[34 Pa.B. 3371]
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COUNTY LAWYER REFERRAL SERVICE
NORTH PENN LEGAL SERVICES
122-124 IRON STREET
LEHIGHTON, PA 18235
(610) 377-5400
www.northpennlegal.org
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION--LAW
___________________________ : (Plaintiff) : : vs.
: No. _________________ : ___________________________ : (Defendant)
TEMPORARY PROTECTION FROM ABUSE ORDER Defendant's Name: __________
Defendant's Date of Birth: __________
Defendant's Social Security Number: __________
Name of All Protected Persons, including Plaintiff and minor child/ren: __________
__________
__________
__________AND NOW, this ______ day of _________________ , 20 ______ , upon consideration of the attached Petition for Protection from Abuse, the court hereby enters the following Temporary Order:
( ) 1. Defendant shall not abuse, harass, stalk or threaten any of the above persons in any place where they might be found.
( ) 2. Defendant is evicted and excluded from the residence at __________
__________(NONCONFIDENTIAL ADDRESS FROM WHICH DEFENDANT IS EXCLUDED) or any other permanent or temporary residence where Plaintiff or any other person protected under this Order may live. Plaintiff is granted exclusive possession of the residence. Defendant shall have no right or privilege to enter or be present on the premises of Plaintiff or any other person protected under this Order.
( ) 3. Except as provided in Paragraph 5 of this order, Defendant is prohibited from having ANY CONTACT with Plaintiff, or any other person protected under this Order, at any location, including but not limited to any contact at Plaintiff's school, business, or place of employment. Defendant is specifically ordered to stay away from the following locations for the duration of this Order: __________
__________
__________
__________( ) 4. Except for such contact with the minor child/ren as may be permitted under Paragraph 5 of this Order, Defendant shall not contact Plaintiff, or any other person protected under this Order, by telephone or by any other means, including through third persons.
( ) 5. Pending the outcome of the final hearing in this matter, Plaintiff is awarded temporary custody of the following minor child/ren: __________
__________
__________Until the final hearing, all contact between Defendant and the child/ren shall be limited to the following: __________
__________
__________The local law enforcement agency in the jurisdiction where the child/ren are located shall ensure that the child/ren are placed in the care and control of the Plaintiff in accordance with the terms of this Order.
( ) 6. Defendant shall immediately relinquish the following weapons to the Sheriff's Office or a designated local law enforcement agency for delivery to the Sheriff's Office. __________
__________
__________
__________Defendant is prohibited from possessing, transferring or acquiring any other weapons for the duration of this order.
( ) 7. The following additional relief is granted: __________
__________
__________
__________( ) 8. A certified copy of this Order shall be provided to the police department where Plaintiff resides and any other agency specified hereafter [insert name of agency]: __________
__________
__________
__________( ) 9. THIS ORDER SUPERSEDES
( ) ANY PRIOR PFA ORDER
AND
( ) ANY PRIOR ORDER RELATING TO CHILD CUSTODY.10. THIS ORDER APPLIES IMMEDIATELY TO DEFENDANT AND SHALL REMAIN IN EFFECT UNTIL _________________ OR UNTIL OTHERWISE MODIFIED OR TERMINATED BY THIS COURT AFTER NOTICE AND HEARING.
NOTICE TO THE DEFENDANT Defendant is hereby notified that violation of this Order may result in arrest for indirect criminal contempt, which is punishable by a fine of up to $1,000.00 and/or up to six months in jail. 23 Pa.C.S. § 6114. Consent of the Plaintiff to Defendant's return to the residence shall not invalidate this Order, which can only be changed or modified through the filing of appropriate court papers for that purpose. 23 Pa.C.S. § 6113. Defendant is further notified that violation of this Order may subject him/her to state charges and penalties under the Pennsylvania Crimes Code and to federal charges and penalties under the Violence Against Women Act, 18 U.S.C. §§ 2261-2262.
NOTICE TO LAW ENFORCEMENT OFFICIALS This Order shall be enforced by the police who have jurisdiction over the plaintiff's residence OR any location where a violation of this order occurs OR where the defendant may be located. If defendant violates Paragraphs 1 through 6 of this Order, defendant shall be arrested on the charge of Indirect Criminal Contempt. An arrest for violation of this Order may be made without warrant, based solely on probable cause, whether or not the violation is committed in the presence of law enforcement.
