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