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2 kZ I0 I0 I0 I0 I0 I0 I0 I0 I0 > * : 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 Prothonotarys 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 defendants 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/respondents 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/respondents 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 defendants 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.
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 persons 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 $22.30 plus $150.00 for custody master. If you are filing an agreement, current filing fee as $22.30.) (Payment in the form of cash or money order)
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/respondents 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 $167.95 plus $150.00 for custody master.) (Payment in the form of cash or money order)
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/respondents name on the second line on the left side of the top of the form. The Court will complete the rest of the form.
Court of Common Pleas of Carbon County
Civil Cover Sheet
For Prothonotary Use only (Docket Number)
A. PLAINTIFFS NAME:DEFENDANTS NAME:
PLANTIFFS ADDRESS & TELEPHONE NUMBER:
DEFENDANTS ADDRESS AND TELEPHONE NUMBER:
PLAINTIFFS NAME:DEFENDANTS NAME:
PLANTIFFS ADDRESS & TELEPHONE NUMBER:
DEFENDANTS ADDRESS & TELEPHONE NUMBER:
TOTAL NUMBER OF PLAINTIFFSTOTAL NUMBER OF DEFENDANTS
B. AMOUNT IN CONTROVERSY
___ $25,000 or less
___ More than $25,000
C. Commencement of Action
___ 1. Complaint
___ 2. Writ of Summons
___ 3. Notice of Appeal
___ 4. Petition Action
D. CASE PROCESS
___ 5. Arbitration
___ 6. Jury
___ 7. Non Jury
___ 8. Class Action
E. TRACK ASSIGNMENT REQUESTED (CHECK ONE) COURT HAS FINAL APPROVAL FOR ALL TRACK ASSIGNMENTS
_____ FAST _____ STANDARD _____ COMPLEX If complex, state reasons:
CODE AND CASE TYPE (See instructions)
G. CODE AND CASE SPECIFIC (See instructions)H. STATUTORY BASIS FOR CAUSE OF ACTION (See instructions)
I. RELATED PENDING CASES (List by Docket Number Indicate whether the related cases have been consolidated)
J. 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 PLAINTIFFS/APPELLANTS ATTORNEYADDRESS
PHONE NUMBER
SUPREME COURT IDENTIFICATION NUMBER
E-MAIL ADDRESS:
________________________________________________________________
FAX NO. (OPTIONAL FOR SERVICE):
DATE: _____________________________ SIGNATURE: _____________________________________________________
Instructions for Completing Civil Cover Sheet
The attorney (or pro se party) filing a case shall complete the form as follows:
Parties
Plaintiff(s)/Defendant(s)
Enter names (last, first, middle initial) of plaintiff and defendant. If the plaintiff or defendant is a government agency or corporation, use the full name of the agency or corporation. In the event there are more than two plaintiffs and/or two defendants, list the additional parties on a separate sheet of paper. Husband and wife should be listed as separate parties.
Parties' Addresses and Telephone Numbers
Enter the address and telephone numbers of the parties at 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.
Number of Plaintiffs/Defendants
Indicate the total number of plaintiffs and the total number of defendants in the action.
Amount in Controversy
Check the appropriate box. Indicate whether an Assessment of Damages Hearing is required.
Commencement of Action
Indicate type of document to be filed to initiate the action.
Other
Indicate whether the case is an arbitration, jury or non-jury case. Check any other appropriate boxes. If the action will require the entry of an Order approving a minor/incapacitated person's compromise, wrongful death or survival action, check the appropriate box.
Track Assignment COURT HAS FINAL APPROVAL FOR ALL TRACK ASSIGNMENTS
If you are requesting the Complex track, please indicate the reasons for your request.