Subsequent to an arrest, the law enforcement officer shall seize all weapons used or threatened to be used during the violation of this Order OR during prior incidents of abuse. Weapons must forthwith be delivered to the Sheriff's office of the county which issued this Order, which office shall maintain possession of the weapons until further Order of this court, unless the weapon/s are evidence of a crime, in which case, they shall remain with the law enforcement agency whose officer made the arrest.
BY THE COURT:
By: ___________________________
Judge___________________________
Date
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION--LAW
___________________________ : (Plaintiff) : : vs.
: No. _________________ : ___________________________ : (Defendant)
PETITION FOR PROTECTION FROM ABUSE 1. Plaintiff's name is: __________
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 checked ''another person,'' please answer all questions referring to that person as the
''Plaintiff,'' and provide your address here, unless confidential: __________
__________If you checked ''Another Person,'' indicate your relationship with Plaintiff:
( ) 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 Plaintiff and minor children, who seek protection from abuse: __________
__________
__________
__________4. ( ) Plaintiff's address is confidential
or
( ) Plaintiff's address is: __________
__________5. 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 Defendant is 17 years old or younger.;
6. Indicate the relationship between Plaintiff and Defendant.
( ) Spouse ( ) Current or former sexual/intimate partner ( ) Other relationship by blood or marriage: _________________ ( ) Ex-spouse ( ) Parent/Child _________________ ( ) Persons who live or have lived like spouses ( ) Parents of the same children ( ) Brother/Sister 7. Have Plaintiff and Defendant been involved in any of the following Court actions?
( ) 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? __________
If you answered yes, is the Defendant currently on probation? __________
9. Plaintiff and Defendant are the parents of the following minor child/ren:
Name(s) Age(s) who reside at (list address unless confidential): _________________ ______ ___________________________ _________________ ______ ___________________________ _________________ ______ ___________________________ _________________ ______ ___________________________ 10. If Plaintiff and Defendant are parents of any minor child/ren together, is there an existing court Order regarding their custody? __________
If you answered yes, describe the terms of the Order (e.g., primary, shared, legal and/or physical custody): __________
If you answered Yes, in what county and state was the order issued? __________
__________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?
Child's Name Person(s) child lives with Address, unless confidential When _________________ _________________ _________________ ______ _________________ _________________ _________________ ______ _________________ _________________ _________________ ______ _________________ _________________ _________________ ______ (b) List any other persons who are known to have or claim a right to custody of each child listed above:
Name Address Basis of Claim _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ 11. The following other minor child/ren presently live with Plaintiff:
Name(s) Age(s) Plaintiff's relationship to child/ren _________________ ______ ___________________________ _________________ ______ ___________________________ _________________ ______ ___________________________ _________________ ______ ___________________________ 12. The facts of the most recent incident of abuse are as follows:
Approximate Date: _________________ Place: _________________
Approximate Time: _________________Describe in detail what happened, including any physical or sexual abuse, threats, injury, incidents of stalking, medical treatment sought, and/or calls to law enforcement (attach additional sheets of paper if necessary):
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________13. If the Defendant has committed prior acts of abuse against Plaintiff or the minor child/ren, describe these prior incidents, including any threats, injuries, or incidents of stalking, and indicate approximately when such acts of abuse occurred (attach additional sheets of paper if necessary):
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________14. List the weapon(s) that Defendant has used or threatened to use against Plaintiff or the minor child/ren:
__________
__________
__________
__________
__________
__________15. Identify the police department or law enforcement agency in the area in which Plaintiff lives that should be provided with a copy of the protection order: __________
__________
__________16. There is an immediate and present danger of further abuse from the Defendant.
CHECK THE FOLLOWING BOXES ONLY IF THEY APPLY TO YOUR CASE AND PROVIDE THE REQUESTED INFORMATION
( ) Plaintiff is asking the Court to evict and exclude the Defendant from the following residence:
__________
__________
__________( ) owned by (list owners, if known): __________
__________( ) rented by (list all names, if known): __________
( ) Defendant owes a duty of support to Plaintiff and/or the minor child/ren.
( ) Plaintiff has suffered out-of-pocket financial losses as a result of the abuse described above. Those losses are: __________
__________
__________
__________FOR THE REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT ENTER A TEMPORARY ORDER, and AFTER HEARING, A FINAL ORDER THAT WOULD DO THE FOLLOWING (CHECK ALL FORMS OF RELIEF REQUESTED):
( ) A. Restrain Defendant from abusing, threatening, harassing, or stalking Plaintiff and/or minor child/ren in any place where Plaintiff may be found.
( ) B. Evict/exclude Defendant from Plaintiff's residence and prohibit Defendant from attempting to enter any temporary or permanent residence of the Plaintiff.
