INSTRUCTIONS FOR FILING A CUSTODY COMPLAINT OR A PETITION FROM MODIFICATION OF PARTIAL CUSTODY OR VISITATION ORDER The following documents should be completed and filed with the filing fees, unless waived by the Court, in the Prothonotary’s office. All information must be typewritten or neatly printed: COVER SHEET Fill in the top part of this form with your name and address and the defendant’s name and address. You are the plaintiff. The person you are filing against is the defendant. Box F should contain a “C” and the word “custody”. You must sign and date the form at the bottom. 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). Insert the defendant/respondent’s name on the second line on the left side of the top of 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). Insert the defendant/respondent’s name on the second line on the left side of the top of the form. Please complete numbers 1, 5 and 6 with your proposed recommendations for custody, partial custody, or visitation. COMPLAINT FOR CUSTODY/PARTIAL CUSTODY/VISITATION Insert your name on the first line on the left side of the top of the form (This is called the caption). Insert the defendant’s name on the second line on the left side of the top of the form. Answer all the questions on the form completely and sign on both signature lines above the word “Plaintiff”. (Current filing fees are $154.90 plus $150.00 for custody master. If you are filing an agreement, current filing fees are $154.90 only) PETITION FOR MODIFICATION OF A PARTIAL CUSTODY OR VISITATION ORDER If you already have a custody order from the court and you wish to change it, complete this form instead of the complaint by inserting your name on the first line on the left side of the top of the form (This is called the caption). Insert the other person’s name on the second line on the left side of the top of the form. You are the “Petitioner” and the other person is the “Respondent”. Insert your case number from your custody order on the right hand side. Answer all the questions on the form completely. Sign the form in both places at the bottom above the word “Petitioner”. (Current filing fees are $20.75 plus $150.00 for custody master.) 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 the caption). Insert the defendant/respondent’s name on the second line on the left side of the top 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 $154.90 plus $150.00 for custody master.) American LegalNet, Inc. www.FormsWorkFlow.com 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 defendant/respondent’s name on the second line on the left side of the top of the form. The Court will complete the rest of the form. American LegalNet, Inc. www.FormsWorkFlow.com Court of Common Pleas of Carbon County For Prothonotary Use only (Docket Number) Civil Cover Sheet PLAINTIFF’S NAME: 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. In 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. DEFENDANT’S NAME: Enter names (last, first, middle initial) of defendant. If the defendant 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. PLANTIFF’S ADDRESS & TELEPHONE DEFENDANT’S ADDRESS AND TELEPHONE NUMBER: Enter the address and telephone numbers of the parties at NUMBER: Enter the address and telephone numbers of the parties at the 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. 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 PLAINTIFF’S NAME: ADDITIONAL DEFENDANT’S NAME: ADDITIONAL PLANTIFF’S ADDRESS/ TELEPHONE NO: ADDITIONAL DEFENDANT’S ADDRESS /TELEPHONE NO: TOTAL NUMBER OF PLAINTIFFS: Indicate the total TOTAL NUMBER OF DEFENDANTS: number of plaintiffs and the total number of defendants in the action. of plaintiffs and the total number of defendants in the action. Indicate the total number STATUTORY BASIS FOR CAUSE OF ACTION If the action is commenced pursuant to statutory authority ("Petition Action"), the specific 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 appearance on behalf of Plaintiff/Petitioner/Appellant. Papers may be served at the address set forth below. NAME OF PLAINTIFF’S/APPELLANT’S ATTORNEY: ADDRESS Unrepresented filers must provide their name, address, telephone number and signature. PHONE 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. Pa.R.CP.440(d) American LegalNet, Inc. www.FormsWorkFlow.com See DATE: _____________________________ SIGNATURE: _____________________________________________________ IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA CIVIL ACTION - LAW PLAINTIFF/PETITIONER VS. DEFENDANT / RESPONDENT You, : : : : : : CUSTODY NO. , (defendant) (respondent), have been sued in court to (obtain / modify) custody, partial custody or visitation 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. If you fail to appear as provided by this order, an order for custody, partial custody or visitation may be entered against you 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, 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 FREE OR NO FEE. North Penn Legal Services 1203 North Street Jim Thorpe, PA 18229 American LegalNet, Inc. www.FormsWorkFlow.com (570) 325-5050 AMERICANS WITH DISABILITIES ACT OF 1990 The Court of Common Pleas of Carbon 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 seventy-two (72) hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing. BY THE COURT: Dated: ______________________________ J. American LegalNet, Inc. www.FormsWorkFlow.com IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA CIVIL ACTION - LAW ____________________________________, Plaintiff/Petitioner NO. ____________________________________, Defendant/Respondent : : : : : : : _____________________________________ - Counsel for Plaintiff _____________________________________ - Counsel for Defendant vs. ORDER OF COURT AND NOW this day of , 20 , it is hereby ORDERED and DECREED as follows: 1. This Order of Court shall govern the custodial situation of the following children: _______________________________________________________________________________ _______________________________________________________________________________ 2. In accordance with the statutory laws of this Commonwealth, each party shall be provided all access to the medical, dental, religious and school records of the child(ren) involved. Absent an emergency situation, each party shall be informed in regard to the medical and dental needs of the child(ren) involved. 