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 applyCrimeSelfOther household memberDate of conviction, guilty plea, no contest plea or pending chargesSentence
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18 Pa.C.S. Ch. 25 (relating to criminal homicide)
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18 Pa.C.S. § 2701 (relating to simple assault)
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18 Pa.C.S. § 2702 (relating to aggravated assault)
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18 Pa.C.S. § 2705 (relating to recklessly endangering another person)
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18 Pa.C.S. § 2706 (relating to terroristic threats)
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18 Pa.C.S. § 2709.1 (relating to stalking)
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18 Pa.C.S. § 2718 (relating to strangulation)
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18 Pa.C.S. § 2901 (relating to kidnapping)
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18 Pa.C.S. § 2902 (relating to unlawful restraint)
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18 Pa.C.S. § 2903 (relating to false imprisonment)
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18 Pa.C.S. § 2904 (relating to interference with custody of children)
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18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)
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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)