===== PAGE 1 ===== # CHECKLIST FOR PRE-TRIAL STATEMENT This checklist is provided for you to chart your progress. The checklist is arranged in chronological order. Please refer to the checklist as you complete the materials in this packet. 1. ___ Complete the PRE-TRIAL CONFERENCE STATEMENT, PARENTING PLAN, and CRIMINAL RECORD AND ABUSE HISTORY AFFIDAVIT 2. ___ Sign and date PRE-TRIAL CONFERENCE STATEMENT, PARENTING PLAN, and CRIMINAL RECORD AND ABUSE HISTORY AFFIDAVIT 3. ___ Copies of PRE-TRIAL CONFERENCE STATEMENT, PARENTING PLAN, and CRIMINAL RECORD AND ABUSE HISTORY AFFIDAVIT made 4. ___ Complete the CONFIDENTIAL INFORMATION FORM 5. ___ Sign and date CONFIDENTIAL INFORMATION FORM ## IMPORTANT: AT LEAST FIVE DAYS PRIOR TO THE PRE-TRIAL CONFERENCE: 6. ___ File PRE-TRIAL CONFERENCE STATEMENT, CONFIDENTIAL INFORMATION FORM, PARENTING PLAN, and CRIMINAL RECORD AND ABUSE HISTORY AFFIDAVIT and all copies with the Prothonotary. 7. ___ Serve PRE-TRIAL CONFERENCE STATEMENT, CONFIDENTIAL INFORMATION FORM, PARENTING PLAN, and CRIMINAL RECORD AND ABUSE HISTORY AFFIDAVIT on the other party/attorney. 8. ___ Complete and file the Certificate of Service with the Prothonotary. ===== PAGE 2 ===== # IN THE COURT OF COMMON PLEAS OF ADAMS COUNTY, PENNSYLVANIA

Plaintiff	:	No.____-SU-
	:
	:	CIVIL ACTION - LAW
VS.	:
	:
	:	CUSTODY
Defendant

Defendant ## CUSTODY PRE-TRIAL STATEMENT ### I. BRIEF SUMMARY OF CASE, INCLUDING INITIALS AND YEARS OF BIRTH OF CHILDREN AT ISSUE AND THE CURRENT CUSTODY SITUATION: Plaintiff, ___ is the (Name of Plaintiff) (Plaintiff's relationship to the child/ren) Defendant, ___ is the (Name of Defendant) (Defendant's relationship to the child/ren) of the following child(ren) at issue:

Child(ren)'s Initials:	Month and Year of Birth:

## THE PRE-TRIAL STATEMENT MUST BE FILED WITH A CONFIDENTIAL INFORMATION FORM Pursuant to Pa.R.C.P. No. 1915.4-4(b) the Pre-Trial Statement: (1) Must be filed with the Prothonotary's Office 5 days PRIOR to the Pre-Trial Conference; and (2) Served on the opposing party/counsel ===== PAGE 3 ===== The present custody situation is as follows (include date of Current Order): The present custody situation has existed since approximately ___ months / years. II. STATEMENT OF ISSUES EXPECTED TO ARISE DURING TRIAL: III. ADMISSION FROM PLEADINGS TO BE MADE PART OF RECORD: IV. STIPULATION OF PARTIES: ===== PAGE 4 ===== ### V. WITNESSES TO BE CALLED:

NAME	ADDRESS	RELATIONSHIP TO PARTY & SUBJECT OF TESTIMONY
1.
2.
3.
4.
5.
6.
7.
8.

Pursuant to Pa.R.C.P. No. 1915.4-4(b)(2) the Pre-Trial Statement must include a statement by the party or the party's counsel that he or she has communicated with each listed witness. VI. STATUS OF EXPERT WITNESSES, REPORTS, EVALUATIONS AND STUDIES: ===== PAGE 5 ===== VII. STATEMENT OF OBJECTIONS OR UNUSUAL EVIDENTIARY PROBLEMS EXPECTED TO ARISE AT TRIAL: (Parties should submit authority for their respective positions with this memorandum.) VIII. SPECIAL REQUESTS, UNCOMPLETED MATTERS: IX. STATEMENT OF SETTLEMENT PROSPECTS: ___ X. ESTIMATED TIME NEEDED FOR TRIAL: ___ Respectfully submitted, ___ Signature _____ Print Name Address – Street City, State and Zip Code Phone Number ===== PAGE 6 ===== # CONFIDENTIAL INFORMATION FORM # Case Records Public Access Policy of the Unified Judicial System of Pennsylvania 204 Pa. Code § 213.81 www.pacourts.us/public-records (Party name as displayed in case caption) Docket/Case No. Vs. (Party name as displayed in case caption) Court This form is associated with the pleading titled ___, dated___, ___. Pursuant to the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania, the Confidential Information Form shall accompany a filing where confidential information is required by law, ordered by the court, or otherwise necessary to effect the disposition of a matter. This form, and any additional pages, shall remain confidential, except that it shall be available to the parties, counsel of record, the court, and the custodian. This form, and any additional pages, must be served on all unrepresented parties and counsel of record.

