===== PAGE 1 ===== # 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 ===== PAGE 2 ===== 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 4. An Order of Court was entered on ___, in the Court of Common Pleas of Date of Order ___ County, in the State of ___, granting me Name of County Name of State □ 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: ===== PAGE 3 ===== 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