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IN THE COURT OF COMMON PLEAS COUNTY, PENNSYLVANIA

PLAINTIFF

VS.

NO. ___



DEFENDANT

# ENTRY OF APPEARANCE AS A SELF-REPRESENTED PARTY

1. I am the ___ Plaintiff ___ Defendant in the above-captioned case.

2. I intend to represent myself in the ___ custody, ___ divorce, ___ support, ___ protection from abuse, ___ paternity case.

Check only one box in Question 3

3. This is a new case and I am representing myself. I have decided not to hire an attorney to represent me. OR

This is not a new case and I am representing myself. I have decided not to hire an attorney to represent me. OR

☐ This is not a new case. ___ previously

(Name of Attorney)

represented me in this case. I have decided not to be represented by that attorney and direct the Prothonotary to remove that attorney as my counsel of record in this case.

I have provided a copy of this form to that attorney listed above at the following address:

That attorney has acknowledged his/her withdrawal from this case by signing this form.

Esq.

(Attorney signature)

4. I am entering my appearance as a self-represented party ___

(Your Signature)

5. I understand that I need to provide a street address or P.O. Box for the purpose of receiving all future pleadings and other legal notices. I further understand that this does not need to be my home address. My address for the purpose of receiving all future pleadings and other legal notices is:

I understand that this address will be the only address to which notices and pleadings in this case will be sent and that I am responsible to check the mail at this address so I do not miss important deadlines or proceedings.

I am not providing my address because I reside at a confidential location protected by the Protection From Abuse Act, 23 Pa. C.S. § 6112 and/or the Address Confidentiality Program, 23 Pa. C.S. § 6701-6713, and/or the Child Custody Act, 23 Pa. C.S. § 5336(b).

6. My telephone number where I can be reached is ___.

I am not providing my telephone number because it is confidential pursuant to the Protection From Abuse Act, 23 Pa. C.S. § 6112 and/or the Child Custody Act, 23 Pa. C.S. § 5336(c).

7. I UNDERSTAND I MUST FILE A NEW FORM EVERY TIME MY ADDRESS OR TELEPHONE NUMBER CHANGES.

8. I understand that I must ensure that a copy of this form is served on all other attorneys or other self-represented parties at the following addresses as listed below: (Use reverse side if you need more space)

Name_____ Address_____

Name_____ Address_____

9. I verify that the statements made in this Entry of Appearance as a Self-Represented Party are true and correct. I understand that if I make false statements herein, that I am subject to the criminal penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities that could result in a fine and/or prison term.

 I am a

Date