Chester Cnty. C.P. Rule 1905.A.(c) Form

Form 4 See CCRCP 1905.A.(c): form req’d by CCRCP 1901.5.A.(a)

IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA

Plaintiff: No.

:

v. : Civil Action

: Indirect Criminal Contempt

Defendant: for Violation of Protection From Abuse Order

COMPLAINT

I, the undersigned, do hereby state under oath:

1. My name is ___________________________________________ and I live/work at

________________________________________________ ;

2. I accuse _________________________________________ , who lives at

____________________________________________________ , with violating a

protection from abuse order entered by Judge ______________ on the______ day of

____________, 20____ (attach copy of order if available);

3. The date (and day of the week) when the accused committed the offense was on or

about __________________________________________________________.

4. The place where the offense was committed was in the County of Chester;

5. The acts committed by the accused were: (place an X before the appropriate

statement(s))

_____ attempting to cause or intentionally, knowingly or recklessly causing bodily injury

to_________________________________________

-or-

_____ using physical menace to put _________________________ in fear of imminent

serious bodily injury,

all of which were in violation of the protection from abuse order entered in accordance

with the Protection from Abuse Act, 23 Pa.C.S. §6101 et seq.;

See CCRCP 1905.A.(c): form req’d by CCRCP 1901.5.A.(a)

6. If the defendant has not already been arrested, I ask that a warrant of arrest be issued

and that the accused be required to answer the charges I have made.

I verify that the statements made in the complaint are true and correct to the best of my

knowledge, information and belief. I further understand that any false statements made herein

are subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities.

________________________________________

Date __________________ Signature of Affiant

The above subscribed affiant personally appeared before me on this date, signed the

complaint in my presence and asserted that the facts therein are true and correct; and wherefore

it appears that there is probable cause for the issuance of process.

Date __________________ ___________________________________(SEAL)

Issuing Authority