← 4507b156-2b69-4301-9218-3df9875df793_Criminal-Record-Abuse-History-Verification-070125_need_help-artifacted.pdf
Rebuilt HTML — PaddleOCR-VL (Baidu)
Semantic HTML reconstructed from the OCR item tree (headings, text, lists, tables, form fields). overlay · view JSON
Page 1
Download HTML
IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW
Name PLAINTIFF CASE NO.
Name
vs. : ACTION IN CUSTODY
Case No.
Name DEFENDANT 1 :
Name
and (if applicable) : :
: :
Name
- CRIMINAL RECORD / ABUSE HISTORY VERIFICATION
□ CRIMINAL RECORD / ABUSE HISTORY VERIFICATION
- ☐ REPORT OF CHILD ABUSE AND PROTECTIVE SERVICES REQUESTED BY THE
□ REPORT OF CHILD ABUSE AND PROTECTIVE SERVICES REQUESTED BY THE
COURT (Court may use the first two pages of the parties’ criminal record/abuse history verification or may complete a new form.)
1. Participants. Please list ALL members in your/the participant's household and attach sheets if necessary:
Name Date of Birth Address Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
- Party requests their residence remain confidential as they are protected by the Protection from Abuse Act, 23 Pa.C.S. § 6112, or the Domestic and Sexual Violence Victim Address Confidentiality Act, 23 Pa.C.S. §§ 6701-6713, or the Child Custody Act, 23 Pa.C.S. § 5336(b), or they are in the process of seeking protection under the same.
□ Party requests their residence remain confidential as they are protected by the Protection from Abuse
Page 2
Download HTML
Please list ALL members in the opposing party's household and attach sheets if necessary:
Name Date of Birth Address Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
Name
Date of Birth
Address
Relationship to Child(ren)
- Party requests their residence remain confidential as they are protected by the Protection from Abuse Act, 23 Pa.C.S. § 6112, or the Domestic and Sexual Violence Victim Address Confidentiality Act, 23 Pa.C.S. §§ 6701-6713, or the Child Custody Act, 23 Pa.C.S. § 5336(b), or they are in the process of seeking protection under the same.
□ Party requests their residence remain confidential as they are protected by the Protection from Abuse
SUBJECT CHILD(REN) – Attach additional sheets if necessary:
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
(intentionally left blank)
Page 3
Download HTML
2. Criminal Offenses. As to the following listed Pennsylvania crimes or offenses, or another jurisdiction's substantially equivalent crimes or offenses, check the box next to any applicable crime or offense in which you or a household member:
- has pleaded guilty or no contest;
- has been convicted;
- has charges pending; or
- has been adjudicated delinquent under the Juvenile Act, 42 Pa.C.S. §§ 6301 - 6375, and the record is publicly available as set forth in 42 Pa.C.S. § 6307.
You should also check the box next to a listed criminal offense even if the offense has been resolved by Accelerated Rehabilitative Disposition (ARD) or another diversionary program, unless it has been expunged pursuant to 18 Pa.C.S. § 9122, or a court has entered an order for limited access, e.g., Clean Slate, pursuant to 18 Pa.C.S. §§ 9122.1 or 9122.2.
| Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
|---|---|---|---|---|---|
□ | 18 Pa.C.S. Ch. 25 (relating to criminal homicide) | □ | □ | ||
□ | 18 Pa.C.S. § 2701 (relating to simple assault) | □ | □ | ||
□ | 18 Pa.C.S. § 2702 (relating to aggravated assault) | □ | □ | ||
□ | 18 Pa.C.S. § 2705 (relating to recklessly endangering another person) | □ | □ | ||
□ | 18 Pa.C.S. § 2706 (relating to terroristic threats) | □ | □ | ||
□ | 18 Pa.C.S. § 2709.1 (relating to stalking) | □ | □ | ||
□ | 18 Pa.C.S. § 2718 (relating to strangulation) | □ | □ | ||
□ | 18 Pa.C.S. § 2901 (relating to kidnapping) | □ | □ | ||
□ | 18 Pa.C.S. § 2902 (relating to unlawful restraint) | □ | □ | ||
□ | 18 Pa.C.S. § 2903 (relating to false imprisonment) | □ | □ | ||
□ | 18 Pa.C.S. § 2904 (relating to interference with custody of children) | □ | □ | ||
□ | 18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure) | □ | □ |
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. Ch. 25 (relating to criminal homicide)
Sentence_18 Pa.C.S. Ch. 25 (relating to criminal homicide)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2701 (relating to simple assault)
Sentence_18 Pa.C.S. § 2701 (relating to simple assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2702 (relating to aggravated assault)
Sentence_18 Pa.C.S. § 2702 (relating to aggravated assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2705 (relating to recklessly endangering another person)
Sentence_18 Pa.C.S. § 2705 (relating to recklessly endangering another person)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2706 (relating to terroristic threats)
Sentence_18 Pa.C.S. § 2706 (relating to terroristic threats)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2709.1 (relating to stalking)
Sentence_18 Pa.C.S. § 2709.1 (relating to stalking)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2718 (relating to strangulation)
Sentence_18 Pa.C.S. § 2718 (relating to strangulation)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2901 (relating to kidnapping)