This Information Pertains to:	Confidential Information:	References in Filing:
	Social Security Number (SSN):	Alternative Reference:SSN 1
(full name of adult)ORThis information pertains to a minor with the initials of ___ and the full name of	Financial Account Number (FAN):	Alternative Reference:FAN 1
	Driver License Number (DLN):	Alternative Reference:DLN 1
(full name of minor)and date of birth: ___	State of Issuance:	Alternative Reference:SID 1
(full name of minor)and date of birth: ___	State Identification Number (SID):	Alternative Reference:SID 1
	Social Security Number (SSN):	Alternative Reference:SSN 2
(full name of adult)ORThis information pertains to a minor with the initials of ___ and the full name of	Financial Account Number (FAN):	Alternative Reference:FAN 2
	Driver License Number (DLN):	Alternative Reference:DLN 2
(full name of minor)and date of birth: ___	State of Issuance:	Alternative Reference:SID 2
(full name of minor)and date of birth: ___	State Identification Number (SID):	Alternative Reference:SID 2

===== PAGE 7 ===== # CONFIDENTIAL INFORMATION FORM Additional page(s) attached. _____ total pages are attached to this filing. 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. ___ Signature of Attorney or Unrepresented Party Name: _____ Address: _____ Date _____ Attorney Number: (if applicable) _____ Telephone: _____ Email: _____ NOTE: Parties and attorney of record in a case will have access to this Confidential Information Form. Confidentiality of this information must be maintained. ===== PAGE 8 ===== ## CONFIDENTIAL INFORMATION FORM

Additional page (if necessary)

This Information Pertains to:	Confidential Information:	References in Filing:
	Social Security Number (SSN):	Alternative Reference:SSN ___
(full name of adult)ORThis information pertains to a minor with the initials of ___ and the full name of	Financial Account Number (FAN):	Alternative Reference:FAN ___
	Driver License Number (DLN):	Alternative Reference:DLN ___
(full name of minor)and date of birth: ___	State of Issuance:	Alternative Reference:SID ___
(full name of minor)and date of birth: ___	State Identification Number (SID):	Alternative Reference:SID ___
	Social Security Number (SSN):	Alternative Reference:SSN ___
(full name of adult)ORThis information pertains to a minor with the initials of ___ and the full name of	Financial Account Number (FAN):	Alternative Reference:FAN ___
	Driver License Number (DLN):	Alternative Reference:DLN ___
(full name of minor)and date of birth: ___	State of Issuance:	Alternative Reference:SID ___
(full name of minor)and date of birth: ___	State Identification Number (SID):	Alternative Reference:SID ___
	Social Security Number (SSN):	Alternative Reference:SSN ___
(full name of adult)ORThis information pertains to a minor with the initials of ___ and the full name of	Financial Account Number (FAN):	Alternative Reference:FAN ___
	Driver License Number (DLN):	Alternative Reference:DLN ___
(full name of minor)and date of birth: ___	State of Issuance:	Alternative Reference:SID ___
(full name of minor)and date of birth: ___	State Identification Number (SID):	Alternative Reference:SID ___

===== PAGE 9 ===== ## Instructions for Completing the Confidential Information Form The following information is confidential and shall not be included in any document filed with a court or custodian, except on a Confidential Information Form filed contemporaneously with the document: 1. Social Security Numbers 2. Financial Account Numbers, except an active financial account number may be identified by the last four digits when the financial account is the subject of the case and cannot otherwise be identified. “Financial Account Numbers” include financial institution account numbers, debit and credit card numbers, and methods of authentication used to secure accounts such as personal identification numbers, user names and passwords. 3. Driver License Numbers 4. State Identification (SID) Numbers 5. Minors’ names and dates of birth except when a minor is charged as a defendant in a criminal matter (see 42 Pa.C.S. § 6355). “Minor” is a person under the age of eighteen. 6. Abuse victim’s address and other contact information, including employer’s name, address and work schedule, in family court actions as defined by Pa.R.C.P. No. 1931(a), except for victim's name. “Abuse Victim” is a person for whom a protection order has been granted by a court pursuant to Pa.R.C.P. No. 1901 et seq. and 23 Pa.C.S. § 6101 et seq. or Pa.R.C.P. No. 1951 et seq. and 42 Pa.C.S § 62A01 et seq. If necessary, this information must be provided on the separate Abuse Victim Addendum. Please note there are separate instructions for the completion of the Addendum located on the form. Please note this form does not need to be filed in types of cases that are sealed or exempted from public access pursuant to applicable authority (e.g. juvenile, adoption, etc.). The best way to protect confidential information is not to provide it to the court. Therefore, only provide confidential information to the court when it is required by law, ordered by the court or is otherwise necessary to effect the disposition of a matter. Do not include confidential information in any other document filed with the court under this docket. If you need to refer to a piece of confidential information in a document, use the alternate references. If you need to attach additional pages, sequentially number each alternate reference – i.e. SSN 3, SSN 4, etc. This form, and any additional pages, must be served on all unrepresented parties and counsel of record. A court or custodian is not required to review or redact any filed document for compliance with the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania. A party’s or attorney’s failure to comply with this section shall not affect access to case records that are otherwise accessible. If a filed document fails to comply with the requirements of the above referenced policy, a court of record may, upon motion or its own initiative, with or without a hearing, order the filed document sealed, redacted, amended or any combination thereof; a magisterial district court may, upon request or its own initiative, redact, amend or both. A court of record may impose sanctions, including costs necessary to prepare a compliant document for filing in accordance with applicable authority. ## THIS FORM IS CONFIDENTIAL ===== PAGE 10 ===== ## CONFIDENTIAL INFORMATION FORM ## Abuse Victim Addendum Instructions for Completing the Abuse Victim Addendum: The Abuse Victim Addendum shall accompany a filing where confidential information is being provided by an abuse victim, as defined in this policy, in family court actions (see Pa.R.C.P. No. 1931(a)), as required by law, ordered by the court, or otherwise necessary to effect the disposition of a matter. This addendum, and any additional pages, shall only be provided to the court and shall remain confidential. The best way to protect confidential information is not to provide it to the court. Therefore, only provide confidential information to the court when it is required by law, ordered by the court or is otherwise necessary to effect the disposition of a matter. ## Type of Family Court Action Divorce, Annulment, Dissolution of Marriage

Support	Paternity	Protection from Abuse
This Information Pertains to:	Confidential Information:	References in Filing:
	AV Address:	Alternative Reference:AV 1 Address
(full name of abuse victim)	AV Employer's Name & Address:	Alternative Reference:AV 1 Employer's Name & Address
Docket/Case No. of Protection Order	AV Work Schedule:	Alternative Reference:AV 1 Work Schedule
Court/County	AV Other contact information:	Alternative Reference:AV 1 Other contact information

Attach additional page(s) if necessary. ===== PAGE 11 ===== # Abuse Victim Addendum Additional page (if necessary)

Type of Family Court Action
Divorce, Annulment, Dissolution of Marriage Support	Paternity	Child Custody Protection from Abuse
This Information Pertains to:	Confidential Information:	References in Filing:
	AV Address:	Alternative Reference:AV ___ Address
(full name of abuse victim)	AV Employer's Name & Address:	Alternative Reference:AV ___ Employer's Name & Address
Docket/Case No. of Protection Order	AV Work Schedule:	Alternative Reference:AV ___ Work Schedule
Court/County	AV Other contact information:	Alternative Reference:AV ___ Other contact information
Type of Family Court Action
Divorce, Annulment, Dissolution of Marriage Support	Child Custody Protection from Abuse
This Information Pertains to:	Confidential Information:	References in Filing:
	AV Address:	Alternative Reference:AV ___ Address
(full name of abuse victim)	AV Employer's Name & Address:	Alternative Reference:AV ___ Employer's Name & Address
Docket/Case No. of Protection Order	AV Work Schedule:	Alternative Reference:AV ___ Work Schedule
Court/County	AV Other contact information:	Alternative Reference:AV ___ Other contact information

===== PAGE 12 ===== Courts' Self-Help Center – Packets # PARENTING PLAN This packet contains information, forms, and instructions on developing a parenting plan with the other parent in a child custody case. ## DISCLAIMER Court staff cannot give you legal advice or help you complete these forms. The information in this packet is not a substitute for professional legal advice. The Court, the Adams County Bar Association and the Family Law Committee assume no responsibility and accept no liability for actions taken by users of these documents, including reliance on their contents. If you want to obtain the services of an attorney but do not know whom to contact, please call the Pennsylvania Lawyer Referral Service at 1-800-692-7375. A list of Attorneys Practicing in Adams County available for consultation on filling out self-help custody and divorce forms can be found on the Courts' Self-Help webpage at https://www.adamscountypa.gov/courts/courtadministration/selfhelpcenter Packet Last Updated: August 5, 2024 ===== PAGE 13 ===== # TABLE OF CONTENTS I. General Information A. Introduction B. Legal Definitions C. Custody Factors D. Criminal Convictions and Charges E. Rules of Civil Procedure F. Basic Procedure G. Service II. Instructions A. Completing the Parenting Plan III. Checklist for Parenting Plan IV. Forms A. Form #1 – Parenting Plan B. Form #2 – Certificate of Service ===== PAGE 14 ===== # GENERAL INFORMATION ### A. Introduction 1. This is the PRE-TRIAL CONFERENCE MEMORANDUM packet. This packet should be used when a Judge in your custody case orders you to complete a PARENTING PLAN or if you need a guideline to help you and your co-parent to resolve your custody case. Please note: i. If you do not have a Custody Order, and would like to obtain one, use the Obtaining a Custody Order packet. ii. If you have a Custody Order and would like to change the Order, use the Modification of a Custody Order packet. iii. If you need to enforce a Custody Order, use the Enforcing a Custody Order packet. 2. This packet of information has been created by members of the Adams County Bar Association. These materials are intended to assist individuals involved in a custody action by providing general information and legal forms. IT IS HIGHLY RECOMMENDED THAT YOU HIRE AN ATTORNEY TO REPRESENT YOU IN ANY CUSTODY ACTION. The information provided herein is not legal advice and is not to be used as a substitute for professional legal advice. Just as you would consult a medical professional for a medical issue, you should consult a legal professional for a legal issue. ### B. Legal Definitions 1. Custody means the legal right to keep, control, care for and make decisions for a child and includes the terms “legal custody,” “physical custody,” and “shared custody.” 2. Legal Custody is the right to make major decisions on behalf of the child, including, but not limited to, medical, religious and educational decisions. i. Sole Legal Custody: The right of one individual to exclusive legal custody of the child. ii. Shared Legal Custody: The right of more than one individual to legal custody of the child. 3. Physical Custody is the actual physical possession and control of a child. When a person has physical custody of the children, regardless if they have legal custody, they can make decisions regarding the child's health in an emergency situation. There are different types of physical custody schedules, including: i. Primary Physical Custody: The right to assume physical custody of the child for the majority of the time. The child lives with one party for the majority of the time. ===== PAGE 15 ===== ii. Shared Physical Custody: The right of more than one individual to assume physical custody of the child, each having significant periods of physical custodial time with the child. The child lives with each party for an equal or substantially equal amount of time. ii. Partial Physical Custody: The right to assume physical custody of the child for less than a majority of the time. The child lives with one party some of the time but not the majority of the time. A common example is when one party has the children every other weekend from Friday to Sunday, and occasionally one day during the week that they do not receive the child on the weekend. iv. Sole Physical Custody: The right of one individual to exclusive physical custody of the child. v. Visitation: Pennsylvania no longer uses the term Visitation. Partial Physical Custody, defined above, is equivalent to Visitation as defined in some states. vi. Non-Professional Supervised Physical Custody: Custodial time during which an adult, designated by the court or agreed upon by the parties, monitors the interaction between the child and the individual with those rights. vii. Professional Supervised Custody: Custodial time during which a professional, with education and training on the dynamics of domestic violence, sexual assault, child abuse, trauma and the impact of domestic violence on children, oversees the interaction between the child and the individual with those custody rights and promotes the safety of the child during the interaction. viii. Household Member: A spouse or an individual who has been a spouse, an individual living as a spouse or who lived as a spouse, a parent or child, another individual related by consanguinity or affinity, a current or former sexual or intimate partner, an individual who shares biological parenthood or any other person, who is currently sharing a household with the child or a party. 4. Relocation: A change in a residence of the child which significantly impairs the ability of a non-relocating party to exercise custodial rights. 5. Further information about the preceding legal definitions and about custody law may be found in the statutes that govern custody, Title 23 Pa. Consolidated Statutes Sections 5321 to 5340 (23 Pa.C.S. §§ 5321 – 5340), and in the Pennsylvania Rules of Civil Procedure, Pa.R.C.P. 1915.1 – 1915.25. ###### C. Custody Factors (23 Pa. C.S. §5328) 1. In ordering any form of custody, the Court shall determine the best interest of the child by considering all relevant factors, giving weighted consideration to those factors which affect the safety of the child, including: i. Which party is more likely to ensure the safety of the child. ===== PAGE 16 ===== ii. The present and past abuse committed by a party or member of the party's household, which may include past or current protection from abuse or sexual violence protection orders where there has been a finding of abuse. iii. The information set forth in section 5329.1(a) (relating to consideration of child abuse and involvement with protective services). iv. Violent or assaultive behavior committed by a party. v. Which party is more likely to encourage and permit frequent and continuing contact between the child and another party if contact is consistent with the safety needs of the child. vi. The parental duties performed by each party on behalf of the child. vii. The need for stability and continuity in the child's education, family life and community life, except if changes are necessary to protect the safety of the child or a party. viii. The availability of extended family. ix. The child's sibling relationships. x. The well-reasoned preference of the child, based on the child's maturity and judgment. xi. The attempts of a party to turn the child against the other party, except in cases of abuse where reasonable safety measures are necessary to protect the safety of the child. A party's reasonable concerns for the safety of the child and the party's reasonable efforts to protect the child shall not be considered attempts to turn the child against the other party. A child's deficient or negative relationship with a party shall not be presumed to be caused by the other party. xii. Which party is more likely to maintain a loving, stable, consistent and nurturing relationship with the child adequate for the child’s emotional needs. xiii. Which party is more likely to attend to the daily physical, emotional, developmental, educational and special needs of the child. xiv. The proximity of residences of the parties. xv. Each party's availability to care for the child or ability to make appropriate child-care arrangements. xvi. The level of conflict between the parties and the willingness and ability of the parties to cooperate with one another. A party's effort to protect a child or self from abuse by another party is not evidence of unwillingness or inability to cooperate with that party. xvii. The history of drug or alcohol abuse of a party or member of a party's household. xviii. The mental and physical condition of a party or member of a party's household. xix. Any other relevant factor. ### D. Criminal Convictions and Charges 1. Where a party seeks any form of custody the Court shall consider whether that party or member of that party's household has been convicted of or has pleaded ===== PAGE 17 ===== guilty or no contest to any of the offenses listed below or an offense in another jurisdiction substantially equivalent to any of the offenses listed below. The Court shall consider such conduct and determine that the party does not pose a threat of harm to the child before making any order of custody to that parent when considering the following charges: Criminal homicide, simple assault, aggravated assault, terroristic threats, recklessly endangering another person, stalking, kidnapping, unlawful restraint, false imprisonment, luring a child into a motor vehicle or structure, interfering with custody of children, rape, statutory sexual assault, involuntary deviate sexual intercourse, sexual assault, aggravated indecent assault, indecent assault, indecent exposure, sexual intercourse with animals, cruelty to animals, aggravated cruelty to animals, animal fighting, possession of animal fighting paraphernalia, offenses relating to sex offenders, arson, incest, concealing death of child, endangering welfare of children, offenses relating to dealing in infant children, prostitution, offenses related to obscene and other sexual materials and performances, corruption of minors, sexual abuse of children, unlawful contact with minor, sexual exploitation of children, contempt for violation of a permanent or temporary Protection From Abuse Order or agreement, driving under the influence of alcohol or controlled substance, driving after imbibing alcohol or utilizing drugs, and offenses related to The Controlled Substance, Drug, Device and Cosmetic Act prohibiting manufacture, sale or delivery, holding, offering for sale or possession of any controlled substance or other drug or device. 2. If you have obtained information about a criminal charge filed against the other party for an offense listed above, you may move for a temporary Custody Order or modification of an existing Custody Order. The Court must schedule an expedited hearing and the Court shall consider whether the party who is or has been charged with an offense poses a risk of physical, emotional or psychological harm to the child. 3. You can find out information about pending criminal charges, criminal convictions, guilty pleas and no contest pleas in Pennsylvania by logging on to the Web Portal for the Unified Judicial System of Pennsylvania at http://ujsportal.pacourts.us/. Once on this website, you can look up the docket information for all minor courts (Magisterial District Judges) and Common Pleas Courts in Pennsylvania. If you have correctly spelled the last name of the individual, you can find out if there are convictions or charges pending against the individual in all counties in Pennsylvania. ### 4. Criminal Record / Abuse History Verification i. The plaintiff or petitioner must file and serve with any Complaint for Custody or Petition for Modification a criminal record verification from regarding any criminal or abuse history of the plaintiff or petitioner and ===== PAGE 18 ===== anyone living in the plaintiff or petitioner's household. This form is available on the Adams County Court's self-help webpage at https://www.adamscountypa.gov/courts/courtadministration/selfhelpcenter. The plaintiff or petitioner must attach a blank criminal history verification form to a Complaint or Petition served upon the defendant or respondent. The defendant or respondent must file with the court a verification regarding any criminal or abuse history of the defendant or respondent and anyone living in the defendant or respondent's household on or before the initial in-person contact with the court, but not later than 30 days after service of the Complaint or Petition upon the defendant or respondent. If a trial is scheduled, both parties shall file and serve updated verification forms at least five days prior to trial. ii. The Obtaining a Custody Order packet and the Modification of a Custody Order packet contain Criminal Record / Abuse History Verification forms for both parties. Additional copies of the blank Verification may be obtained from outside the law library on the third floor of the Adams County Courthouse or from the Courts' Self-Help Center at https://www.adamscountypa.gov/courts/courtadministration/selfhelpcenter. ### E. Rules of Civil Procedure 1. A copy of the Pennsylvania Rules of Civil Procedure and Adams County Local Rules can be obtained from the law library located on the Third Floor of the Adams County Courthouse. The applicable rules of court are Rules 1915.1 through 1915.25 of the Pennsylvania Rules of Civil Procedure. ### F. Basic Procedure – PARENTING PLAN 1. This packet contains instructions and forms for completing the PARENTING PLAN. If the Judge in your custody case orders you to complete a PARENTING PLAN, you may use the instructions and forms from this packet to do so. If there is no custody order involving the children and you want to obtain a custody order, you should not use this packet but rather you should use the Obtaining a Custody Order packet and use the parenting plan packet to facilitate a discussion with your co-parent to possibly resolve your case. If you have an existing custody order and you wish to modify it, you should not use this packet but rather you should use the Modification of a Custody Order packet. If you are experiencing difficulties with regard to the other party following an already existing custody order, then you should not use this packet but rather you should use the Enforcing a Custody Order packet. ### G. Service ### 1. STOP!! READ THE FOLLOWING PARAGRAPH CAREFULLY! ===== PAGE 19 ===== 2. The Pennsylvania Rules of Civil Procedure require that all documents (including Petitions, Complaints and Orders) that you file with the Court must be served by you on the other party, or their attorney of record, if any. This includes any Orders you receive scheduling an appearance before the Judge as a result of your filing. Although the Prothonotary’s Office may send a copy of a Scheduling Order to the parties, THIS IS NOT SERVICE. If you do not properly serve all other parties, your case may be delayed, or even dismissed. This packet includes information on how to properly serve the other party. ## INSTRUCTIONS FOR COMPLETING THE PARENTING PLAN ### A. Completing the PARENTING PLAN 1. In a contested custody proceeding, the Judge may require that the parties submit PARENTING PLANS for the care and custody of the child to aid the Court in resolving the custody dispute. You may also use this form to guide your informal discussion with your co-parent in an attempt to settle the custody dispute. i. If the parties cannot come to an agreement on a custody schedule at the custody presentation or at conciliation, the Judge will schedule a date and time for trial. ii. If a trial is scheduled, the Judge may order you and the other parties to each complete a PARENTING PLAN. iii. You must complete, file, and serve the PARENTING PLAN on the other party at least a week prior to the date of the trial. iv. Please refer to the following instructions for completing the PARENTING PLAN. ### 2. CAPTION i. Print the name of the Plaintiff in the line for Plaintiff, the name(s) of the other parent or guardian of the child/ren in the line(s) for Defendant(s), and the case number. This should appear exactly as the caption looks on all other documents for this case, such as the COMPLAINT FOR CUSTODY or PETITION TO MODIFY CUSTODY. DO NOT REVERSE THE NAMES! ### 3. THIS PARENTING PLAN INVOLVES THE FOLLOWING CHILD/CHILDREN i. Print the INITIALS, age, and residence of each child that will be involved with the parenting plan. Do not use full names of the child/ren. The child/ren involved in this custody case are the child/ren you should list here. Please use initials instead of a child's name. ### 4. CHILDREN NOT ADDRESSED BY THIS PARENTING PLAN i. Print the initials, age, and residence of all other children you have, that are not part of this custody case. Please use initials instead of a child's name. ===== PAGE 20 ===== ### 5. LEGAL CUSTODY i. Circle whether both parties plan to decide together or whether the Plaintiff or Defendant only will make decisions as to the listed legal custody items. ### 6. EXPLAIN THE PROCESS YOU WILL USE TO MAKE DECISIONS i. Explain how you and your co-parent plan to make decisions pertaining to the child/ren involved with this custody case. ### 7. PHYSICAL CUSTODY i. List where and with whom the child/ren involved in this custody case will be residing. ### 8. DESCRIBE WHICH DAYS AND WHICH TIMES OF THE DAY THE CHILD/CHILDREN WILL BE WITH EACH PERSON i. For each day of the week, list the planned custody schedule of the child/ren involved with this custody case. ### 9. DESCRIBE WHERE AND WHEN THE CHILD/REN WILL BE DROPPED OFF AND/OR PICKED UP i. Print the location, time and day of the planned custody exchanges, based on the planned custody schedule. ### 10. IF ONE OF YOU DOESN'T SHOW UP, HOW LONG WILL THE OTHER WAIT? i. For the planned custody exchanges, list how long the other parent should wait at the planned custody exchange location when one parent is late or hasn’t shown up. ### 11. IF THERE ARE ANY EXTRAORDINARY COSTS, WHO WILL PAY? i. List which parent (or if both parents) plans to pay for which costs if custody exchanges require extraordinary costs, such as the cost of taxis, trains, and airplanes. ### 12. HOLIDAYS i. For each holiday, list which parent will have custody of the child. 11. The PARENTING PLAN allows for an alternating schedule (YEAR A/YEAR B) or for one parent to have custody on each year. 1. For example, Mother might like to have custody of the child fo 1. For example, Mother might like to have custody of the child for Memorial Day in Year A, and give Father custody of the child on this day in the next year, Year B. This schedule would then alternate year to year. 2. For example, Father might like to have custody of the child on every Father's Day, and Mother on every Mother's Day. iii. If a listed holiday does not apply, you may draw a line through that holiday or write “Not-Applicable”. ===== PAGE 21 ===== iv. If there are other holidays not listed, please write-in the holiday you wish to schedule in the “Other” spaces. ### 13. SUMMER VACATION PLANS i. In the space provided, describe how you plan to share custody of the child/ren over the summer (non-school) months. ii. Please also indicate any periods of time you would like to reserve for vacation that you would like to take with the child/ren and the time required. ### 14. SPECIAL ACTIVITIES or SCHOOL ACTIVITIES i. For each child, list special activities and school activities and whether both parents may attend, and if not, which parent attends. ### 15. TEMPORARY CHANGES TO THIS PARENTING SCHEDULE i. From time to time, one of you might want or need to rearrange the parenting time schedule due to work, family, or other reasons. You can attempt to agree on these changes. If you cannot agree, the parent receiving the request will make the final decision. ii. Please describe which methods the asking parent may use to contact the receiving parent. Please check all that apply. iii. Please indicate how far ahead of time the request must be made. iv. Please indicate the methods the receiving parent may use to reply to the asking parent. Check all that apply. v. Please indicate how long the receiving parent has to reply to the request. ### 16. MAY PARENTS CONTACT ONE ANOTHER? i. Indicate whether the parents may contact one another, and describe by which methods. ### 17. WHEN THE CHILD/CHILDREN IS/ARE WITH ONE OF YOU, HOW MAY THEY CONTACT THE OTHER PARENT? i. Please describe how the child may contact the parent not exercising custody when the child is with the parent exercising custody. ### 18. WHEN AND HOW MAY YOU CONTACT THE CHILD WHEN THE CHILD IS WITH THE OTHER PARENT? i. Describe how you may contact the child when the child is with the other parent. ### 19. CHANGES TO PARENTING PLAN AND CUSTODY ORDER i. In the event that proposed changes, disputes or alleged breaches of this PARENTING PLAN and Custody Order are necessary or desired, describe how the parties plan to address such changes. ### 20. OTHER Instructions ===== PAGE 22 ===== i. If there is anything else that you and the other parent want to agree on, please list it here. This will help the Judge in making the custody decision. ### 21. Completing the PARENTING PLAN i. After you have completed the PARENTING PLAN 1. Sign and date the PARENTING PLAN. 2. Have a witness who saw you sign and date the PARENTING PLAN sign and date as a witness. ii. You must then make at least two (2) copies of the PARENTING PLAN. iii. File the original and all copies with the Prothonotary's Office at least a week prior to attending the custody trial. iv. The Prothonotary will keep the original and return to you the copies of the PARENTING PLAN. Save one copy for yourself and serve the other on the other party, see below. ### 22. Serve the PARENTING PLAN on the other parties i. You must serve the PARENTING PLAN on all of the other parties at least a week prior to the custody trial. ii. Service may be completed by mailing a copy of the PARENTING PLAN to the other parties via First Class Mail. iii. Please complete the Certificate of Service form, and file the Certificate of Service with the Prothonotary. The Certificate of Service form is located at the end of this packet. ===== PAGE 23 ===== # IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

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

CASE NO. _____ ACTION IN CUSTODY ## PARENTING PLAN This parenting plan involves the following child/children:

Child's INITIALS	Age	Where does the child live?
1.
2.
3.

If you have children not addressed by this parenting plan, name here:

Child's INITIALS	Age	Where does the child live?
1. ________	______	______
2. ________	______	______
3. ________	______	______

===== PAGE 24 =====

Legal Custody (who makes decisions about certain things):

Check one
Diet	Both parties decide together	Plaintiff	Defendant
Religion	Both parties decide together	Plaintiff	Defendant
Medical Care	Both parties decide together	Plaintiff	Defendant
Mental Health Care	Both parties decide together	Plaintiff	Defendant
Discipline	Both parties decide together	Plaintiff	Defendant
Choice of School	Both parties decide together	Plaintiff	Defendant
Choice of Study	Both parties decide together	Plaintiff	Defendant
School Activities	Both parties decide together	Plaintiff	Defendant
Sports Activities	Both parties decide together	Plaintiff	Defendant
Additional Items	Both parties decide together	Plaintiff	Defendant
Explain the process you will use to make decisions:(For example, the parent confronted with or anticipating the choice will call the other parent when the choice presents itself, and the other parent must agree or disagree within 24 hours of any deadline.)

===== PAGE 25 ===== Physical Custody (where the child/ren live): The child/ren’s residence is with: 广 Describe which days and which times of the day the child/ren will be with each person: Sunday: _____ Monday: _____ Tuesday: _____ Wednesday: ___ Thursday: ___ Friday: _____ Saturday: ___ Describe where and when the child/ren will be dropped off and/or picked up (day and time of day): Drop-Off: Where:_____ When: ___ Pick-Up: Where: ___ When: _____ ===== PAGE 26 =====

If there are any extraordinary costs (taxi, train, airplane, etc.), who will pay for which costs?

HOLIDAYS – Where will the child/children stay?

HOLIDAYS – where will the child/children stay?
HOLIDAY	YEAR A	YEAR B	EVERY YEAR
Martin Luther King Day
Presidents Day
Easter
Memorial Day
Fourth of July
Labor Day
Yom Kippur
Rosh Hashanah
Thanksgiving
Vacation after Thanksgiving
Christmas Vacation
Kwanzaa
New Year's Eve/Day
Spring Vacation
Easter Sunday

===== PAGE 27 ===== Child’s Birthday ___ ___ ___ ___ Mother’s Day ___ ___ ___ ___ Father’s Day ___ ___ ___ ___ Other ___ ___ ___ ___ Other ___ ___ ___ ___ Other ___ ___ ___ ___ Summer Schedule/ Vacation Plans: The quick brown fox jumps over the lazy dog.

Special Activities or School Activities:
Child’s Initials	List Activity	Both attend? If not, which parent attends?

===== PAGE 28 ===== Temporary changes to this parenting schedule: From time to time, one of you might want or need to rearrange the parenting time schedule due to work, family, or other events. You can attempt to agree on these changes. If you cannot agree, the parent receiving the request will make the final decision.

The parent asking for the change will ask: (check all that apply)
in person	by letter/mail	by phone	by email	by co-parenting app
No later than:	12 hours	24 hours	1 week	1 month ahead of time.
The parent being asked for a change will reply: (check all that apply)
in person	by letter/mail	by phone	by email	by co-parenting app
No later than	12 hours	24 hours	1 week	1 month after being asked

Generally, by what method may parents contact one another?

When the child/ren is/are with one of you, how may they contact the other parent?

When and how may you contact the child when the child is with the other parent?

In the event that proposed changes, disputes or alleged breaches of this parenting plan and custody order are necessary or desired, the parties agree that such changes will be addressed by the following method (specify method, i.e., informal discussion, mediation, court action, etc.)

===== PAGE 29 ===== Other (Anything else you want to agree on):

Date	Signature of Mother
Date	Signature of Father
Date	Signature of Mother’s Witness
Date	Signature of Father’s Witness

===== PAGE 30 ===== # IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

Name	PLAINTIFF
vs.
Name	DEFENDANT 1 and (if applicable)
Name	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: 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)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2701 (relating to simple assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2702 (relating to aggravated assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2705 (relating to recklessly endangering another person)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2706 (relating to terroristic threats)	☐	☐

===== PAGE 31 =====

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. § 2709.1 (relating to stalking)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2718 (relating to strangulation)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2901 (relating to kidnapping)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2902 (relating to unlawful restraint)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2903 (relating to false imprisonment)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2904 (relating to interference with custody of children)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3121 (relating to rape)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3122.1 (relating to statutory sexual assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3124.1 (relating to sexual assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3125 (relating to aggravated indecent assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3126 (relating to indecent assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3127 (relating to indecent exposure)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3129 (relating to sexual intercourse with animal)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders)	☐	☐

===== PAGE 32 =====

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. § 3301 (relating to arson and related offenses)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 4302 (relating to incest)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 4303 (relating to concealing death of child)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 4304 (relating to endangering welfare of children)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 4305 (relating to dealing in infant children)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5533 (relating to cruelty to animal)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5534 (relating to aggravated cruelty to animal)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5543 (relating to animal fighting)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5544 (relating to possession of animal fighting paraphernalia)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5902(b) (relating to prostitution and related offenses)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5903(c) or (d) (relating to obscene and other sexual materials and performances)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 6301 (relating to corruption of minors)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 6312 (relating to sexual abuse of children)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 6318 (relating to unlawful contact with minor)	☐	☐

===== PAGE 33 =====

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. § 6320 (relating to sexual exploitation of children)	☐	☐
YES☐	NO☐	23 Pa.C.S. § 6114 (relating to contempt for violation of protection order or agreement)	☐	☐
YES☐	NO☐	Driving under the influence of drugs or alcohol	☐	☐
YES☐	NO☐	Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device	☐	☐
YES☐	NO☐	18 Pa.C.S. Ch. 30 (relating to human trafficking)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5902(b.1) (relating to prostitution and related offenses)	☐	☐

===== PAGE 34 ===== 2. Unless indicated by my checking the “YES” box next to an item below, I have checked the “NO” box to indicate that neither I nor any other member of my household have a history of violent or abusive conduct including the following:

Check YES to all that apply	Check NO to all that DO NOT apply		Self	Other household member	Date
YES\|	NO	A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction
YES\|	NO\|	Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction
YES\|	NO\|	Other:

3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse: 4. If any conviction above applies to a household member, not a party, state that person's name, date of birth, and relationship to the child: 5. If you are aware that the other party or members of the other party’s household has or have a criminal record/abuse history, please explain: ===== PAGE 35 ===== 6a. Has/have the child/children involved with this custody case been the subject of an indicated or founded report of child abuse? YES NO 6b. Has a party or a member of a party's household been identified as the perpetrator in an indicated or founded report of child abuse? YES NO 6c. If you answered YES to question 6a and/or 6b, please complete the following: Name of perpetrator: ___ Date(s) of incidents of child abuse: ___ Circumstances of child abuse incident(s): County and state where child abuse investigation took place: _____ 7a. Has a party or a member of a party's household been provided services by children & youth services, child protective services, or general protective services? YES NO 7b. If you answered YES to question 7a, please complete the following: Name of agency that provided services: ___ Type of services provided: rvices provided: ___ The circumstances surrounding the provision of services: The status of services: ___ Date(s) services provided: ___ County and State where the services were provided: ___ ===== PAGE 36 ===== 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 8b. If you answered YES to question 8a, please complete the following: Name of agency where investigation is pending: ___ Status of the investigation: 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 SIGNATURE _____

(Printed Name)

(Address)

(__________)

(Home Phone)

(__________)

(Work Phone)

===== PAGE 37 ===== # IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

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

CASE NO. ___ ACTION IN CUSTODY ## DEFENDANT'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: 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)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2701 (relating to simple assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2702 (relating to aggravated assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2705 (relating to recklessly endangering another person)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2706 (relating to terroristic threats)	☐	☐

===== PAGE 38 =====

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. § 2709.1 (relating to stalking)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2718 (relating to strangulation)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2901 (relating to kidnapping)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2902 (relating to unlawful restraint)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2903 (relating to false imprisonment)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2904 (relating to interference with custody of children)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3121 (relating to rape)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3122.1 (relating to statutory sexual assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3124.1 (relating to sexual assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3125 (relating to aggravated indecent assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3126 (relating to indecent assault)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3127 (relating to indecent exposure)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3129 (relating to sexual intercourse with animal)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders)	☐	☐

===== PAGE 39 =====

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. § 3301 (relating to arson and related offenses)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 4302 (relating to incest)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 4303 (relating to concealing death of child)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 4304 (relating to endangering welfare of children)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 4305 (relating to dealing in infant children)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5533 (relating to cruelty to animal)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5534 (relating to aggravated cruelty to animal)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5543 (relating to animal fighting)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5544 (relating to possession of animal fighting paraphernalia)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5902(b) (relating to prostitution and related offenses)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5903(c) or (d) (relating to obscene and other sexual materials and performances)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 6301 (relating to corruption of minors)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 6312 (relating to sexual abuse of children)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 6318 (relating to unlawful contact with minor)	☐	☐

===== PAGE 40 =====

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. § 6320 (relating to sexual exploitation of children)	☐	☐
YES☐	NO☐	23 Pa.C.S. § 6114 (relating to contempt for violation of protection order or agreement)	☐	☐
YES☐	NO☐	Driving under the influence of drugs or alcohol	☐	☐
YES☐	NO☐	Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device	☐	☐
YES☐	NO☐	18 Pa.C.S. Ch. 30 (relating to human trafficking)	☐	☐
YES☐	NO☐	18 Pa.C.S. § 5902(b.1) (relating to prostitution and related offenses)	☐	☐

===== PAGE 41 ===== 2. Unless indicated by my checking the “YES” box next to an item below, I have checked the “NO” box to indicate that neither I nor any other member of my household have a history of violent or abusive conduct including the following:

Check YES to all that apply	Check NO to all that DO NOT apply		Self	Other household member	Date
YES\|	NO	A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction
YES\|	NO\|	Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction
YES\|	NO\|	Other:

3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse: 4. If any conviction above applies to a household member, not a party, state that person's name, date of birth, and relationship to the child: 5. If you are aware that the other party or members of the other party’s household has or have a criminal record/abuse history, please explain: ===== PAGE 42 ===== 6a. Has/have the child/children involved with this custody case been the subject of an indicated or founded report of child abuse? YES NO 6b. Has a party or a member of a party's household been identified as the perpetrator in an indicated or founded report of child abuse? YES NO 6c. If you answered YES to question 6a and/or 6b, please complete the following: Name of perpetrator: ___ Date(s) of incidents of child abuse: ___ Circumstances of child abuse incident(s): County and state where child abuse investigation took place: _____ 7a. Has a party or a member of a party's household been provided services by children & youth services, child protective services, or general protective services? YES NO 7b. If you answered YES to question 7a, please complete the following: Name of agency that provided services: ___ Type of services provided: vices provided: ___ The circumstances surrounding the provision of services: The status of services: ___ Date(s) services provided: ___ County and State where the services were provided: ___ ===== PAGE 43 ===== 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 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: ___ 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	SIGNATURE
	(Printed Name)
	(Address)
	(_____)
	(Home Phone)
	(_____)
	(Work Phone)

===== PAGE 44 ===== # IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

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

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 Street Address of person served City State Zip Code Date: ___ Signature of person certifying service Name of person certifying service (printed or typed) Street Address of person certifying service City State Zip Code ___ Area Code Telephone Number of person certifying service Certificate of Service – Pre-Trial Conference/Parenting Plan/History Verification – Form #1 Page 1 of 1