===== PAGE 1 ===== # PETITION FOR EMERGENCY RELIEF FROM ABUSE On-Call MDJ:

On-Call MDJ:

Mag. Dist. No: MDJ-51-3-01, Honorable Matthew Robert Harvey Address/Phone: 525 Boyds School Road, Suite 900, Gettysburg, PA 17325, 717-334-7810

Mag. Dist. No: MDJ-51-3-02, Honorable Christopher A. Snyder Address/Phone: 45D West Hanover Street, Bonneauville, PA 17325, 717-334-7810

Mag. Dist. No: MDJ-51-3-03, Honorable Tony J. Little Address/Phone: 40 Church Road, East Berlin, PA 17316 717-337-5770

Mag. Dist. No: MDJ-51-3-04: Honorable Mark D. Beauchat Address/Phone: 525 Boyds School Road, Suite 900, Gettysburg, PA 17325, 717-337-3870

V. Docket No: Case Filed: — ## PETITION OF THE PLAINTIFF l, ___, hereby petition for emergency relief from abuse (Name of Plaintiff - please print) On behalf of myself. On behalf of the following minor (child) (children) of whom I am a (parent) (adult household member) (guardian). On behalf of the following incapacitated person to whom I am guardian.

(Name)

(Address)	(Age)
(Address)	(Age)

The cause for seeking relief is as follows:

项目名称	规格型号	规格型号	数量	单价
1.00	0.00	0.00	0.00	0.00
2.00	0.00	0.00	0.00	0.00
3.00	0.00	0.00	0.00	0.00
4.00	0.00	0.00	0.00	0.00
5.00	0.00	0.00	0.00	0.00
6.00	0.00	0.00	0.00	0.00
7.00	0.00	0.00	0.00	0.00
8.00	0.00	0.00	0.00	0.00
9.00	0.00	0.00	0.00	0.00
10.00	0.00	0.00	0.00	0.00
11.00	0.00	0.00	0.00	0.00
12.00	0.00	0.00	0.00	0.00
13.00	0.00	0.00	0.00	0.00
14.00	0.00	0.00	0.00	0.00
15.00	0.00	0.00	0.00	0.00
16.00	0.00	0.00	0.00	0.00
17.00	0.00	0.00	0.00	0.00
18.00	0.00	0.00	0.00	0.00
19.00	0.00	0.00	0.00	0.00
20.00	0.00	0.00	0.00	0.00
21.00	0.00	0.00	0.00	0.00
22.00	0.00	0.00	0.00	0.00
23.00	0.00	0.00	0.00	0.00
24.00	0.00	0.00	0.00	0.00
25.00	0.00	0.00	0.00	0.00
26.00	0.00	0.00	0.00	0.00
27.00	0.00	0.00	0.00	0.00
28.00	0.00	0.00	0.00	0.00
29.00	0.00	0.00	0.00	0.00
30.00	0.00	0.00	0.00	0.00
31.00	0.00	0.00	0.00	0.00
32.00	0.00	0.00	0.00	0.00
33.00	0.00	0.00	0.00	0.00
34.00	0.00	0.00	0.00	0.00
35.00	0.00	0.00	0.00	0.00
36.00	0.00	0.00	0.00	0.00
37.00	0.00	0.00	0.00	0.00
38.00	0.00	0.00	0.00	0.00
39.00	0.00	0.00	0.00	0.00
40.00	0.00	0.00	0.00	0.00
41.00	0.00	0.00	0.00	0.00
42.00	0.00	0.00	0.00	0.00
43.00	0.00	0.00	0.00	0.00
44.00	0.00	0.00	0.00	0.00
45.00	0.00	0.00	0.00	0.00
46.00	0.00	0.00	0.00	0.00
47.00	0.00	0.00	0.00	0.00
48.00	0.00	0.00	0.00	0.00
49.00	0.00	0.00	0.00	0.00
50.00	0.00	0.00	0.00	0.00
51.00	0.00	0.00	0.00	0.00
52.00	0.00	0.00	0.00	0.00
53.00	0.00	0.00	0.00	0.00
54.00	0.00	0.00	0.00	0.00
55.00	0.00	0.00	0.00	0.00
56.00	0.00	0.00	0.00	0.00
57.00	0.00	0.00	0.00	0.00
58.00	0.00	0.00	0.00	0.00
59.00	0.00	0.00	0.00	0.00
60.00	0.00	0.00	0.00	0.00
61.00	0.00	0.00	0.00	0.00
62.00	0.00	0.00	0.00	0.00
63.00	0.00	0.00	0.00	0.00
64.00	0.00	0.00	0.00	0.00
65.00	0.00	0.00	0.00	0.00
66.00	0.00	0.00	0.00	0.00
67.00	0.00	0.00	0.00	0.00
68.00	0.00	0.00	0.00	0.00
69.00	0.00	0.00	0.00	0.00
70.00	0.00	0.00	0.00	0.00
71.00	0.00	0.00	0.00	0.00
72.00	0.00	0.00	0.00	0.00
73.00	0.00	0.00	0.00	0.00
74.00	0.00	0.00	0.00	0.00
75.00	0.00	0.00	0.00	0.00
76.00	0.00	0.00	0.00	0.00
77.00	0.00	0.00	0.00	0.00
78.00	0.00	0.00	0.00	0.00
79.00	0.00	0.00	0.00	0.00
80.00	0.00	0.00	0.00	0.00
81.00	0.00	0.00	0.00	0.00
82.00	0.00	0.00	0.00	0.00
83.00	0.00	0.00	0.00	0.00
84.00	0.00	0.00	0.00	0.00
85.00	0.00	0.00	0.00	0.00
86.00	0.00	0.00	0.00	0.00
87.00	0.00	0.00	0.00	0.00
88.00	0.00	0.00	0.00	0.00
89.00	0.00	0.00	0.00	0.00
90.00	0.00	0.00	0.00	0.00
91.00	0.00	0.00	0.00	0.00
92.00	0.00	0.00	0.00	0.00
93.00	0.00	0.00	0.00	0.00
94.00	0.00	0.00	0.00	0.00
95.00	0.00	0.00	0.00	0.00
96.00	0.00	0.00	0.00	0.00
97.00	0.00	0.00	0.00	0.00
98.00	0.00	0.00	0.00	0.00
99.00	0.00	0.00	0.00	0.00
100.00	0.00	0.00	0.00	0.00

