9(b) – If you, the plaintiff, are a grandparent of the child, who is seeking physical or legal custody of the child, and you do not stand in loco parentis to the child, then you must state facts that establish standing pursuant to 23 Pa.C.S. § 5324(3).

9(c) – If you, the plaintiff, are a person seeking physical and/or legal custody, and you do not stand in loco parentis to the child, then you must plead facts establishing standing pursuant to 23 Pa.C.S. § 5324(4) and (5).

9(d)- If you, the plaintiff, are a grandparent or great-grandparent of the child, and you are seeking partial physical custody or supervised physical custody of the grandchild or great-grandchild, then you must state facts establishing standing under 23 Pa.C.S. § 5325.

i. Complete this section only if you have checked “Yes” to Emergency Order Requested on Page 1 of Form #3. Describe in detail the emergency situation which needs the Court’s immediate attention. Be sure to complete Paragraph 11 with Emergency Contact Information for all parties.

i. Please include Emergency Contact Information for both the Plaintiff and the Defendant(s).

i. Attach the completed Plaintiff's Criminal Record / Abuse History Verification form to the Complaint.

i. Check all of the box(es) which apply to your request. Remember, the court may not grant all of your requests.

i. Read carefully, and then date and sign the form.

Print your name on the Plaintiff line and indicate who is the other parent(s) or guardian(s) of the child on the Defendant line(s).

The line for Case No. should be left blank because the Prothonotary will fill in this blank when you bring your completed form to the