Dauphin Cnty. C.P. Rule 1915.15 - Petition for Modification of a Custody Order 8

WHEREFORE, Petitioner requests that Respondent be held in contempt of court.

_______________________ ____________________________________

Date Signature of Petitioner

_______________________ ____________________________________

Date Signature of Petitioner (If more than one petitioner)

VERIFICATION

I, ___________________________, verify that the statements made in this Petition for Civil

Contempt of a Custody Order 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.

____________________ ____________________________________

Date Signature of Petitioner

____________________ ______________________________________

Date Signature of Petitioner (If more than one petitioner)

May 22, 2024 5

CERTIFICATION

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.

____________________ ____________________________________

Date Signature of Petitioner

____________________ ______________________________________

Date Signature of Petitioner (If more than one petitioner)

BEFORE YOU FILE THIS PETITION FOR CIVIL CONTEMPT OF

A CUSTODY ORDER WITH THE PROTHONOTARY, MAKE

SURE YOU HAVE COMPLETED THE FOLLOWING FORMS:

• Confidential Information Form.

• Confidential Information Form Abuse Victim Addendum if you are an abuse victim and do

not want to disclose your contact information to anyone but the Court.

• Criminal Record/Abuse History Verification.

• Self-Represented Party Entry of Appearance.

These forms must be filed with the Prothonotary at the same

time as the Petition for Civil Contempt of a Custody Order.

May 22, 2024 6

8-9-2024

_________________________________, IN THE COURT OF COMMON PLEAS

Plaintiff(s) DAUPHIN COUNTY, PENNSYLVANIA

v. CIVIL ACTION – CUSTODY

_________________________________, NO. _____________________________

Defendant(s)

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:

1. U

nless indicated by my checking the “YES” box next to a crime below, neither I nor any other

member of my household have been convicted or pled guilty or pled no contest or was adjudicate d

del

inquent 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, includi ng

pend

ing charges:

A

nswer

Yes or No

Crime Self Other

household

member

Date of conviction,

guilty plea, no

contest plea or

pending charges

Sentence

18 Pa.C.S. Ch. 25 (relating to

criminal homicide)

__________ _______

18 Pa.C.S. §2701 (relating to

simple assault)

__________ _______

18 Pa.C.S. §2702 (relating to

aggravated assault)

__________ _______

18 Pa.C.S. §2705 (relating to

recklessly endangering

another person)

__________ _______

18 Pa.C.S. §2706

(relating to terroristic threats)

__________ _______

8-9-2024

Answer

Yes or No

Crime Self Other

household

member

Date of conviction,

guilty plea, no

contest plea or

pending charges

Sentence

18 Pa.C.S. §2709.1

(relating to stalking)

18 P

a.C.S. §2718

(relating to strangulation)

__________

____

______

_______

____

____

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. §2904

(relating to interference with

custody of children)

__________ _______

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)

__________ _______

Answer Crime Self Other Date of conviction, Sentence

Yes or No household guilty plea, no

member contest plea or

pending charges

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. §5533 __________ _______

(relating to cruelty to animal)

8-9-2024

Answer Crime Self Other Date of conviction, Sentence

Yes or No household guilty plea, no

member contest plea or

pending charges

18 Pa.C.S. §5534 __________ _______

(relating to aggravated cruelty

to animal)

18 Pa.C.S. §5543 __________ _______

(relating to animal fighting)

18 Pa.C.S. §5544 __________ _______

(relating to possession of

animal fighting paraphernalia)

18 Pa.C.S. §5902(b) __________ _______

(relating to prostitution and

related offenses)

18 Pa.C.S. §5903(c) or (d) __________ _______

(relating to obscene and other

sexual materials and

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)

8-9-2024

8-9-2024

Answer

Yes or No

Crime Self Other

household

member

Date of conviction,

guilty plea, no

contest plea or

pending charges

Sentence

23 Pa.C.S. § 6114

(relating to contempt for

violation of protection order or

agreement)

__________ _______

Driving under the influence of

alcohol or controlled

substances

__________ _______

Driving after imbibing alcohol

or utilizing drugs

__________ _______

Manufacture, sale, delivery,

holding, offering for sale or

possession of any controlled

substance or other drug or

device

__________ _______

2. U

nless indicated by my checking the “YES” box next to an item below, neither I nor any other

member of my household have a history of violent or abusive conduct, or involvement with a Children &

Youth agency including the following:

A

nswer

Yes or No

Se lf Other

household

member

Date

A finding of abuse by a Children & Youth Agency or similar

agency in Pennsylvania or similar statute in another

jurisdiction

_______

Abusive conduct as defined under the Protection from

Abuse Act in Pennsylvania or similar statute in another

jurisdiction

I

nvolvement with a Children & Youth Agency or similar

agency in Pennsylvania or another jurisdiction.

