IN THE COURT OF COMMON PLEAS OF _____ COUNTY, PENNSYLVANIA CIVIL ACTION

Print the name of the county in which you filed exactly as you wrote it on Form 1.

PLAINTIFF :

Print the name of the Plaintiff exactly as it appears on Form 1.
Print the name of the Defendant exactly as it appears on Form 1.

DEFENDANT

VS. :

Case No. _____

Print the docket number that the Prothonotary's Office wrote on Form 1 at the time of filing.

CERTIFICATE OF SERVICE

The undersigned hereby certifies that on this date, a true and correct copy of the following have been served: (check any of the following that apply)

Notice of Intention to File a Praecipe to Transmit the Record of Section 3301(d), OR Section 3301(c)(2)

Mark the box or boxes naming the document(s) you are mailing to your spouse. If you are mailing a form not listed, write the name of the form in the “other” space provided.

Affidavit of Non-Military Service

Mark the box or boxes naming the document(s) you are mailing to your spouse. If you are mailing a form not listed, write the name of the form in the “other” space provided.

Notice of Intention to Request Entry of Section 3301(c)(1) Divorce Decree, and Counter-Affidavit Under 3301(c)(1)

Mark the box or boxes naming the document(s) you are mailing to your spouse. If you are mailing a form not listed, write the name of the form in the “other” space provided.

(Other)___

If you are mailing a form not listed, above, write the name of the form on this line.
Mark the box or boxes naming the document(s) you are mailing to your spouse. If you are mailing a form not listed, write the name of the form in the “other” space provided.

The undersigned hereby certifies that the above documents were served by first class mail to the following:

Print your spouse's name.

(spouse's name)

Print your spouse's address

(spouse's address)

Print your spouse's city, state, and zip code.
Print your spouse's telephone number. format is XXX-XXX-XXXX

(spouse's telephone)

Date:_____

Write the date. Format is XX/XX/XXXX
Sign your name.

(Signature)

Print your name.

Print Name

Divorce Form 11 Certificate of Service AOPC 5.1.14.