INSTRUCTIONS: Applications for telephone conference/hearing requests should be submitted at least 10 days before the scheduled conference/hearing, along with all financial a nd medical insurance information listed on the order to appear/checklist . Be SPECIFIC as to the reason for the request and be sure to include the telephone number where you can be reached at the time of the conference or hearing. You are responsible for the costs of the telephone conference. The DRS will call you at the number you provided when the proceeding is ready to b e g in . If you are not at the phone number provide d when you are called, the proceeding will take place in your absence and a n order may be entered in your absence or your complaint/petition may be dismissed. The DRS will notify the filing party of the decision on the request for the telephone conference/hearing. A new request is required for each proceeding. Completed application should be returned to Berks County Domestic Relations by: mail or in person to 633 Court St, 6 th Floor, Reading PA 19601, email to Support.Berks@PACSES.com, or fax to (610) 898 - 5579. IN THE COURT OF COMMON PLEAS OF BERKS COUNTY, PENNSYLVANIA DOMESTIC RELATIONS SECTION APPLICATION FOR TELEPHONE CONFERENCE/HEARING APPLICATION IS HEREBY MADE TO PARTICIPATE BY PHONE FOR THE FOLLOWING CASE AND PROCEEDING : DOCKET Plaintiff VS PACSES CASE ID Defendant Scheduled conference/hearing DATE: TIME: ( EST ) Reason(s) for request for telephone conference/hearing: (be specific) Telephone number, including area code, where I can be contacted on the day of the conference/hearing: Is this number confidential? Yes / No I understand by making this request, I will: 1) S ubmit the required f inancial and medical information listed on the Telephone C onference/ H earing C hecklist including, copies of paystubs , most recent tax return and/or any pertinent financial information no later than 10 days prior to the conference/hearing. 2) B e responsible for the costs of the telephone conference/hearing . 3) B e available at the telephone number provided on the day of the conference/hearing (Hearings require being available for the entire AM (9 - 12) or PM (1 - 4) . If I am not available, the conference/hearing wil l proceed in my absence. All conference and hearing times are Eastern Standard Time . 4) A ttach a copy of my identification to verify my identity. If I fail to submit any of these documents, this application may be denied. Applicant name (Please Print) Date FOR COURT USE ONLY ACTION TAKEN : ( ) Application is * CONDITIONALLY APPROV ED ( ) Application is APPROVED ( ) Application is DENIED *Applicant must provide: F INANCIAL I NFORMATION , P ROOF OF I NABILITY TO W ORK /D ISABILITY OR O THER Rev 10.17 Unit Manager, Hearing Officer, or Judge Date PC001 American LegalNet, Inc. www.FormsWorkFlow.com IN THE COURT OF COMMON PLEAS OF BERKS COUNTY, PENNSYLVANIA DOMESTIC RELATIONS SECTION TELEPHONE CONFERENCE CHECKLIST Name PACSES case # Conference date The below information is required in order to participate by telephone. This information must be submitted for the hearing even if already provided at the confe rence. Income and Expense sheet provided to you with the order to appear Copies of last 6 months pay stubs or if YTD totals are listed, your most recent paystub Copy of your most recent income tax return s Verification of child care expenses, if applicable Proof of available medical coverage for the children/spouse (copies of cards, etc.) and cost to provide coverage Verification of any other source of income, including welfare benefits, SSI, SSD, unemployment benefits, workers compensation benefits, disability benefits (VA or private), if applicable Medical documentation, if unable to work due to a m edical condition . This form maybe requested from the Domestic Relations Section Other: If you are not currently employed and have no source of income, please explain: Completed application should be returned to Berks County Domestic Relations by: mail or in person to 633 Court St, 6 th Floor, Reading PA 19601, email to Support.Berks@PACSES.com, or fax to (610) 898 - 5579. American LegalNet, Inc. www.FormsWorkFlow.com