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If you checked a box in (2) or (3), list any evaluation, counseling, or other treatment received as a result:" }, { "id": "p7.3", "order": 18, "type": "table", "bbox": { "l": 49.68, "t": 639.36, "r": 553.68, "b": 277.68 }, "text": "", "attrs": { "block_label": "table", "n_rows": 3, "n_cols": 1, "integrity": { "cells_checked": 3, "cells_flagged": 0 } }, "children": [ { "id": "p7.3.1", "order": 19, "type": "table_cell", "bbox": { "l": 50.4, "t": 638.5678, "r": 80.376311, "b": 627.6598 }, "text": "result:", "attrs": { "row": 0, "col": 0, "rowspan": 1, "colspan": 1, "bbox_refit": true } }, { "id": "p7.3.2", "order": 20, "type": "table_cell", "bbox": { "l": 50.4, "t": 527.5688, "r": 553.300914, "b": 500.7006 }, "text": "5. If you checked a box in (2) or (3) that applies to your household member, who is not a party, state that person's name, date of birth, and relationship to the child.", "attrs": { "row": 1, "col": 0, "rowspan": 1, "colspan": 1, "bbox_refit": true }, "children": [ { "id": "p7.3.2.1", "order": 21, "type": "form_field", "bbox": { "l": 49.162, "t": 627.482, "r": 552.199, "b": 532.706 }, "text": "", "attrs": { "field_kind": "text", "pdf_field_name": "Question 4(CRAHV)", "source": "acroform", "label": "2", "row": 1, "col": 0, "rowspan": 1, "colspan": 1, "label_source": "parent_text", "label_ref": "p7.3.2" } }, { "id": "p7.3.2.2", "order": 22, "type": "form_field", "bbox": { "l": 49.0662, "t": 498.738, "r": 552.103, "b": 403.963 }, "text": "", "attrs": { "field_kind": "text", "pdf_field_name": "Question 5(CRAHV)", "source": "acroform", "label": "2", "row": 1, "col": 0, "rowspan": 1, "colspan": 1, "label_source": "parent_text", "label_ref": "p7.3.2" } } ] }, { "id": "p7.3.3", "order": 23, "type": "table_cell", "bbox": { "l": 50.4, "t": 400.6088, "r": 540.881533, "b": 373.861 }, "text": "6. If you are aware that the other party or the other party's household member has a criminal record or abuse history, please explain.", "attrs": { "row": 2, "col": 0, "rowspan": 1, "colspan": 1, "bbox_refit": true }, "children": [ { "id": "p7.3.3.1", "order": 24, "type": "form_field", "bbox": { "l": 48.808, "t": 372.414, "r": 551.845, "b": 277.638 }, "text": "", "attrs": { "field_kind": "text", "pdf_field_name": "Question 6(CRAHV)", "source": "acroform", "row": 2, "col": 0, "rowspan": 1, "colspan": 1, "label": "6. If you are aware that the other party or the other party's household member has a criminal record or abuse history, please explain.", "label_source": "parent_text", "label_ref": "p7.3.3" } } ] } ] }, { "id": "p7.4", "order": 25, "type": "heading", "bbox": { "l": 47.04, "t": 262.56, "r": 549.84, "b": 234 }, "text": "ONLY A PARTY CAN SIGN THIS FORM. IF A PARTY IS REPRESENTED BY AN ATTORNEY, THE ATTORNEY CANNOT SIGN THIS FORM ON BEHALF OF THE PARTY.", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p7.5", "order": 26, "type": "text", "bbox": { "l": 47.52, "t": 221.04, "r": 562.8, "b": 178.8 }, "text": "I verify that the information above is true and correct to the best of my knowledge, information or belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities." }, { "id": "p7.6", "order": 27, "type": "text", "bbox": { "l": 49.92, "t": 145.44, "r": 178.08, "b": 136.08 }, "text": "___" }, { "id": "p7.7", "order": 28, "type": "text", "bbox": { "l": 47.04, "t": 142.32, "r": 483.6, "b": 121.92 }, "text": "Plaintiff/Defendant Signature", "children": [ { "id": "p7.7.1", "order": 29, "type": "form_field", "bbox": { "l": 266.4, "t": 151.8145, "r": 482.4, "b": 138.5254 }, "text": "", "attrs": { "field_kind": "text", "source": "blank_line", "label": "Plaintiff/Defendant Signature", "label_source": "parent_text", "label_ref": "p7.7" } } ] }, { "id": "p7.8", "order": 30, "type": "table", "bbox": { "l": 263.52, "t": 140.4, "r": 484.32, "b": 81.6 }, "text": "", "attrs": { "block_label": "table", "n_rows": 2, "n_cols": 1, "integrity": { "cells_checked": 2, "cells_flagged": 0 } }, "children": [ { "id": "p7.8.1", "order": 31, "type": "table_cell", "bbox": { "l": 266.40004, "t": 135.64919999999995, "r": 407.929189, "b": 124.74120000000005 }, "text": "Plaintiff/Defendant Signature", "attrs": { "row": 0, "col": 0, "rowspan": 1, "colspan": 1, "bbox_refit": true } }, { "id": "p7.8.2", "order": 32, "type": "table_cell", "bbox": { "l": 266.40004, "t": 94.24919999999997, "r": 340.595643, "b": 83.34119999999996 }, "text": "(Printed Name)", "attrs": { "row": 1, "col": 0, "rowspan": 1, "colspan": 1, "bbox_refit": true }, "children": [ { "id": "p7.8.2.1", "order": 33, "type": "form_field", "bbox": { "l": 266.4, "t": 121.866, "r": 482.4, "b": 98.4 }, "text": "", "attrs": { "field_kind": "text", "label": "(Printed Name)", "pdf_field_name": "Printed Name(CRAHV)", "source": "acroform", "row": 1, "col": 0, "rowspan": 1, "colspan": 1, "label_source": "parent_text", "label_ref": "p7.8.2" } } ] } ] }, { "id": "p7.9", "order": 34, "type": "text", "bbox": { "l": 48.72, "t": 137.76, "r": 177.84, "b": 123.84 }, "text": "Date", "children": [ { "id": "p7.9.1", "order": 35, "type": "form_field", "bbox": { "l": 50.4, "t": 160.943, "r": 176.4, "b": 139.8 }, "text": "", "attrs": { "field_kind": "text", "label": "Date", "pdf_field_name": "Date(CRAHV)", "source": "acroform", "label_source": "parent_text", "label_ref": "p7.9" } } ] } ], "excluded_furniture": { "first": [], "last": [] } }