___________________________________ Name ___________________________________ Address ___________________________________ : : : : : IN THE COURT OF COMMON PLEAS : ___________________________________ : OF LACKAWANNA COUNTY Phone Number : Plaintiff(s) : FAMILY DIVISION vs. : : 20______ FC ________ ___________________________________ : Name : ___________________________________ : Address : ___________________________________ : : ___________________________________ : Phone Number : Defendant(s) : ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ORDER AND NOW, this ______ day of __________________, 20_____, upon consideration of the foregoing Petition for Emergency Relief, it is Ordered and Decreed that: _______ _______ _______ Temporary physical custody is granted to the petitioner until further Order of Court. Emergency relief is denied. Emergency relief is denied, Court Administrator is to set Conciliation Conference. Hearing/Conference is to be held on the _______ day of _________________________, 20______, at ________ .M. before __________________________________________ at the Lackawanna County Family Center, 200 Adams Avenue, Scranton, PA. _____ 2nd Floor, Courtroom No. _______ _____ 1st Floor, Court Administrator's Office ­ Family Court Division BY THE COURT: ________________________, J. American LegalNet, Inc. www.FormsWorkFlow.com _______________________________ : IN THE COURT OF COMMON PLEAS Plaintiff(s) : : OF LACKAWANNA COUNTY vs. : : FAMILY COURT : _______________________________ : 20_______ FC _________ Defendant(s) : : ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: PETITION FOR EMERGENCY SPECIAL RELIEF AND NOW, comes the petitioner, ____________________________, filling the following petition for Special Relief. Petitioner's relationship to the minor child(ren) _______________________________________________. 1. _______________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________________________. 2. _______________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________________________. 3. _______________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________________________. 4. _______________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________________________. 5. _______________________________________________________________________________ __________________________________________________________________________________. American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, the petitioner ___________________________________, respectfully request that this Court issue an Order granting primary physical custody of the child/children until further Order of Court. Respectfully Submitted, __________________________ Date: _______________________ American LegalNet, Inc. www.FormsWorkFlow.com : IN THE COURT OF COMMON PLEAS : : OF LACKAWANNA COUNTY : vs. : FAMILY COURT : ______________________________ : 20_____ FC _________ Defendant(s) : : ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: VERIFICATION _____________________________ Plaintiff(s) I, _____________________, the petitioner, do hereby affirm that the facts set forth in the foregoing Petition for Special Relief are true and correct to the best of my knowledge, information and belief. I affirm that there are no outstanding custody matters concerning the minor child(ren) in any other jurisdiction. I understand that false statements made herein are subject to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn falsification to authorities. ______________________________ Petitioner _______________________ Date American LegalNet, Inc. www.FormsWorkFlow.com