completely and sign on both (Current filing fees are $199.65 plus $150.00 for custody master. If you are filing an agreement, current filing fee is $199.65 only.) Complete the Criminal Record/Abuse History Verification regarding criminal offense(s) for all parties and members of the household. RELOCATION No party may make a change in the residence of any child which significantly impairs the ability of the other party to exercise custodial rights without first complying with all of the applicable provisions of 23 Pa.C.S. 2475337 and Pa.R.C.P. No. 1915.17 regarding relocation. American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR WAIVER OF COSTS (if applicable) Complete this form ONLY if you cannot afford to pay the initial filling fees and costs. Insert your name on the first line on the left side of the top of the form (This is called of the form. Answer all the questions on the form completely. You must sign and date the form at the bottom. (Current filing fees are $199.65 plus $150.00 for custody master.) ORDER OF COURT FOR WAIVING PAYMENT OF COSTS (if applicable) If you complete the Petition for Waiver of Costs, insert your name on the first line on the left side of the top of the form (This is called the caption). Insert the defenname on the second line on the left side of the top of the form. The Court will complete the rest of the form. PENNSYLVANIA RULE OF CIVIL PROCEDURE 1930.4 SERVICE OF ORIGINAL PROCESS IN DOMESTIC RELATIONS MATTERS Proper service is required. Kindly review this rule which explains the proper procedure for effecting service. American LegalNet, Inc. www.FormsWorkFlow.com CARBON COUNTY CUSTODY Intake: COMPLAINT/MODIFICATION/CONTEMPT Docket Number: Plaintiff (Mother Father Other) Name: Date of Birth: Address: Apt: City: State: Zip: Home Phone: Other Phone Phone: Defendant (Mother Father Other) Name: Date of Birth: Address: Apt: City: State: Zip: Home Phone: Other Phone Children With whom does child(ren) reside? Mother Father Other Has child(ren) and custodian resided in Carbon County for six months? Yes No Interpreter: Does either party need an Interpreter? Yes No If Yes, what language? Mediation: Are there allegations of domestic violence or child abuse? Yes No Does either party live more than 75 miles from Courthouse? Yes No Incarceration: Is a party currently incarcerated? Yes No (Attorney for Plaintiff) (Plaintiff) Date DELIVER THIS FORM WITH PLEADING TO PROTHONOTARY American LegalNet, Inc. www.FormsWorkFlow.com Court of Common Pleas of Carb on County Civil Cover Sheet For Prothonotary Use only (Docket Number) Enter names (last, first, middle initial) of plaintiff. If the plaintiff is a government agency or corporation, use the full name of the agency or corporation. I n the event there are more than two plaintiffs, list the additional parties on a separate sheet of paper. Husband and wife should be listed as separate parties. Enter names (last, first, middle initial) of defendant. If the defendan t is a government agency or corporation, use the full name of the agency or corporation. In the event there are more than two defendants, list the additional parties on a separate sheet of paper. Husband and wife should be listed as separate parties. PLAN Enter the address and telephone numbers of the parties at the time of filing of the action. If any party is a corporation, enter the address and telephone number of the registered office of the corporation. ADDRESS AND TELEPHONE NUMBER: Enter the address and telephone numbers of the parties at the time of filing of the action. If any party is a corporation, enter the address and telephone number of the registered office of the corporation. ADDITIONAL PL TOTAL NUMBER OF PLAINTIFFS: Indicate the total number of plaintiffs and the total number of defendants in th e action. TOTAL NUMBER OF DEFENDANTS: Indicate the total number of plaintiffs and the total number of defendants in the action. STATUTORY BASIS FOR CAUSE OF ACTION If the action is commenced pursuant to statutory authority ("Petition Action"), the sp ecific statute must be cited RELATED PENDING CASES: ( All previously filed related cases must be identified by docket number. Indicated whether they have been consolidated by Court Order or Stipulation.) TO THE PROTHONOTARY: Kindly enter my appearan ce on behalf of Plaintiff/Petitioner/Appellant. Papers may be served at the address set forth below. Unrepresented filers must provide their name, address, telephone number and signature. ADDRESS PHON E NUMBER SUPREME COURT IDENTIFICATION NUMBER E - MAIL ADDRESS: FAX NO. (OPTIONAL FOR SERVICE): Providing the fax number shall authorize the service of legal papers by facsimile transmission. See Pa.R.CP.440(d) DATE: SIGNATURE: American LegalNet, Inc. www.FormsWorkFlow.com IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA CIVIL ACTION - LAW : PLAINTIFF : VS. : CUSTODY : NO. : DEFENDANT : You, , defendant, have been sued in court to OBTAIN (shared legal custody) (sole legal custody) (partial physical custody) (primary physical custody) (shared physical custody) (sole physical custody) (supervised physical custody) of the child(ren): . You are ordered to appear in person at the First Floor or Third Floor Conference Room, Carbon County Courthouse, Jim Thorpe, Pennsylvania, 18229, on , 20, at M., prevailing time, for a conciliation or mediation conference. a pretrial conference. a hearing before the court. Any party to a custody action, who is incarcerated and cannot attend any scheduled proceeding and wishes to participate by electronic means, shall request permission from Court Administration seven (7) days before the scheduled event. Said party shall be responsible for making the arrangements with Court Administration and the Warden of said facility where the party is incarcerated. If you fail to appear as provided by this order, an order for custody may be entered against you or the court may issue a warrant for your arrest. You must file with the court a verification regarding any criminal American LegalNet, Inc. www.FormsWorkFlow.com record or abuse history regarding you and anyone living in your household on or before the initial in-person contact with the court (including, but not limited to, a conference with a conference officer or judge or conciliation) but not later than 30 days after service of the complaint or petition. No party may make a change in the residence of any child which significantly impairs the ability of the other party to exercise custodial rights without first complying with all of the applicable provisions of 23 Pa.C.S. 2475337 and Pa.R.C.P. No. 1915.17 regarding relocation. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. North Penn Legal Services 101 West Broad Street, Suite 713 Hazleton, PA 18201 (877) 953-4250 or Carbon County Lawyer Referral 811 Blakeslee Blvd. Dr. East, Suite 130 Lehighton, PA 18235 Phone 1-610-379-4950 Fax (610) 379-4952 AMERICANS WITH DISABILITIES ACT OF 1