3. Jurisdiction of the child(ren) and this matter shall remain with the Court of Common Pleas of Carbon County, Pennsylvania, unless or until jurisdiction would change under the Uniform Child Custody Jurisdiction Act. 4. The welfare of the child(ren) shall be the primary consideration of the parties in any application of the terms of this Agreement. The parties shall exert every reasonable effort to foster a feeling of affection between the child(ren) of the other party. Neither party shall do anything to estrange the child(ren) from the other party, to injure the opinion of the child(ren) as to the other party, or to hamper the free and natural development of the child(ren)'s love and respect of the other party. 5. Primary Physical custody of the child(ren) shall be as follows: _______________________________________________________________________________ _______________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 6. The Plaintiff/Defendant, Father/Mother, shall have partial physical custody and visitation rights in accordance with the following schedule: (a) (b) (c) (d) (e) (f) (f) (g) (h) During the week:_____________________________________________________; Weekends:__________________________________________________________; Major Holidays:______________________________________________________; Minor Holidays:_____________________________________________________; Mother's Day and Mother's Birthday shall be with the Mother; Father's Day and Father's Birthday shall be with the Father. Child(ren)'s Birthday(s):_______________________________________________; Vacation/Summers:___________________________________________________; Other times:_________________________________________________________. 7. All other periods of partial custody by either party shall be by mutual agreement of both parties after reasonable request, and such agreement shall not be unreasonably withheld. 8. Each party agrees to keep the other advised of their current residential address and telephone number. Each party shall be entitled to speak to the child(ren) by telephone at reasonable times and intervals when the child(ren) is/are in the custody of the other party. 9. Each party agrees to give to the other a general itinerary of all vacations they plan to take with the child(ren). 10. Each party shall endeavor to give at least twenty-four (24) hours prior notice to the other in the event that it will not be possible to exercise any of the rights herein identified. The attached "Appendix to Order" is incorporated herein and shall be part of this Order. BY THE COURT: ____________________________________ J. American LegalNet, Inc. www.FormsWorkFlow.com APPENDIX TO ORDER Certain rules of conduct generally applicable to custody matters are set forth below and are binding on both parties, the breach of which could become the subject of contempt proceedings before this Court, or could constitute grounds for amendment of our order. If these general rules conflict with the specific requirements of our order, the order shall prevail. 1. Neither party will undertake nor permit in his or her presence the poisoning of the minor child's mind against the other party by conversation, which explicitly or inferentially derides, ridicules, condemns, or in any manner derogates the other party. 2. The parties shall not conduct arguments or heated conversations when they are together in the presence of their child(ren). 3. Neither party will question the child(ren) as to the personal lives of the other parent except insofar as necessary to insure the personal safety of the child(ren). By this we mean that the child(ren) will not be used as a spy on the other party. It is harmful to a child to be put in the role of "spy". 4. Neither party will make extravagant promises to the minor child(ren) for the purposes of ingratiating himself or herself to the minor child(ren) at the expense of the other party; further, any reasonable promise to the child(ren) should be made with the full expectation of carrying it out. 5. The parties should at all times consider the child(ren)'s best interests, and act accordingly. It is in a child(ren)'s best interests to understand that he or she is trying desperately to cope with the fact of his parents' separation, and needs help in loving both parents, rather than interference of censure. American LegalNet, Inc. www.FormsWorkFlow.com 6. The parties should remember that they cannot teach their child(ren) moral conduct by indulging in improper conduct themselves. Children are quick to recognize hypocrisy, and the parent who maintains a double standard will lose the respect of his or her child(ren). 7. Weekend and evening visitation shall be subject to the following rules: A. Arrangements will be worked out beforehand between the parties without forcing the child(ren) to make choices and run the risk of parental displeasure. However, the child shall be consulted as to his or her schedule. B. Visitation rights should be exercised at reasonable hours and under circumstances reasonably acceptable to the other party and to the needs and desires of the minor child(ren). C. If a party finds him or herself unable to keep an appointment, he or she should give immediate notice to the other party, so as to avoid subjecting the child(ren) to unnecessary apprehension and failure of expectations. D. The party having custody of the child(ren) should prepare him or her both physically and mentally for the visitation with the other party and have him or her available at the time and place mutually agreed upon. E. If either party or the child(ren) has plans which conflict with a scheduled visit and wish to adjust such visitation, the parties should make arrangements for an adjustment acceptable to the schedules of everyone involved. Predetermined schedules are not written in stone, and both parties should be flexible for the sake of the child(ren). F. If a party shows up for a visit under the influence of alcohol or drugs, the visit may be considered forfeited on those grounds alone. 