PETITION FOR EMERGENCY RELIEF IN CONNECTION WITH CLAIMS OF SEXUAL VIOLENCE OR INTIMIDATION COMMONWEALTH OF PENNSYLVANIACOUNTY OF Mag. Dist. No: MDJ Name:Address:Telephone:v.Docket No:Case Filed: PETITION OF THE PLAINTIFFI, , hereby petition for emergency relief:(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 is required because there is immediate and present danger posed by the defendant to me and/or to the above listed minor (child) (children) (incapacitated person). (Print additional names/addresses on a separate sheet of paper and attach hereto.) 306A www.pacourts.us/language-rights FREE INTERPRETER 1 American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR EMERGENCY RELIEF IN CONNECTION WITH CLAIMS OF SEXUAL VIOLENCE OR INTIMIDATION COMMONWEALTH OF PENNSYLVANIACOUNTY OF Mag. Dist. No: MDJ Name:Address:Telephone:v.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) 306A www.pacourts.us/language-rights FREE INTERPRETER 2 American LegalNet, Inc. www.FormsWorkFlow.com