PA · rules

Dauphin Cnty. C.P. Rule 1915.15 - Petition for Modification of a Custody Order 6

Check the appropriate box

activein force · 2026-09-30 – presentact-effective-date

If you provided a copy of the Self-Represented Entry of Appearance form to attorneys or self-represented parties list the name and address.

If you are a victim of abuse, you acknowledge your understanding that the Confidential Information

Form Abuse Victim Addendum should not be sent to any attorney or self-represented party but that

the Self-Represented Entry of Appearance Form should be sent to any attorney or self-represented

party.

SIGN AND DATE the form and file this at the same time you file your petition.

CRIMINAL RECORD/ABUSE HISTORY VERIFICATION

• Complete the caption as you did for the custody complaint.

• The petitioner must file a verification regarding any criminal or abuse history of the petitioner or anyone living

in the petitioner’s household. At the custody conference, the conference officer will perform an initial

evaluation to determine whether the existence of a criminal or abuse history of either party or members of

their household pose a threat to the child(ren).

• Follow the directions as found on this form.

• Information regarding criminal charges are available to the public through the UJS portal at

http://ujsportal.pacourts.us.

PETITION FOR CIVIL CONTEMPT

OF AN EXISTING CUSTODY ORDER

FORMS

IT IS STRONGLY RECOMMENDED THAT

YOU CONSULT AN ATTORNEY

DISCLAIMER

THE SELF HELP CENTER STAFF AND COURT STAFF ARE NOT PERMITTED TO GIVE

YOU LEGAL ADVICE. THE INFORMATION IN THIS PACKET IS NOT A SUBSTITUTE

FOR PROFESSIONAL LEGAL ADVICE. THE COURT ASSUMES NO RESPONSIBILITY

AND ACCEPTS NO LIABILITY FOR ACTIONS TAKEN BY USERS OF THESE

DOCUMENTS, INCLUDING RELIANCE ON THEIR CONTENTS. IF YOU WANT TO

OBTAIN THE SERVICES OF AN ATTORNEY BUT DO NOT KNOW WHOM TO CONTACT,

YOU SHOULD CALL MIDPENN LEGAL SERVICES AT (717) 232-0581.

PLEASE NOTE: A free custody clinic is available for eligible individuals through

MidPenn Legal Services. At each monthly clinic, attorneys explain the custody

process, help you prepare the custody forms, and file the forms on your behalf.

Although the attorneys are not representing you, the service is an excellent way to

ensure that your forms are completed correctly. For more information, please

telephone (717) 232-0581.

May 22, 2024 1

_______________________________ : IN THE COURT OF COMMON PLEAS

Plaintiff (Name of Plaintiff(s) on Current Custody Order): DAUPHIN COUNTY, PENNSYLVANIA

v. : NO. _____ CV ______ CU

(Docket Number on Current Custody Order)

_______________________________ : CIVIL ACTION - LAW

Defendant (Name of Defendant(s) on Current Custody: IN CUSTODY

Order)

PETITION FOR CIVIL CONTEMPT OF A CUSTODY ORDER

If you are an abuse victim and do not want to reveal your contact information, you

are not required to list your address, telephone number and email address but you

must complete a Confidential Information Form (CIF) Abuse Victim Addendum and

file this form with the Prothonotary at the same time you file the Petition for Civil

Contempt. An abuse victim is defined as a person for whom a protection order has

been granted by a court. Write “See CIF Abuse Victim Addendum” on the paragraph

instead of listing this information. When you serve the opposing party(ies), do not

include the CIF Abuse Victim Addendum. The information contained on the CIF

Abuse Victim Addendum will only be available to the Court and Court staff.

AND NOW COMES __________________________________________ who

(Your Name(s))

file(s) this Petition for Civil Contempt of a Custody Order and allege(s) as follows:

1. Plaintiff’s full name: _____________________________________________

Plaintiff’s complete mailing address:

______________________________________________________________________

Street, City, State, Zip Code, and County If confidential, write “See CIF Abuse Victim Addendum”

Plaintiff’s telephone number: _______________________________________________

If confidential, write “See CIF Abuse Victim Addendum”

Plaintiff’s email address: __________________________________________________

If confidential, write “See CIF Abuse Victim Addendum”

Plaintiff’s date of birth: __________________

Plaintiff’s relationship to the minor child(ren) is parent other _________________

(please specify).