Emergency relief from abuse is required because there is immediate and present danger of abuse by the defendant to me and to the above listed minor (child) (children) (incapacitated person). (Print additional names/addresses on a separate sheet of paper and attach hereto.) Has Defendant been determined to be a perpetrator in a founded or indicated report under the Child Protective Services Law, 23 Pa.C.S. §§ 6301-6386? Yes No If you answered Yes, what county's court or child protective services agency issued the founded or indicated report? ===== PAGE 2 =====

On-Call MDJ:

Mag. Dist. No: MDJ-51-3-01, Honorable Matthew Robert Harvey Address/Phone: 525 Boyds School Road, Suite 900, Gettysburg, PA 17325, 717-334-7810

Mag. Dist. No: MDJ-51-3-02, Honorable Christopher A. Snyder Address/Phone: 45D West Hanover Street, Bonneauville, PA 17325, 717-334-7810

Mag. Dist. No: MDJ-51-3-03, Honorable Tony J. Little Address/Phone: 40 Church Road, East Berlin, PA 17316 717-337-5770

Mag. Dist. No: MDJ-51-3-04: Honorable Mark D. Beauchat Address/Phone: 525 Boyds School Road, Suite 900, Gettysburg, PA 17325, 717-337-3870

# PETITION FOR EMERGENCY RELIEF FROM ABUSE

Docket No: Case Filed:

## - 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.