W

here: ________________________________

____

___

[binding.law: PDF page 18 withheld — the text engines read it differently]

IN THE COURT OF COMMON PLEAS

______________________________________________ DAUPHIN COUNTY, PENNSYLVANIA

PLAINTIFF

vs.

NO. _____________________________

______________________________________________

DEFENDANT

SELF-REPRESENTED PARTY ENTRY OF APPEARANCE

1. I am the Plaintiff Defendant in the above-captioned (MARK ONE) custody, divorce, support,

protection from abuse, paternity case.

This (MARK ONE) is is NOT a new case. I have decided not to hire an attorney to represent me. I am

entering my appearance as a self-represented party.

__________________________________________________

(Signature of Self-Represented Party)

2. If this is not a new case, please check one box and complete the information. (Skip if this is a new case.)

This is NOT a new case and (Name of Prior Attorney) ___________________________________________

previously represented me in this case. I have decided not to be represented by that attorney and direct the

Prothonotary to remove that attorney as my counsel of record in this case.

I have provided a copy of this form to that attorney listed above at the following address:

______________________________________________________________________________________

This is NOT a new case, and my prior attorney acknowledges their withdrawal as my attorney in this case.

__________________________________________________

(Signature of Prior Attorney)

3. Check one box.

I am a victim of abuse and the other party to this action was the abuser. My address, phone number, and

email address are listed on the Confidential Information Form Abuse Victim Addendum filed along with this Self-Represented Party Entry of Appearance.

I am not an abuse victim and my address, phone number and email address for the purpose of receiving all

future pleadings and other legal notices are listed below. I understand that this address will be the only address to

which notices and pleadings in this case will be sent. I understand that I am responsible to regularly check my mail at

this address to ensure that I do not miss important deadlines or proceedings.

Complete Mailing Address: _______________________________________________________________________

_____________________________________________________________________________________________

Phone Number: ___________________________ Email: _____________________________________________

Updated 5-22-2024

4. I UNDERSTAND I MUST FILE A NEW FORM AND CONFIDENTIAL INFORMATION FORM ABUSE VICTIM

ADDENDUM (IF APPLICABLE) EVERY TIME MY ADDRESS OR PHONE NUMBER CHANGES.

5. Check one box.

I have provided a copy of this form to all other attorneys or other self-represented parties at the following

addresses as listed below: (Do not list yourself. Use reverse side if you need more space)

Name______________________________ Address__________________________________________

Name______________________________ Address__________________________________________

I am a victim of abuse and the other party to this action was the abuser. I understand that I should only

provide a copy of this form to all other attorneys or self-represented parties BUT THAT I SHOULD NOT

PROVIDE A COPY OF THE CONFIDENTIAL INFORMATION FORM ABUSE VICTIM ADDENDUM TO

ANYONE EXCEPT TO THE COURT BY FILING THAT FORM WITH THE APPROPRIATE FILING OFFICE

(PROTHONOTARY OR DOMESTIC RELATIONS).

6. I fully understand that by deciding to represent myself, the Court will hold me to the same standards of

knowledge regarding the statutory law, evidence law, Local and State Rules of Procedure and applicable

case law as a Pennsylvania licensed attorney, and that I must be fully prepared to meet those

responsibilities.

I verify that the statements made in this Entry of Appearance as a Self-Represented Party are true and correct.

I understand that if I make false statements herein, that I am subject to the criminal penalties of 18 Pa.C.S. §

4904 relating to unsworn falsification to authorities which could result in a fine and/or prison term.

_____________________ _________________________________________________________

Date Signature of Self-Represented Party

CERTIFICATION

I, (Your Name) ________________________________________, 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.

_____________________ _________________________________________________________

Date Signature of Self-Represented Party

Updated 5-22-2024