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

Name_6(PCCOForm)

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

Name_7(PCCOForm)

Name_8(PCCOForm)

CASE NO_2(PCCOForm)

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

your

No □

I, ___, representing myself, state that: Name of Petitioner

Name of Petitioner(PCCOForm)

1. I, ___, Petitioner, currently reside at Name of Petitioner.

Name of Petitioner_2(PCCOForm)

Address, including City, State, Zip and County(PCCOForm)

Address, including City, State, Zip and County

___ of:

State the Relationship (for example, grandparent(PCCOForm)

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

Address,

State the Relationship (for example, grandparent)

Initials of Child 1(PCCOForm)

Child(PCCOForm)

Initials of Child 2(PCCOForm)

Child_2(PCCOForm)

Initials of Child 3(PCCOForm)

Child_3(PCCOForm)

Initials of Child 4(PCCOForm)

Child_4(PCCOForm)

Initials of Child 5(PCCOForm)

Initials of Child 5 Child's Year of Birth

Child_5(PCCOForm)

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3. ___ is the □ mother, □ father, Respondent or □ ___ of the child(ren), and resides at State the Relationship (for example, grandparent)

Respondent(PCCOForm)

Mother(PCCOForm)

Father(PCCOForm)

State Relationship(PCCOForm)

Other(PCCOForm)

Address(PCCOForm)

Address, including City, State, Zip and County

An Order of Court was entered on ____________________, in the Court of Common Pleas of

Date of Order(PCCOForm)

Name of County(PCCOForm)

Name of State(PCCOForm)

legal custody, □ physical custody, or □ other, of the child(ren). A true and correct copy of the Order of Court is attached.

Legal Custody(PCCOForm)

Physical Custody(PCCOForm)

Other2(PCCOForm)

5. The Respondent has violated the Order in the following way:

Violation(PCCOForm)

6.I last visited with the child(ren) on _____.

Date(PCCOForm)

Date

7. _____ is now in contempt for failing to obey the Order Respondent's Name dated ___. Date of Order

RespondentsName(PCCOForm)

Date of Order2(PCCOForm)

8. Request for Emergency Order

The following emergency situation requires immediate attention by the Court. Describe this situation in detail:

Situation(PCCOForm)

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9. Emergency Contact Information:

Plaintiff: _____

Emergency Contact Information(PCCOForm)

Telephone Number: ___

Telephone Number(PCCOForm)

Defendant number 1: _____

Defendant number 1(PCCOForm)

Telephone Number: _____

Telephone Number_2(PCCOForm)

Defendant number 2: _____

Defendant number 2(PCCOForm)

Telephone Number: ___

Telephone Number_3(PCCOForm)

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:

Respondent’s Name3(PCCOForm)

ReliefSought(PCCOForm)

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: _____

Date4(PCCOForm)

Signature