8a. Are you aware of any pending investigations of abuse of either party or members of either party’s household by any children & youth services agency, child protective services, or general protective services agency, or the equivalent agency in another jurisdiction, concerning the children in this custody case or any other children?
YES NO
YES □
NO □
8b. If you answered YES to question 8a, please complete the following:
Name of agency where investigation is pending: ___
Status of the investigation:
ot the investigation: ___
Name of agency where investigation is pending:
Status of the investigation:
The circumstances surrounding the investigation:
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.
DATE
DATE
SIGNATURE
SIGNATURE
(Printed Name)
(Address)
(Printed Name)
(_____)
(Address)
(Home Phone)
(_______)_________________
(Home Phone)
(_____)
(Work Phone)
(_______)_________________
(Work Phone)