Type of Action - Case Type
Select and insert the applicable case type and code from the first two columns of the following list:
@Asbestos Case9Mandamus001Assault/Battery037Motor.Veh. Accdt.<$25,000XAssessment Appeal#Miscellaneous018Class Action005M V Prop DamageACivil ActionFMortgage Foreclosure015Consumer Credit009 Negotiable InstrumentCCustody$Municipal Appeal019Contract - Construction032Partition1Declaratory Judgment7Name Change011Contract - Sale of Goods002Premises LiabilityDDivorceQQuiet Title012Contract - Other003Personal InjuryBDJ AppealRReplevin025Defamation027Product LiabilityWEjectment!Tax Sale035Discrimination006Property Damage (non-veh)NEminent Dom./Dec. of Tak.VZoning Appeal030Employment/Wrongful Disc.010Recov. Overpaymt.2EminentDomain/Pet.Viewers016Fraud013Rent/Lease/EjectmentEEquity040Indirect Criminal Contempt039Right to KnowLLicense Appeal008Insurance-Declar. Judgment024Stockholder Suit034Malicious Prosecution014Title to Real Property022Malpractice-PROF.004Torts to Land033Mechanics Lien023Toxic Tort-Pers. Injury042Medical Malpractice031Toxic Waste/Environ.007Motor Veh. Accdt.>$25,000021Wast/Contam/EnvCode Case Type Code Case Type Code Case Specific Code Case
G. Case Specific Insert applicable case specific and code from the last two columns of the above list.
H. Statutory Basis for Cause of Action
If the action is commenced pursuant to statutory authority ("Petition Action"), the specific statute must be cited.
I. Related Pending Cases
All previously filed related cases must be identified. Indicated whether they have been consolidated by Court
Order or Stipulation.
J. Plaintiff's/Appellant's/Petitioner's Attorney - Entry of Appearance
The name of filing party's attorney must be inserted, together with the other required information. Unrepresented filers must provide their name, address, telephone number and signature. Providing the fax number shall authorize the service of legal papers by facsimile transmission. See Pa.R.CP.440(d)
CARBON COUNTY CUSTODY
Intake: COMPLAINT/MODIFICATION/CONTEMPT
Docket Number: _______ ____- FC -_______________
Plaintiff (____Mother ____Father ____Other)
Name: _____________________________________ Date of Birth: ______________________
Address: __________________________________________ Apt: _____________________
City: ______________________________ State: ____________ Zip: _____________________
Home Phone: _______________________ Other Phone _______________________________
Plaintiffs Attorney: _______________________ Attorneys Phone: ______________________
Defendant (____Mother ____Father ____Other)
Name: _____________________________________ Date of Birth: ______________________
Address: __________________________________________ Apt: ______________________
City: ______________________________ State: ____________ Zip: _____________________
Home Phone: _______________________ Other Phone _______________________________
Defendants Attorney: ____________________ Attorney Phone: ________________________
Children
With whom does child(ren) reside? ___ Mother ___ Father ___ Other
Has child(ren) and custodian resided in Carbon County for six months? ___Yes ___No
Interpreter:
Does either party need an Interpreter? ___ Yes ___ No
If Yes, what language? _______________________
Mediation:
Are there allegations of domestic violence or child abuse? ____ Yes ___ No
Does either party live more than 75 miles from Courthouse? ____ Yes ___ No
Incarceration:
Is a party currently incarcerated? ____Yes ____No
If yes, what is inmates identification number, and facility address: ____________________________________________________________________
_____________________________________ _____________________________
Attorney for Moving Party Date
(Signature not required)
DELIVER THIS FORM WITH PLEADING TO PROTHONOTARY
Attny Intake
3/28/2011
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
:
PLAINTIFF/PETITIONER :
VS. : CUSTODY
: NO.
:
DEFENDANT / RESPONDENT :
You, , (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.
RULE 1018.1 - NOTICE TO DEFEND. FORM
As required by Pa.R.C.P.1018.1(c), the following shall be designated in the notice to defend as the person from whom legal referral can be obtained:
North Penn Legal Services
101 West Broad Street, Suite 713
Hazleton, PA 18201
Phone 1-877-953-4250
Fax (570) 455-3625
or
Carbon County Lawyer Referral
777 Blakeslee Blvd. Dr., Suite 2
Lehighton, PA 18235
Phone 1-610-379-4950
Fax (610) 379-4952
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.
FORM B
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
____________________________________, :
Plaintiff/Petitioner :
:
vs. : NO.
