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