( ) C. Require Defendant to provide Plaintiff and/or minor child/ren with other suitable housing.
( ) D. Award Plaintiff temporary custody of the minor child/ren and place the following restrictions on contact between Defendant and child/ren: __________
__________( ) E. Prohibit Defendant from having any contact with Plaintiff and/or minor child/ren, either in person, by telephone, or in writing, personally or through third persons, including but not limited to any contact at Plaintiff's school, business, or place of employment, except as the court may find necessary with respect to partial custody and/or visitation with the minor child/ren.
( ) F. Prohibit Defendant from having any contact with Plaintiff's relatives and Plaintiff's children listed in this Petition, except as the court may find necessary with respect to partial custody and/or visitation with the minor child/ren.
( ) G. Order Defendant to temporarily turn over weapons to the Sheriff of this County and prohibit Defendant from transferring, acquiring or possessing any such weapons for the duration of the Order.
( ) H. Order Defendant to pay temporary support for Plaintiff and/or the minor child/ren, including medical support and [ ] payment of the rent or mortgage on the residence.
( ) I. Direct Defendant to pay Plaintiff for the reasonable financial losses suffered as the result of the abuse, to be determined at the hearing.
( ) J. Order Defendant to pay the costs of this action, including filing and service fees.
( ) K. Order Defendant to pay Plaintiff's reasonable attorney's fees.
( ) L. Order the following additional relief, not listed above: __________
__________
__________
__________
__________
__________
__________
__________( ) M. Grant such other relief as the court deems appropriate.
( ) N. Order the police or other law enforcement agency to serve the Defendant with a copy of this Petition, any Order issued, and the Order for Hearing. The petitioner will inform the designated authority of any addresses, other than Defendant's residence, where Defendant can be served.
VERIFICATION I verify that I am the petitioner as designated in the present action and that the facts and statements contained in the above Petition are true and correct to the best of my knowledge. I understand that any false statements are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.
___________________________
SIGNATURE___________________________
DATE
PSP Data Sheet Information Defendant Information: __________
First Middle Last Suffix (Jr, Sr,)Defendant's Alias: __________
Defendant's Sex: Male / Female Home Phone: _________________
Defendant's Race: Caucasian / African American / Hispanic / Latino /
Asian American / Pacific Islander / Other _________________Defendant's Date of Birth: ______ ______ ______ Age: ______
Month Day Year (20 ______ )_______________________________________________
Defendant's Address (if known): __________
City/State/Zip __________
Defendant's State of Birth: __________
Defendant's Skin Tone: Fair / Light / Medium / Dark / Other __________
Defendant's Height (approx.): _________________ Defendant's Weight (in pounds): _________________
Defendant's Eye Color: _________________ Defendant's Hair Color: _________________
Defendant's Scars, Marks, Tattoos: __________
Defendant's Social Security Number: __________
FBI Number: __________
Defendant's Miscellaneous Number: __________
Defendant's Spends Time (Bars, Friends, etc.): __________
Defendant's Operator's License Number: __________
Defendant's Operator's License State: _________________ Operator's License Year: _________________
_______________________________________________
Defendant's Vehicle Registration Number: __________
Defendant's Vehicle Registration State: __________
Defendant's Vehicle Registration Year: __________
Defendant's Vehicle Registration Type: __________
Defendant's Vehicle Identification Number: __________
Defendant's Vehicle Year: __________
Vehicle Model: __________
Defendant's Vehicle Style: __________
First Color of Vehicle: __________
Second Color of Vehicle: __________
Miscellaneous Information (vehicle): __________
__________Defendant's Place of Employment: __________
Employer's Address: __________
City / State / Zip CodeEmployer's Telephone Number: _________________ Shift worked _________________
Does Defendant have access to any weapons? Yes / No
Is this an eviction? Yes / No Hearing Date: __________
Plaintiff Information:
_______________________________________________
First Middle Last Suffix (Jr, Sr, etc.)Sex: Male / Female Race: Caucasian / African American / Hispanic / Latino /
Asian American / Pacific Islander / Other ______Date of Birth: ______ / ______ / ______
Plaintiff Telephone Number: __________
_____ Address is confidential
Address is: __________
City / State / Zip CodeAttorney Name: _________________ Phone No.: __________
Other Protected Person(s):
1. __________
First Middle Last Suffix (Jr, Sr, etc.)Sex: Male / Female Race: Caucasian / African American / Hispanic / Latino /
Asian American / Pacific Islander / Other ______Date of Birth: ______ / ______ / ______
Telephone Number: __________
_____ Same Address of Person Above
Address: __________City / State / Zip Code
2. _______________________________________________
First Middle Last Suffix (Jr, Sr, etc.)Sex: Male / Female Race: Caucasian / African American / Hispanic / Latino /
Asian American / Pacific Islander / Other ______Date of Birth: ______ / ______ / ______