:
____________________________________, :
Defendant/Respondent :
_____________________________________ - Counsel for Plaintiff
_____________________________________ - Counsel for Defendant
AFFIDAVIT
I, ______________________________________________________, hereby swear or affirm that I, or a member of my household (Circle One) HAVE HAVE NOT been charged, convicted of, or pleaded guilty or no contest to any of the following offenses, either in the Commonwealth of Pennsylvania or in another jurisdiction with substantially equivalent offenses as listed below:
18 Pa.C.S. Ch. 25 (relating to criminal homicide)
18 Pa.C.S. 2702 (relating to aggravated assault)
18 Pa.C.S. 2706 (relating to terroristic threats)
18 Pa.C.S. 2709.1 (relating to stalking)
18 Pa.C.S. 2901 (relating to kidnapping)
18 Pa.C.S. 2902 (relating to unlawful restraint)
18 Pa.C.S. 2903 (relating to false imprisonment)
18 Pa.C.S. 2910 (relating to luring a child into a motor vehicle or structure)
18 Pa.C.S. 3121 (relating to rape)
18 Pa.C.S. 3122.1 (relating to statutory sexual assault)
18 Pa.C.S. 3123 (relating to involuntary deviate sexual intercourse)
18 Pa.C.S. 3124.1 (relating to sexual assault)
Effective July 26, 2004
Revision effective December 1, 2012
18 Pa.C.S. 3125 (relating to aggravated indecent assault)
18 Pa.C.S. 3126 (relating to indecent assault)
18 Pa.C.S. 3127 (relating to indecent exposure)
18 Pa.C.S. 3129 (relating to sexual intercourse with animal)
18 Pa.C.S. 3130 (relating to conduct relating to sex offenders)
18 Pa.C.S. 3301 (relating to arson and related offenses)
18 Pa.C.S. 4302 (relating to incest)
18 Pa.C.S. 4303 (relating to concealing death of child)
18 Pa.C.S. 4304 (relating to endangering welfare of children)
18 Pa.C.S. 4305 (relating to dealing in infant children)
18 Pa.C.S. 5902(b) (relating to prostitution and related offenses)
18 Pa.C.S. 5903(c) (relating to obscene and other sexual materials and
or (d) performances)
18 Pa.C.S. 6301 (relating to corruption of minors)
18 Pa.C.S. 6312 (relating to sexual abuse of children)
18 Pa.C.S. 6318 (relating to unlawful contact with minor)
18 Pa.C.S. 6320 (relating to sexual exploitation of children)
Section 6114 (relating to contempt for violation of order or agreement)
The former
75 Pa.C.S. 3731 (relating to driving under influence of alcohol or controlled substance)
75 Pa.C.S. Ch. 38 (relating to driving after imbibing alcohol or utilizing drugs)
Section 13 (a) (1) of the act of April 14, 1972 (P.L. 233, No. 64), known as The Controlled Substance, Drug, Device and Cosmetic Act, to the extent that it prohibits the manufacture, sale or delivery, holding, offering for sale or possession of any controlled substance or other drug or device.
IF PARTY, LIST OFFENSE OR OFFENSES BELOW:
NONE: _____________________
IF YES:
NAME OF PARTY OFFENSE DATE
_________________________ ________________________________ __________
________________________________ __________
________________________________ __________
Effective July 26, 2004
Revision effective December 1, 2012
LIST NAMES OF ADULTS RESIDING IN HOUSEHOLD:
______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
IF AN OFFENSE ADDRESSES A MEMBER OF HOUSEHOLD AND NOT A PARTY, LIST THE NAME OF HOUSEHOLD MEMBER AND OFFENSE BELOW:
NONE: _____________________
IF YES:
NAME OF HOUSEHOLD MEMBER OFFENSE DATE
_________________________ _____________________________ __________
_________________________ _____________________________ __________
_________________________ _____________________________ __________
VERIFICATION
I, the undersigned, do hereby verify that the statements made herein are true and correct to the best of my own personal knowledge, information and belief. I understand that false statements made herein are subject to the penalties of 18 Pa. C.S. 4904 (relating to unsworn falsifications to authorities).
DATE: ______________________ ____________________________________
Effective July 26, 2004
Revision effective December 1, 2012
"FORM A"
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
____________________________________, :
Plaintiff/Petitioner :
:
vs. : NO.