If there is more than one plaintiff listed in the caption, please complete the following

information. If there is only one plaintiff listed in the caption, please skip to question 2.

Additional Plaintiff’s full name: _____________________________________________

May 22, 2024 2

Additional Plaintiff’s complete mailing address:

______________________________________________________________________

Street, City, State, Zip Code, and County If confidential, write “See CIF Abuse Victim Addendum”

Additional Plaintiff’s telephone number: _______________________________________

If confidential, write “See CIF Abuse Victim Addendum”

Additional Plaintiff’s email address: ________________________________________

If confidential, write “See CIF Abuse Victim Addendum”

Additional Plaintiff’s date of birth: __________________

Additional Plaintiff’s relationship to the minor child(ren) is parent other

_______________________________

(please specify)

2. Defendant’s full name: _____________________________________________

Defendant’s complete mailing address:

______________________________________________________________________

Street, City, State, Zip Code, and County If confidential, write “See CIF Abuse Victim Addendum”

Defendant’s telephone number: _____________________________________________

If confidential, write “See CIF Abuse Victim Addendum”

Defendant’s email address: _______________________________________________

If confidential, write “See CIF Abuse Victim Addendum”

Defendant’s date of birth: __________________

Defendant’s relationship to the minor child(ren) is parent other ______________

(please specify).

If there is more than one defendant listed in the caption, please complete the following

information. If there is only one defendant listed in the caption, please skip to question 3.

Additional Defendant’s full name: ___________________________________________

Additional Defendant’s complete mailing address:

______________________________________________________________________

Street, City, State, Zip Code, and County If confidential, write “See CIF Abuse Victim Addendum”

Additional Defendant’s telephone number: ____________________________________

If confidential, write “See CIF Abuse Victim Addendum”

Additional Defendant’s email address: _______________________________________

If confidential, write “See CIF Abuse Victim Addendum”

Additional Defendant’s date of birth: __________________

Additional Defendant’s relationship to the minor child(ren) is parent other

_______________________________

(please specify)

May 22, 2024 3

3. The subject child(ren) are:

SEE CONFIDENTIAL INFORMATION FORM FOR THE COMPLETE NAME AND DATE OF

BIRTH OF THE CHILD(REN). DO NOT WRITE THE CHILD(REN)’S NAME OR COMPLETE

DATE OF BIRTH ON THIS PETITION. IF YOU HAVE MORE THAN FIVE CHILDREN WHO ARE

THE SUBJECT OF THIS CUSTODY ACTION, PLEASE USE AN ADDITIONAL PAGE AND

REFER TO THEM AS CHILD 6, ETC. AND LIST THEIR YEAR OF BIRTH.

Address of Child 1 (No name) ________________________________________ __________

ADDRESS of Child or write “See CIF Abuse Victim Addendum” YEAR of Birth

Address of Child 2 (No name) ___________________________________________ __________

ADDRESS of Child or write “See CIF Abuse Victim Addendum” YEAR of Birth

Address of Child 3 (No name) __________________________________________ __________

ADDRESS of Child or write “See CIF Abuse Victim Addendum” YEAR of Birth

Address of Child 4 (No name) ____________________________________________ __________

ADDRESS of Child or write “See CIF Abuse Victim Addendum” YEAR of Birth

Address of Child 5 (No name) ____________________________________________ __________

ADDRESS of Child or write “See CIF Abuse Victim Addendum” YEAR of Birth

The Confidential Information Form and CIF Abuse Victim Addendum (If

applicable) must be completed and filed with this civil contempt petition.

4. O n _________________________, 20____ a Custody Order of Court was

(Date of the Custody Order Currently in Effect)

entered at the above-captioned docket and attached to this Petition is a copy of the current

Custody Order.

5. Respondent has willfully failed to abide by that Order in the following ways: IF YOU NEED

TO IDENTIFY THE CHILD(REN) IN THIS PARAGRAPH, USE CHILD 1, CHILD 2, ETC.

DO NOT USE THEIR NAMES.

___________________________________________________________________________

___________________________________________________________________________.

6. I have attached the criminal record/abuse history verification form required

pursuant to Pa.R.C.P. 1915.3-2.

Provenance

Source: www.dauphincounty.gov
Retrieved: 2026-09-30
Edition: 2026-09-30
Content hash: 2cf29894a8b47209790f5236ea255e3070171844ef8b4a8845c534d9c09fa719

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