Telephone Number: __________
_____ Address is same as the Person above.
Address: __________City / State / Zip Code
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL DIVISION
PLAINTIFF NAME: ______ ADDRESS: ______ TELEPHONE NO. ______ DATE OF BIRTH: ______ VS. NO: ______ DEFENDANT'S NAME: ______ ADDRESS: ______ TELEPHONE NO. ______ DATE OF BIRTH: ______
PROTECTION FROM ABUSE I understand if I fail to attend the final hearing, the PFA order will be dismissed and I will be required to pay the filing and service fees of approximately $170.00.
It is understood the costs of this proceeding will be addressed by the Judge at the time of the final hearing.
I further understand, in the event of my relocation, I am required to notify the Prothonotary's Office of such change in address.
DATE: _________________ ___________________________ Plaintiff
IN THE COURT OF COMMON PLEAS OF CARBON COUNTY, PENNSYLVANIA
CIVIL ACTION--LAW
_________________ : (Plaintiff) : : vs.
: No. _________________ : _________________ : (Defendant)
FINAL ORDER OF COURT Defendant's Name: __________
Defendant's Date of Birth: __________
Defendant's Social Security Number: __________
Names and Dates of Birth of All Protected Persons, including Plaintiff and minor children:
Names Dates of Birth ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ CHECK ALL THAT APPLY:
Plaintiff or Protected Person(s) is/are:
[ ] spouse or former spouse of Defendant
[ ] parent of a common child with Defendant
[ ] current or former sexual or intimate partner with Defendant
[ ] child of Plaintiff
[ ] child of Defendant
[ ] family member related by blood (consanguinity) to Defendant
[ ] sibling (person who shares biological parenthood) of Defendant
[ ] current or former cohabitant (person who lives with) Defendant
Defendant was served in accordance with Pa.R.C.P 1930.4 and provided notice of the time, date and location of the hearing scheduled in this matter.
AND NOW, this _________________ day of _________________ , 20 ______ , the court having jurisdiction over the parties and subject-matter, it is ORDERED, ADJUDGED AND DECREED as follows: __________
__________
__________[ ] Plaintiff's request for a final protection order is denied.
OR
[ ] Plaintiff's request for final protection order is granted.
[ ] 1. Defendant shall not abuse, stalk, harass, threaten or attempt to use physical force that would reasonably be expected to cause bodily injury to the Plaintiff or any other protected person in any place where they might be found.
[ ] 2. Defendant is completely evicted and excluded from the residence at (NONCONFIDENTIAL ADDRESS FROM WHICH DEFENDANT IS EXCLUDED) or any other residence where Plaintiff or any other person protected under this Order may live. Exclusive possession of the residence is granted to Plaintiff. Defendant shall have no right or privilege to enter or be present on the premises of Plaintiff or any other person protected under this Order.
[ ] On _________________ , 20 ______ , at ______ a.m./p.m., Defendant may enter the residence to retrieve his/her clothing and other personal effects, provided that Defendant is in the company of a law enforcement officer when such retrieval is made and ___________________________ .
[ ] 3. Except as provided in Paragraph 5 of this Order, Defendant is prohibited from having ANY CONTACT with the Plaintiff, or any other person protected under this Order, at any location, including but not limited to any contact at the Plaintiff's school, business, or place of employment. Defendant is specifically ordered to stay away from the following locations for the duration of this Order: __________
_______________________________________________
_______________________________________________ .[ ] 4. Except as provided in Paragraph 5 of this Order, Defendant shall not contact the Plaintiff, or any other person protected under this Order, by telephone or by any other means, including through third persons.
[ ] 5. Custody of the minor children, __________
_________________ shall be as follows: (state to whom primary physical custody awarded; state terms of partial custody or visitation, if any.) __________
__________
__________[ ] 6. Defendant shall immediately turn over to the Sheriff's Office, or to a local law enforcement agency for delivery to the Sheriff's Office, the following weapons used or threatened to be used by Defendant in an act of abuse against Plaintiff and/or the minor child/ren: _________________________________________________________
_______________________________________________ .[ ] 7. Defendant is prohibited from possessing, transferring or acquiring any other weapons for the duration of this Order. Any weapons delivered to the sheriff under Paragraph 6 of this Order or under Paragraph 6 of the Temporary Order shall not be returned until further order of court.