8. During the time that the child(ren) is/are living with a party, that party has the responsibility of imposing and enforcing the rules for day-to-day living. However, unless otherwise ordered, both parents should consult with one another on the major decisions affecting the child(ren)'s life, such as education, religious training, medical treatment, and so forth. American LegalNet, Inc. www.FormsWorkFlow.com IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA CIVIL ACTION - LAW _______________________________________ PLAINTIFF VS. _______________________________________ DEFENDANT : : : : : : : CUSTODY NO. COMPLAINT FOR CUSTODY / PARTIAL CUSTODY / VISITATION 1. The plaintiff is_______________________________________________, residing at ________________________________________________________________________ (Street) (City) (Zip Code) (County) 2. The defendant is _________________________________________________residing at _______________________________________________________________________. (Street) (City) (Zip Code) (County) 3. Plaintiff seeks (custody) / (partial custody) / (visitation) of the following child(ren): NAME PRESENT RESIDENCE AGE __________________ __________________ __________________ ___________________________________ ___________________________________ ___________________________________ ______ ______ ______ The child(ren) (was) / (was not) born out of wedlock. The child(ren) is presently in the custody of ______________________________(Name) who resides at ___________________________________________________________. (Street) (City) (State) During the past five years, the child(ren) has resided with the following persons and at the following addresses: (List all Persons) (List all Addresses) (Dates) ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ____________ ____________ ____________ American LegalNet, Inc. www.FormsWorkFlow.com The mother of the child(ren) is ______________________________________, currently residing at _______________________________________________________________ She is (married) / (divorced) / (single). The father of the child(ren) is _______________________________________, currently residing at _______________________________________________________________ He is (married) / (divorced) / (single). 4. The relationship of plaintiff to the child(ren) is that of ____________________________ The plaintiff currently resides with the following persons: NAME ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ 5. RELATIONSHIP ______________________________ The relationship of defendant to the child(ren) is that of __________________________. The defendant currently resides with the following persons: NAME ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ 6. RELATIONSHIP ______________________________ 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 any other 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(ren) 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(ren) or claims to have custody or visitation rights with respect to the child(ren). The name and address of such person is: ________________________________________________________________________ _______________________________________________________________________. American LegalNet, Inc. www.FormsWorkFlow.com 7. The best interest and permanent welfare of the child(ren) 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 of the child(ren). ____________________________________ _______________________________________________________________________. 8. 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 parties to this action. All other persons, named below, who are known to have or claim a right to custody or visitation of the child(ren) will be given notice of the pendency of this action and the right to intervene: NAME ADDRESS BASIS OF CLAIM __________________ ______________________________ ____________ __________________ ______________________________ ____________ __________________ ______________________________ ____________ Wherefore, Plaintiff requests the court to grant (custody) / (partial custody) / (visitation) of the child(ren). _________________________________________ 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 penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. ________________________________________ Plaintiff American LegalNet, Inc. www.FormsWorkFlow.com IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA CIVIL ACTION - LAW _______________________________________ PETITIONER VS. _______________________________________ RESPONDENT : : : : : : : CUSTODY NO. PETITION FOR MODIFICATION OF A PARTIAL CUSTODY OR VISITATION ORDER 1. The petition of ___________________________________________ respectfully represents that on ________________________________, 20____, an Order of Court was entered for (partial custody) / (visitation), a true and correct copy of which is attached. 