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

Name

Plaintiff

vs. Case No.

Action in Custody

Defendant

Name

Defendant 1 :

Case No

AFFIDAVIT OF ACCOUNTABILITY OF SUPERVISOR

I, _____, hereby agree to supervise the physical custody of _____ (name of party) with the following child(ren):

AFFIDAVIT OF ACCOUNTABILITY OF SUPERVISOR
Name of Party

NAME AGE DATE OF BIRTH

NAME [1]
AGE [1]
DATE OF BIRTH [1]
NAME [2]
AGE [2]
DATE OF BIRTH [2]
NAME [3]
AGE [3]
DATE OF BIRTH [3]
NAME [4]
AGE [4]
DATE OF BIRTH [4]

The supervised physical custody is provided in an Order dated ___. A copy of the Order is attached to this Affidavit as Exhibit "A."

Dated

My relationship to the aforesaid minor child(ren) is that of _____.

Relationship

I agree to abide by and fulfill the following requirements and conditions of the role of supervisor: (Check boxes of all that apply)

I am aware that circumstances have arisen showing a need for supervised physical custody.

custody.

I understand that the role of a supervisor requires my physical presence with the child(ren) and the person to be supervised in the manner and for the period of time that supervision is required pursuant to the custody order, i.e. the whole visit, overnight only.

child(ren) and the person to be supervised in the manner and for the period of time that

Affidavit of Accountability of Supervisor Page 1 of 2

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I understand that I must accompany the minor child(ren) and the person to be supervised on any and all excursions, no matter how short or long in duration, as required by the custody order and if such excursions are permissible in this case.

supervised on any and all excursions, no matter how short or long in duration, as required

I will make prompt notations of any behavior of the person to be supervised which I believe to be harmful to the best interests of the child(ren) in this matter and I will make a prompt report of those observations to counsel for both parties.

I believe to be harmful to the best interests of the child(ren) in this matter and I will make

I will not permit the person to be supervised to drive a motor vehicle after having consumed alcoholic beverages or controlled substances, or while under the influence of alcohol or controlled substances, with the child(ren) present in the motor vehicle. At all times, I shall ensure that the child(ren) are securely fastened in an appropriate passenger restraint.

consumed alcoholic beverages or controlled substances, or while under the influence of
presence of the child(ren) after having consumed alcoholic beverages or controlled

I understand that I cannot delegate my responsibility as a supervisor to anyone else without prior approval of the Court.

without prior approval of the Court.
Additional Provisions

I agree to be fully accountable to the Court as a supervisor in this matter.

DATE

Signature of Supervisor

Print Name
Street Address
City/State/Zip Code
Home Phone
Work Phone
Email Address

Affidavit of Accountability of Supervisor Page 2 of 2