===== PAGE 1 ===== # IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

Name	Plaintiff	:
		:
	vs.	Case No.
		:
		Action in Custody
Name	Defendant 1	:
		:

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

NAME	AGE	DATE OF BIRTH

The supervised physical custody is provided in an Order dated ___. A copy of the Order is attached to this Affidavit as Exhibit "A." My relationship to the aforesaid minor child(ren) is that of _____. 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. 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. ===== PAGE 2 ===== 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. 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 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. I will not permit the person to be supervised to operate dangerous machinery in the presence of the child(ren) after having consumed alcoholic beverages or controlled substances, or while under the influence of alcohol or controlled substances. I understand that I cannot delegate my responsibility as a supervisor to anyone else 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