90fdce07-c6ae-4263-92db-680eed562b05_PreTrialStatementConfInfoFormParentingPlanHistoryVerificationPacket080524_need_help-artifacted.pdf — PaddleOCR-VL (Baidu)

IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

PLAINTIFF

CASE NO

Name	PLAINTIFF
vs.
Name	DEFENDANT 1 and (if applicable)
Name	DEFENDANT 2

DEFENDANT 1

DEFENDANT 2

CASE NO. ___ ACTION IN CUSTODY

PLAINTIFF'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:

Petitioner

1. Unless indicated by my checking the “YES” box next to a crime below, I have checked the “NO” box to indicate that neither I nor any other member of my household have been convicted or pled guilty or pled no contest or was adjudicated delinquent 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, including pending charges:

Check YES to all that apply	Check NO to all that DO NOT apply	Crime	Self	Other household member	Date of conviction, guilty plea, no contest plea or pending charges	Sentence
YES☐	NO☐	18 Pa.C.S. Ch. 25 (relating to criminal homicide)	undefined	undefined	undefined	undefined
YES☐	NO☐	18 Pa.C.S. § 2701 (relating to simple assault)	undefined	undefined	undefined	undefined
YES☐	NO☐	18 Pa.C.S. § 2702 (relating to aggravated assault)	undefined	undefined	undefined	undefined
YES☐	NO☐	18 Pa.C.S. § 2705 (relating to recklessly endangering another person)	undefined	NO	undefined	undefined
YES☐	NO☐	18 Pa.C.S. § 2706 (relating to terroristic threats)	undefined	undefined	undefined	undefined

Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. Ch. 25 (relating to criminal homicide)

Sentence_18 Pa.C.S. Ch. 25 (relating to criminal homicide)

Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2701 (relating to simple assault)

Sentence_18 Pa.C.S. § 2701 (relating to simple assault)

Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2702 (relating to aggravated assault)

Sentence_18 Pa.C.S. § 2702 (relating to aggravated assault)

Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2705 (relating to recklessly endangering another person)

Sentence_18 Pa.C.S. § 2705 (relating to recklessly endangering another person)

Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2706 (relating to terroristic threats)

Sentence_18 Pa.C.S. § 2706 (relating to terroristic threats)