_____________________________ Plaintiff v. _____________________________ Defendant : : : : : : : : : : : : : IN THE COURT of COMMON PLEAS COUNTY, PENNSYLVANIA No. CIVIL ACTION - LAW PROTECTION FROM ABUSE PETITION FOR PROTECTION FROM ABUSE 1. Plaintiff's name is: Plaintiff's date of birth: 2. I am filing this Petition on behalf of: Myself and/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: (only if not the Plaintiff) Filer's address is confidential or Filer's address is: Address: American LegalNet, Inc. www.FormsWorkflow.com If you checked "Another Person", indicate your relationship with Plaintiff: (Check all that apply) 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) 3. Name(s) of ALL person(s), including minor children, who seek protection from abuse. (Note: You do NOT need to enter the Plaintiff's name again.) Name of Person 1. This is a child of BOTH the Plaintiff and the Defendant. This is a minor child living with the Plaintiff, but whose parents are NOT BOTH the Plaintiff & Defendant. Neither of the above. This is a minor child, and the Plaintiff is requesting custody. Name of Person 2. This is a child of BOTH the Plaintiff and the Defendant. This is a minor child living with the Plaintiff, but whose parents are NOT BOTH the Plaintiff & Defendant. Neither of the above. This is a minor child, and the Plaintiff is requesting custody. Name of Person 3. This is a child of BOTH the Plaintiff and the Defendant. This is a minor child living with the Plaintiff, but whose parents are NOT BOTH the Plaintiff & Defendant. Neither of the above. This is a minor child, and the Plaintiff is requesting custody. Name of Person 4. This is a child of BOTH the Plaintiff and the Defendant. This is a minor child living with the Plaintiff, but whose parents are NOT BOTH the Plaintiff & Defendant. Neither of the above. This is a minor child, and the Plaintiff is requesting custody. American LegalNet, Inc. www.FormsWorkflow.com 4. Plaintiff's Address: Plaintiff's address is confidential or Plaintiff's address is: 5. Defendant Information: Defendant's Name is: Defendant's address is unknown. or Defendant is believed to live at the following address: Defendant's Social Security Number (if known) is: Defendant's Date of Birth is: Defendant's Place of Employment is: - - Check here if you have reason to believe that Defendant is a licensed firearms dealer or is employed in a profession that requires Defendant to handle firearms or to carry a firearm as a condition of employment. Is the Defendant 17 years old or yo unger: Yes No Don't Know 6. Indicate the relationship between the Plaintiff and the Defendant: Spouse Brother / Sister Current or former sexual/intimate partner Ex-spouse American LegalNet, Inc. www.FormsWorkflow.com Parent / Child Parents of the same children Persons who live or have lived like spouses Other relationship by blood or marriage: (If "other", please specify:) 7. Have the Plaintiff and the Defendant been involved in any of the following court actions? (Check all that apply) 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: 8. Has the Defendant been involved in any criminal court action? Yes No Don't know If you answered Yes, is the defendant currently on probation or parole? Yes No Don't know If you answered Yes, is it County and/or State probation/parole? County probation/parole: (list counties/states of county probation/parole) State probation/parole: (list states of state probation/parole) 9. Plaintiff and Defendant are the parents of the following minor child/ren: Name of Child 1. Child's address is confidential or American LegalNet, Inc. www.FormsWorkflow.com Child's current address is: Child's Age: Name of Child 2. Child's address is confidential or Child's current address is: Child's Age: Name of Child 3. Child's address is confidential or Child's current address is: Child's Age: Name of Child 4. Child's address is confidential or Child's current address is: Child's Age: 10. If Plaintiff and Defendant are parents of any minor child/ren together, is there an existing court order regarding their custody? Yes No Don't know American LegalNet, Inc. www.FormsWorkflow.com If you answered "yes", describe the terms of the order (e.g., primary, shared, Legal and/or physical custody): (Please be sure to indicate which terms of the order apply to which children.) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ If you answered "yes", in what county and state was the order issued? County: State: 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? (Please include the Child's name, person(s) child lived with, address unless confidential, and when.) Child 1. Child 2. Child 3. Child 4. (b) List any other persons who are known to have or claim a right to cus tody of each child listed above. Name of Person 1. This person's address is confidential American LegalNet, Inc. www.FormsWorkflow.com or This person's address is: Indicate the basis of this person's claim, and for which child/ren it applies in the space below. Name of Person 2. This person's address is confidential or This person's address is: Indicate the basis of this person's claim, and for which child/ren it applies in the space below. 11. The following other minor child/ren presently live with Plaintiff: Name of Child 1. Child's Age: Plaintiff's relationship to this child: Name of Child 2. Child's Age: Plaintiff's relationship to this child: Name of Child 3. Child's Age: Plaintiff's relationship to this child: American LegalNet, Inc. www.FormsWorkflow.com Name of Child 4. Child's Age: Plaintiff's relationship to this child: 12. The facts of the most recent incident