IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW
Name(CSPTSPPCRV)
Name PLAINTIFF vs. Name DEFENDANT 1 and (if applicable) Name DEFENDANT 2 CASE NO. ___
Name(CSPTSPPCRV)
Name(CSPTSPPCRV)
CASE NO(CSPTSPPCRV)
CASE NO.
ACTION IN CUSTODY
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on this date, a true and correct copy of the foregoing PRE-TRIAL CONFERENCE MEMORANDUM, PARENTING PLAN, and CRIMINAL RECORD/ABUSE HISTORY VERIFICATION was served by first class mail to the following:
Name of person served(CSPTSPPCRV)
Name of person served
Street Address of person served(CSPTSPPCRV)
Street Address of person served
City(CSPTSPPCRV)
City State Zip Code
State(CSPTSPPCRV)
Zip Code(CSPTSPPCRV)
Date: _____
Date(CSPTSPPCRV)
<table><tr><td>Signature of person certifying service</td></tr></table>
Signature of person certifying service
Name of person certifying service (printed or typed(CSPTSPPCRV)
Name of person certifying service (printed or typed)
Street Address of person certifying service(CSPTSPPCRV)
Street Address of person certifying service
Zip Code(CSPTSPPCRV)
City(CSPTSPPCRV)
City State Zip Code
State(CSPTSPPCRV)
___
Telephone Number of person certifying service(CSPTSPPCRV) (format: numeric)
Area Code(CSPTSPPCRV)
Area Code Telephone Number of person certifying service Certificate of Service – Pre-Trial Conference/Parenting Plan/History Verification – Form #1 Page 1 of 1