COMMONWEALTH OF PENNSYLVANIACOUNTY OF Mag. Dist. No: MDJ Name:Address:Telephone: PETITION FOR EMERGENCY RELIEF FROM ABUSEv. Docket No:Case Filed: PETITION OF THE PLAINTIFF I, hereby petition for emergency relief from abuse (Name of Plaintiff - please print)On behalf of myself.On behalf of the following minor (child) (children) of whom I am a (parent) (adult household member) (guardian).On behalf of the following incapacitated person to whom I am guardian.(Name)(Address)(Age)The cause for seeking relief is as follows:(Address)(Age)(Name) Emergency relief from abuse is required because there is immediate and present danger of abuse by the defendant to me and to the above listed minor (child) (children) (incapacitated person).(Print additional names/addresses on a separate sheet of paper and attach hereto.) 307A www.pacourts.us/language-rights FREE INTERPRETER 1 American LegalNet, Inc. www.FormsWorkFlow.com COMMONWEALTH OF PENNSYLVANIACOUNTY OF Mag. Dist. No: MDJ Name:Address:Telephone: PETITION FOR EMERGENCY RELIEF FROM ABUSEv. Docket No:Case Filed: I certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania that require filing confidential information and documents differently than non-confidential information and documents. (Signature of the Plaintiff) 307A www.pacourts.us/language-rights FREE INTERPRETER 2 American LegalNet, Inc. www.FormsWorkFlow.com