Check all that applySelfHousehold memberChild
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Other:
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Other

4. If you checked a box in (2) or (3), list any evaluation, counseling, or other treatment received as a result:

  1. 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.
  2. 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.

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Date

Plaintiff/Defendant Signature

Date

Plaintiff/Defendant Signature (Printed Name)

Printed Name