Sentence_18 Pa.C.S. § 2901 (relating to kidnapping)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2902 (relating to unlawful restraint)
Sentence_18 Pa.C.S. § 2902 (relating to unlawful restraint)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2903 (relating to false imprisonment)
Sentence_18 Pa.C.S. § 2903 (relating to false imprisonment)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2904 (relating to interference with custody of children)
Sentence_18 Pa.C.S. § 2904 (relating to interference with custody of children)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)
Sentence_18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)
Page 4
Download HTML
| Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
|---|---|---|---|---|---|
□ | 18 Pa.C.S. Ch. 30 (relating to human trafficking) | □ | □ | ||
□ | 18 Pa.C.S. § 3121 (relating to rape) | □ | □ | ||
□ | 18 Pa.C.S. § 3122.1 (relating to statutory sexual assault) | □ | □ | ||
□ | 18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse) | □ | □ | ||
□ | 18 Pa.C.S. § 3124.1 (relating to sexual assault) | □ | □ | ||
□ | 18 Pa.C.S. § 3125 (relating to aggravated indecent assault) | □ | □ | ||
□ | 18 Pa.C.S. § 3126 (relating to indecent assault) | □ | □ | ||
□ | 18 Pa.C.S. § 3127 (relating to indecent exposure) | □ | □ | ||
□ | 18 Pa.C.S. § 3129 (relating to sexual intercourse with animal) | □ | □ | ||
□ | 18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders) | □ | □ | ||
□ | 18 Pa.C.S. § 3301 (relating to arson and related offenses) | □ | □ | ||
□ | 18 Pa.C.S. § 4302 (relating to incest) | □ | □ | ||
□ | 18 Pa.C.S. § 4303 (relating to concealing death of child) | □ | □ | ||
□ | 18 Pa.C.S. § 4304 (relating to endangering welfare of children) | □ | □ | ||
□ | 18 Pa.C.S. § 4305 (relating to dealing in infant children) | □ | □ |
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. Ch. 30 (relating to human trafficking)
Sentence_18 Pa.C.S. Ch. 30 (relating to human trafficking)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3121 (relating to rape)
Sentence_18 Pa.C.S. § 3121 (relating to rape)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3122.1 (relating to statutory sexual assault)
Sentence_18 Pa.C.S. § 3122.1 (relating to statutory sexual assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)
Sentence_18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3124.1 (relating to sexual assault)
Sentence_18 Pa.C.S. § 3124.1 (relating to sexual assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3125 (relating to aggravated indecent assault)
Sentence_18 Pa.C.S. § 3125 (relating to aggravated indecent assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3126 (relating to indecent assault)
Sentence_18 Pa.C.S. § 3126 (relating to indecent assault)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3127 (relating to indecent exposure)
Sentence_18 Pa.C.S. § 3127 (relating to indecent exposure)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3129 (relating to sexual intercourse with animal)
Sentence_18 Pa.C.S. § 3129 (relating to sexual intercourse with animal)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders)
Sentence_18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 3301 (relating to arson and related offenses)
Sentence_18 Pa.C.S. § 3301 (relating to arson and related offenses)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 4302 (relating to incest)
Sentence_18 Pa.C.S. § 4302 (relating to incest)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 4303 (relating to concealing death of child)
Sentence_18 Pa.C.S. § 4303 (relating to concealing death of child)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 4304 (relating to endangering welfare of children)
Sentence_18 Pa.C.S. § 4304 (relating to endangering welfare of children)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 4305 (relating to dealing in infant children)
Sentence_18 Pa.C.S. § 4305 (relating to dealing in infant children)
Page 5
Download HTML
| Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
|---|---|---|---|---|---|
□ | 18 Pa.C.S. § 4304 (relating to endangering welfare of children) | □ | □ | ||
□ | 18 Pa.C.S. § 5534 (relating to aggravated cruelty to animal) | □ | □ | ||
□ | 18 Pa.C.S. § 5543 (relating to animal fighting) | □ | □ | ||
□ | 18 Pa.C.S. § 5544 (relating to possession of animal fighting paraphernalia) | □ | □ | ||
□ | 18 Pa.C.S. § 5902(b) or (b.1) (relating to prostitution and related offenses) | □ | □ | ||
□ | 18 Pa.C.S. § 5903(c) or (d) (relating to obscene and other sexual materials and performances) | □ | □ | ||
□ | 18 Pa.C.S. § 6301 (relating to corruption of minors) | □ | □ | ||
□ | 18 Pa.C.S. § 6312 (relating to sexual abuse of children) | □ | □ | ||
□ | 18 Pa.C.S. § 6318 (relating to unlawful contact with minor) | □ | □ | ||
□ | 18 Pa.C.S. § 6320 (relating to sexual exploitation of children) | □ | □ | ||
□ | Finding of contempt of a Protection from Abuse order or agreement under 23 Pa.C.S. § 6114 | □ | □ | ||
□ | Finding of contempt of a Protection of Victims of Sexual Violence and Intimidation order or agreement under 42 Pa.C.S. § 62A14 | □ | □ | ||
□ | Driving under the influence of drugs or alcohol | □ | □ |
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 4304 (relating to endangering welfare of children)