:
____________________________________, :
Defendant/Respondent :
_____________________________________ - Counsel for Plaintiff
_____________________________________ - Counsel for Defendant
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:
_________________________________________________________________________
_________________________________________________________________________
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.
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.
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
Effective July 26, 2004
Revision effective December 1, 2012
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.
Primary Physical custody of the child(ren) shall be as follows:
_______________________________________________________________
The Plaintiff/Defendant, Father/Mother, shall have partial physical custody and visitation rights in accordance with the following schedule:
(a) During the week:______________________________________________
(b) Weekends:___________________________________________________;
(c) Major Holidays:_______________________________________________;
(d) 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 unreasonable 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).
Effective July 26, 2004
Revision effective December 1, 2012
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.
11. The custodial parent(s) shall not change the residence of the child(ren) if such change significantly impairs the custodial schedule or the ability of the other parent to spend time with the child(ren) and participate in the child(ren)s life. In the event the custodial parent desires to relocate as described above, he/she shall provide Notice as required by 23 P.S. 5337. No relocation shall occur without written consent of the other parent, or without Order of Court.
12. The attached "Appendix to Order" is incorporated herein and shall be part of this Order.
BY THE COURT:
____________________________________
J.
Effective July 26, 2004
Revision effective December 1, 2012
APPENDIX TO ORDERPRIVATE
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
Effective July 26, 2004
Revision effective December 1, 2012
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.
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).
Effective July 26, 2004
Revision effective December 1, 2012
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.
Effective July 26, 2004
Revision effective December 1, 2012
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
_______________________________________ :
PLAINTIFF :
: CUSTODY
VS. : NO.
:
_______________________________________ :
DEFENDANT :
COMPLAINT FOR CUSTODY / PARTIAL CUSTODY / VISITATION
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)
________________________ ________________________ ____________
________________________ ________________________ ____________
________________________ ________________________ ____________
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 RELATIONSHIP
______________________________ ______________________________
______________________________ ______________________________
______________________________ ______________________________
5. The relationship of defendant to the child(ren) is that of __________________________.
The defendant currently resides with the following persons:
NAME 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:
________________________________________________________________________
_______________________________________________________________________.
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
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
_______________________________________ :
PETITIONER :
: CUSTODY
VS. : NO.
:
_______________________________________ :
RESPONDENT :
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.
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
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION
____________________________________, :
Plaintiff/Petitioner :
:
vs. : NO.
:
____________________________________, :
Defendant/Respondent :
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 sheriffs 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.
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION
____________________________________ :
Plaintiff/Petitioner :
:
vs. : NO.
:
____________________________________ :
Defendant/Respondent :
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:_________________________________________________________
SOCIAL SECURITY NUMBER:________________________________________
(B) EMPLOYMENT:
If you are presently employed, state:
EMPLOYER:________________________________________________________
ADDRESS:_________________________________________________________
SALARY OR WAGES PER MONTH:___________________________________
TYPE OF WORK:____________________________________________________
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:___________________________________
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:______________________________________________________
MISCELLANEOUS HOUSEHOLD EXPENSES:___________________________
(G) PERSONS DEPENDENT UPON YOU FOR SUPPORT:
CHILDREN, IF ANY:
NAME:______________________________________________AGE:__________
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: ______________________________
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
____________________________________, :
Plaintiff :
:
vs. : NO.
:
____________________________________, :
Defendant :
CRIMINAL RECORD/ABUSE HISTORY VERIFICATION
I, ______________________________________________________, hereby swear or affirm, subject to penalties of law including 18 Pa.C.S. 4904 relating to unsworn falsification to authorities that:
Unless indicated by my checking the box next to a crime below, neither I nor any other member of my household have been convicted or plead guilty or pled no contest or was adjudicated delinquent where the record is publicly available pursuant to the Juvenile Act, 42 Pa.C.S. 6307 to any of the following crimes in Pennsylvania or a substantially equivalent crime in any other jurisdiction, including pending charges:
Check Other Date of conviction, guilty
all that household plea, no contest plea or
apply Crime S e l f m e m b e r p e n d i n g c h a r g e s S e n t e n c e
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