2. This Order should be modified because: _______________________________________ WHEREFORE, Petitioner requests that the Court modify the existing Order for (partial custody) / (visitation) because it will be in the best interest of the child(ren). ___________________________________ Petitioner I verify that the statements made in this Complaint 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. ________________________________________ Petitioner American LegalNet, Inc. www.FormsWorkFlow.com IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA CIVIL ACTION ____________________________________, : Plaintiff/Petitioner : : vs. : : ____________________________________, : Defendant/Respondent : NO. ORDER OF COURT AND NOW this ___________ day of _________________,________, it is hereby ORDERED and DECREED that the (Plaintiff/Petitioner)/(Defendant/Respondent), be GRANTED leave to proceed in forma pauperis in the above action. At this time, (Plaintiff/Petitioner)/(Defendant/Respondent) is relieved from paying the initial filing fees and sheriff’s costs only. (Plaintiff/Petitioner)/(Defendant/Respondent) shall promptly notify the Court of any material change in his/her income during the pendency of this action. BY THE COURT: __________________________________________ J. American LegalNet, Inc. www.FormsWorkFlow.com IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA CIVIL ACTION ____________________________________ Plaintiff/Petitioner vs. ____________________________________ Defendant/Respondent : : : : : : : NO. PETITION FOR WAIVER OF COSTS 1. I am the (Plaintiff/Petitioner) (Defendant/Respondent) in the above matter and because of my financial condition am unable to pay the fees and costs of prosecuting or defending the action or proceeding. 2. I am unable to obtain funds from anyone, including my family and associates, to pay the costs of litigation. 3. I represent that the information below relating to my ability to pay the fees and costs is true and correct: (A) NAME:_____________________________________________________________ ADDRESS:_________________________________________________________ (B) EMPLOYMENT: If you are presently employed, state: EMPLOYER:________________________________________________________ ADDRESS:_________________________________________________________ SALARY OR WAGES PER MONTH:___________________________________ TYPE OF WORK:____________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com If you are presently unemployed state: DATE OF LAST EMPLOYMENT:______________________________________ SALARY OR WAGES PER MONTH:____________________________________ TYPE OF WORK:____________________________________________________ (C) OTHER INCOME WITHIN THE LAST TWELVE MONTHS: BUSINESS OR PROFESSIONAL:_______________________________________ OTHER SELF-EMPLOYMENT:________________________________________ INTEREST:_________________________________________________________ DIVIDENDS:________________________________________________________ PENSION OR ANNUITIES:____________________________________________ SOCIAL SECURITY BENEFITS:_______________________________________ SUPPORT PAYMENTS:______________________________________________ DISABILITY PAYMENTS:___________________________________________ UNEMPLOYMENT COMPENSATION/SUPPLEMENTAL BENEFITS:_______ WORKERS COMPENSATION:________________________________________ PUBLIC ASSISTANCE:_______________________________________________ OTHER:____________________________________________________________ (D) OTHER CONTRIBUTIONS TO HOUSEHOLD SUPPORT: HUSBAND/WIFE - NAME:____________________________________________ If your (husband/wife) is employed state: EMPLOYER:________________________________________________________ SALARY OR WAGES PER MONTH:____________________________________ TYPE OF WORK:____________________________________________________ CONTRIBUTIONS FROM CHILDREN:__________________________________ CONTRIBUTIONS FROM PARENTS:___________________________________ American LegalNet, Inc. www.FormsWorkFlow.com OTHER CONTRIBUTIONS:___________________________________________ (E) PROPERTY OWNED: CASH:_____________________________________________________________ CHECKING ACCOUNT:______________________________________________ SAVINGS ACCOUNT:________________________________________________ CERTIFICATES OF DEPOSIT:_________________________________________ REAL ESTATE (INCLUDING HOME):__________________________________ MOTOR VEHICLE: MAKE:____________________________YEAR:_________ COSTS:_____________________AMOUNT OWED:_________________ STOCKS, BONDS:___________________________________________________ OTHER:____________________________________________________________ (F) DEBTS AND OBLIGATIONS PER MONTH: MORTGAGE/RENT:_________________________________________________ UTILITIES: ELECTRIC:__________________WATER/SEWER:____________ OIL/GAS/COAL:____________________PHONE:___________________ CABLE:______________________ LOANS:____________________________________________________________ CREDIT CARDS:____________________________________________________ FOOD:________________________NON FOOD:__________________________ CHILD SUPPORT:___________________________________________________ CHILD CARE:_______________________________________________________ TRANSPORTATION COSTS:__________________________________________ MEDICAL BILLS:___________________________________________________ BACK TAXES:______________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com MISCELLANEOUS HOUSEHOLD EXPENSES:___________________________ (G) PERSONS DEPENDENT UPON YOU FOR SUPPORT: (WIFE) (HUSBAND) NAME: ____________________________________ CHILDREN, IF ANY: NAME: ______________________________________________AGE:__________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ OTHER PERSONS: NAME: _____________________________________________________ RELATIONSHIP: ______________________________________________ 4. I understand that I have a continuing obligation to inform the court of improvement in my financial circumstances, which would permit me to pay the costs incurred herein. 5. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to penalties of 18 Pa. C.S. Sect 4904, relating to unsworn falsification to authorities. DATE: _____________________ SIGNATURE: ______________________________ American LegalNet, Inc. www.FormsWorkFlow.com