12 13 COURT OF COMMON PLEAS OF 12 COUNTY, PENNSYLVANIA 13 COURT OF COMMON PLEAS OF 13 COUNTY, PENNSYLVANIA

IN 13 OURT OF COMMON PLEAS O PLAINTIFF 15 VS. DEFFENDANT Case No. 14

underbrace IN 13OURT OF COMMON PLEAS OFunderbrace □ □,: COUNTY, PENNSYLVANIA

DEFENDANT : IN DIVORCE

Case No. boxed 14

COMMONWEALTH OF PENNSYLVANIA

COUNTY OF ___

On this, the ___ day of ___, 20___, personally appeared before me, a Notary Public in and for said Commonwealth and County, ___ (full married name), known to me (or satisfactorily proven) to be the person who is the person whose name is subscribed to the within document and acknowledged that she executed the same for the purposes therein contained.

Notary Public:

My Commission Expires: