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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
PETITION FOR CIVIL CONTEMPT FOR DISOBEDIENCE OF CUSTODY ORDER
If you believe the circumstances in your case require the Court’s immediate attention, please check “Yes” in the box below. If not, please check “No”:
Emergency Order Requested Yes No
I, ___, representing myself, state that: Name of Petitioner
- 1. I, ___, Petitioner, currently reside at Name of Petitioner.
Address, including City, State, Zip and County
- ___ of:
| 2. I am the mother, father, or | State the Relationship (for example, grandparent) |
|---|---|
| Initials of Child 1 | Child's Year of Birth |
| Initials of Child 2 | Child's Year of Birth |
| Initials of Child 3 | Child's Year of Birth |
| Initials of Child 4 | Child's Year of Birth |
| Initials of Child 5 | Child's Year of Birth |
Initials of Child 5 Child's Year of Birth
- 3. ___ is the □ mother, □ father, Respondent or □ ___ of the child(ren), and resides at State the Relationship (for example, grandparent)
Address, including City, State, Zip and County
- An Order of Court was entered on ____________________, in the Court of Common Pleas of
- legal custody, □ physical custody, or □ other, of the child(ren). A true and correct copy of the Order of Court is attached.
- 5. The Respondent has violated the Order in the following way:
- 6.I last visited with the child(ren) on _____.
Date
- 7. _____ is now in contempt for failing to obey the Order Respondent's Name dated ___. Date of Order
- 8. Request for Emergency Order
The following emergency situation requires immediate attention by the Court. Describe this situation in detail:
- 9. Emergency Contact Information:
Plaintiff: _____
Telephone Number: ___
Defendant number 1: _____
Telephone Number: _____
Defendant number 2: _____
Telephone Number: ___
- 10. Petitioner has attached the Criminal Record / Abuse History Verification form required pursuant to Pa.R.C.P. 1915.3-2.
FOR THESE REASONS, I request the Court to issue an Order finding
in contempt, enforce custody, and order any other Respondent's Name oppropriate relief relating to custody with the child(ren), including:
VERIFICATION
I verify that the statements made in the foregoing document are true and correct. I understand that false statements herein are made subject to the penalties of perjury of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
Date: _____
Signature
Signature