Sentence_18 Pa.C.S. § 4304 (relating to endangering welfare of children)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 5534 (relating to aggravated cruelty to animal)
Sentence_18 Pa.C.S. § 5534 (relating to aggravated cruelty to animal)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 5543 (relating to animal fighting)
Sentence_18 Pa.C.S. § 5543 (relating to animal fighting)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 5544 (relating to possession of animal fighting paraphernalia)
Sentence_18 Pa.C.S. § 5544 (relating to possession of animal fighting paraphernalia)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 5902(b) or (b.1) (relating to prostitution and related offenses)
Sentence_18 Pa.C.S. § 5902(b) or (b.1) (relating to prostitution and related offenses)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 5903(c) or (d) (relating to obscene and other sexual materials and performances)
Sentence_18 Pa.C.S. § 5903(c) or (d) (relating to obscene and other sexual materials and performances)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 6301 (relating to corruption of minors)
Sentence_18 Pa.C.S. § 6301 (relating to corruption of minors)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 6312 (relating to sexual abuse of children)
Sentence_18 Pa.C.S. § 6312 (relating to sexual abuse of children)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 6318 (relating to unlawful contact with minor)
Sentence_18 Pa.C.S. § 6312 (relating to sexual abuse of children)
Date of conviction, guilty plea, no contest plea or pending charges_18 Pa.C.S. § 6320 (relating to sexual exploitation of children)
Sentence_18 Pa.C.S. § 6320 (relating to sexual exploitation of children)
Date of conviction, guilty plea, no contest plea or pending charges_Finding of contempt of a Protection from Abuse order or agreement under 23 Pa.C.S. § 6114
Sentence_Finding of contempt of a Protection from Abuse order or agreement under 23 Pa.C.S. § 6114
Date of conviction, guilty plea, no contest plea or pending charges_Finding of contempt of a Protection of Victims of Sexual Violence and Intimidation order or agreement under 42 Pa.C.S. § 62A14
Sentence_Finding of contempt of a Protection of Victims of Sexual Violence and Intimidation order or agreement under 42 Pa.C.S. § 62A14
Date of conviction, guilty plea, no contest plea or pending charges_Driving under the influence of drugs or alcohol
Sentence_Driving under the influence of drugs or alcohol
Page 6
Download HTML
| Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
|---|---|---|---|---|---|
□ | Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device | □ | □ |
Date of conviction, guilty plea, no contest plea or pending charges_Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device
Sentence_Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device
3. Abuse or Agency Involvement. Check the box next to any statement that applies to you, a household member, or your child.
| Check all that apply | Self | Household member | Child | |
□ | Involvement with a children and youth social service agency in Pennsylvania or a similar agency in another jurisdiction.What jurisdiction?: ____________ | □ | □ | □ |
□ | A determination or finding of abuse (i.e., indicated or founded report) by a children and youth social service agency or court in Pennsylvania or a similar agency or court in another jurisdiction.What jurisdiction?: ____________ | □ | □ | □ |
□ | An adjudication of dependency involving this child or any other child under Pennsylvania's Juvenile Act, or a similar law in another jurisdiction.What jurisdiction?: ____________Is the case active?: ____________ | □ | □ | □ |
□ | A history of perpetrating “abuse” as that term is defined in the Protection from Abuse Act, 23 Pa.C.S. § 6102. | □ | □ | □ |
□ | A history of perpetrating “sexual violence” or “intimidation” as those terms are defined in 42 Pa.C.S. § 62A03 (relating to protection of victims of sexual violence and intimidation). | □ | □ | □ |
What jurisdiction
What jurisdiction
What jurisdiction
Is the case active
Page 7
Download HTML
| Check all that apply | Self | Household member | Child | |
□ | Other: | □ | □ | □ |
Other
4. If you checked a box in (2) or (3), list any evaluation, counseling, or other treatment received as a result:
- If you checked a box in (2) or (3) that applies to your household member, who is not a party, state that person's name, date of birth, and relationship to the child.
- If you are aware that the other party or the other party's household member has a criminal record or abuse history, please explain.
ONLY A PARTY CAN SIGN THIS FORM. IF A PARTY IS REPRESENTED BY AN ATTORNEY, THE ATTORNEY CANNOT SIGN THIS FORM ON BEHALF OF THE PARTY.
I verify that the information above is true and correct to the best of my knowledge, information or belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
___
Date
Plaintiff/Defendant Signature
Date
Plaintiff/Defendant Signature (Printed Name)
Printed Name
Page 8
Download HTML
I certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania that require filing confidential information and documents differently than non-confidential information and documents.
Signature of Filer
Printed Name