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
Name DEFENDANT 2 :
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