| 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) | □ | □ |