[ ] 8. The following additional relief is granted as authorized by § 6108 of the Act:
_______________________________________________
_______________________________________________
_______________________________________________ .[ ] 9. Defendant is directed to pay temporary support for: (insert the names of the persons for whom support is to be paid) __________
as follows: (insert amount, frequency and other terms and conditions of the support order)
_______________________________________________
_______________________________________________
_______________________________________________ .This order for support shall remain in effect until a final order is entered by this Court. However, this order shall lapse automatically if the Plaintiff does not file a complaint for support with the Domestic Relations Section of the court within two weeks of the date of this order. The amount of this temporary order does not necessarily reflect the Defendant's correct support obligation, which shall be determined in accordance with the guidelines at the support hearing. Any adjustments in the final amount of support shall be credited, retroactive to this date, to the appropriate party.
[ ] 10. The costs of this action are waived as to the Plaintiff and imposed on Defendant.
[ ] 11. Defendant shall pay $ _________________ to Plaintiff as compensation for plaintiff's out-of-pocket losses, which are as follows:
OR
[ ] Plaintiff is granted leave to present a petition, with appropriate notice to Defendant, to _________________ [insert the name of the Judge or Court to which the petition should be presented] requesting recovery of out-of-pocket losses. The petition shall include an exhibit itemizing all claimed out-of-pocket losses, copies of all bills and estimates of repair, and an order scheduling a hearing. No fee shall be required by the Prothonotary's Office for the filing of this petition.
[ ] 12. THIS ORDER SUPERCEDES [ ] ANY PRIOR PFA ORDER AND [ ] ANY PRIOR ORDER RELATING TO CHILD CUSTODY.
13. All provisions of this order shall expire in eighteen months, on _________________ , 20 ______ .
NOTICE TO DEFENDANT VIOLATION OF THIS ORDER MAY RESULT IN YOUR ARREST ON THE CHARGE OF INDIRECT CRIMINAL CONTEMPT WHICH IS PUNISHABLE BY A FINE OF UP TO $1,000 AND/OR A JAIL SENTENCE OF UP TO SIX MONTHS. 23 PA.C.S. § 6114. VIOLATION MAY ALSO SUBJECT YOU TO PROSECUTION AND CRIMINAL PENALTIES UNDER THE PENNSYLVANIA CRIMES CODE.
THIS ORDER IS ENFORCEABLE IN ALL FIFTY (50) STATES, THE DISTRICT OF COLUMBIA, TRIBAL LANDS, U.S. TERRITORIES AND THE COMMONWEALTH OF PUERTO RICO UNDER THE VIOLENCE AGAINST WOMEN ACT, 18 U.S.C. § 2265. IF YOU TRAVEL OUTSIDE OF THE STATE AND INTENTIONALLY VIOLATE THIS ORDER, YOU MAY BE SUBJECT TO FEDERAL CRIMINAL PROCEEDINGS UNDER THAT ACT, 18 U.S.C. §§ 2261-2262. IF YOU POSSESS A FIREARM OR ANY AMMUNITION WHILE THIS ORDER IS IN EFFECT, YOU MAY BE CHARGED WITH A FEDERAL OFFENSE EVEN IF THIS PENNSYLVANIA ORDER DOES NOT EXPRESSLY PROHIBIT YOU FROM POSSESSING FIREARMS OR AMMUNITION. 18 U.S.C § 922(g)(8).
NOTICE TO LAW ENFORCEMENT OFFICIALS The police who have jurisdiction over the plaintiff's residence OR any location where a violation of this order occurs OR where the defendant may be located, shall enforce this order. An arrest for violation of Paragraphs 1 through 7 of this order may be without warrant, based solely on probable cause, whether or not the violation is committed in the presence of the police. 23 Pa.C.S. § 6113.
Subsequent to an arrest, the police officer shall seize all weapons used or threatened to be used during the violation of the protection order or during prior incidents of abuse. The [insert appropriate name or title] ______ shall maintain possession of the weapons until further order of this Court.
When the defendant is placed under arrest for violation of the order, the defendant shall be taken to the appropriate authority or authorities before whom defendant is to be arraigned. A ''Complaint for Indirect Criminal Contempt'' shall then be completed and signed by the police officer OR the plaintiff. Plaintiff's presence and signature are not required to file this complaint.
If sufficient grounds for violation of this order are alleged, the defendant shall be arraigned, bond set and both parties given notice of the date of hearing.
BY THE COURT:
___________________________
Judge___________________________
Date
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